Care Support of America on overlooked healthcare issues in eldercare and family caregiving

Sep 11 2009

The following is a commentary by Dan Tobin, M.D., a nationally recognized eldercare and family caregiving expert and Founder and CEO of Care Support of America.

As healthcare reform is being debated in Congress and on Main Street, vital and practical issues in eldercare and family caregiving are being overlooked. Some 30 million U.S. baby boomers are family caregivers for their aging parents, trying to keep their parents safe at home and helping them navigate the complexities of Medicare and manage an advancing illness. If they had their say, most elderly people would prefer to age in their own homes. Regardless of how the overall healthcare debate unfolds, some incremental and cost sensitive changes in Medicare that support care coordination, family caregiving, and aging at home could help older Americans and family caregivers, while reducing hospitalizations and institutional care.

The Dartmouth Atlas of Healthcare, which for more than 20 years has tracked services provided to the Medicare population, has consistently found a lack of uniform utilizations of hospitals in serious illness. Instead, it found that in regions where people get more care, they do not necessarily get better care - or better outcomes.

Medicare's "fee for service" structure focuses on acute care and "well" visits and neglects serious chronic illness care coordination, which often falls on overwhelmed family members. This has been well documented in studies by such organizations as The Partnership for Solutions, the National Family Caregivers Association, the Family Caregiver Alliance, and the National Alliance for Caregiving.

It turns out that care coordination makes a difference. Major studies have found that if physicians initiate care coordination, families are better able to plan for "aging in place," with far fewer hospitalizations and nursing home stays. A comprehensive 2007 review for the Agency for Healthcare Research and Quality by McDonald, Sundaram, Bravata, et al., along with other studies of older patients with complicated health issues, indicate that when patients and family caregivers understand their doctors' recommendations, coordinate medical and non-medical home care, and plan for the progression of illness, there can be significant reductions in hospitalizations and institutional transfer, as well as improved quality of life.

Cost-sensitive regulatory and legislative changes could vastly improve the quality of life for seniors and their loved ones. In one currently evolving model, "the medical home," the patient's primary care physician would focus on coordinating care, provide ongoing health education and counseling, while also linking to community services that support family caregivers coordinating aging at home for their loved ones. This model is being developed by organizations such as the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association.

In another complementary approach, Care Support of America has a family care manager service that is paid for by adult children and proven in independent peer-review studies to improve the quality of life for family caregivers and reduce hospitalizations. While some parts of dealing with serious illness are undeniably difficult, other problems can be minimized or prevented with information, planning, and support - and make a tremendous difference in people's lives.

For example, our group devised a simple five-question form to guide patient-physician communication and help alleviate patients' uncertainty around diagnosis, treatment, and prognosis. This brief form greatly helped patients and their caregivers better understand the treatment they were receiving, communicate more effectively with their doctors, and more easily plan for future needs - all from one brief form containing a few key questions.

There is an agreed-upon need for physician-initiated care coordination that helps families plan for aging in place and avoids hospitalizations and transfers to nursing homes. Inevitably, our parents will become frail, and our cultural fear of death should not prevent us from looking at proactive ways to help them plan their own care so that they can be as independent as possible for as long as possible - and safe, always.

Evidence-based methods of care coordination and health counseling for family caregiving and aging in place already exist, and the American Medicare model could take a distinctly humanistic as well as fiscally prudent approach to supporting adult children and their parents as they age.

It is time for Medicare to integrate what we already know about accountable quality outcomes and non-directive, shared decision-making, and become more than just a national payer of senior healthcare services. Common sense Medicare changes should integrate evidence-based efforts into the baseline services that are being discussed. Just look at the numbers - some 80 million members of Gen X and Gen Y will become family caregivers in the years ahead.