The Stern Center for Evidence-Based Policy
Addressing the Health Needs of
an Aging America
New Opportunities for Evidence-Based
Policy Solutions
Addressing the Health Needs of an Aging America | 1
The Stern Center for Evidence-Based Policy
The Stern Center for Evidence-Based Policy (“Stern Center”) fosters, supports, and leads rigorous scientific research initiatives that generate actionable, evidence-based health policy recommendations. By leveraging significant advances in evidence-based research methods and collaborating
with key stakeholders, the Stern Center aims to empower policymakers with the best research information available. The goal of the Center is to improve the health of the U.S. population by increasing
the use of evidence in the policymaking process.
Housed in the University of Pittsburgh’s Health Policy Institute, the Stern Center brings together experts from across the health sciences, including medicine, public health, pharmacy, nursing, dentistry
and the rehabilitation sciences, to collaborate on applied policy research. Subject matter experts are
supported by a team of political scientists, health economists, biostatisticians, information scientists
and regulatory experts who provide the methodological and analytical backbone for the Center’s
projects. The Center partners with other academic institutions, research organizations, associations,
stakeholder groups and governmental entities to enrich our work and disseminate findings.
Acknowledgements
We would like to acknowledge the multidisciplinary team of researchers at the University of Pittsburgh
that conducted this study. The team was led by Dr. Sally Morton (Graduate School of Public Health)
and Dr. William Dunn (Graduate School of Public and International Affairs). Researchers that contributed were:
•
Johanna Bellon, MS, CFA, PhD (Health Policy Institute)
•
Kim Coley, PharmD, FCCP (School of Pharmacy)
•
Stephen Coulthart, PhD (Graduate School of Public and International Affairs)
•
Howard Degenholtz, PhD (Graduate School of Public Health)
•
Anthony Delitto, PhD, PT, FAPTA (School of Health and Rehabilitation Sciences)
•
Julia Driessen, PhD (Graduate School of Public Health)
•
Meredith Hughes, (Health Policy Institute)
•
Everette James, JD, MBA (Health Policy Institute)
•
Taafoi Kamara, MPH (Aging Institute)
•
Alyssa Landen, MPH (Graduate School of Public Health)
•
Sally Caine Leathers (Health Policy Institute)
•
Melissa McGivney, PharmD, FCCP (School of Pharmacy)
•
Maqui Ortiz (Health Policy Institute)
•
Ana Progovac, PhD (Health Policy Institute)
•
Charles Reynolds, MD (Aging Institute)
•
Philip Rocco, PhD (Health Policy Institute)
•
Jogeshwar Singh, MHA, MD (Graduate School of Public Health)
•
Joel Stevans, PhD (Health and Rehabilitation Sciences)
•
Barb Folb, MLS, MPH (Health Sciences Library System)
•
Charles B. Wessel, MLS (Health Sciences Library System)
Addressing the Health Needs of an Aging America | 2
Table of Contents
Executive Summary
4
Introduction
7
The Challenges of Caring for an Aging America
8
Identifying Opportunities for Evidence-Based Policy Solutions
10
Where Evidence and Policy Meet
13
Evidence Searching for Policy Levers
24
Policy Recommendations Searching for an Evidence Base
26
Conclusion
32
Appendix A: Research Methodology
33
Appendix B: Results
35
Addressing the Health Needs of an Aging America | 3
Executive Summary
The U.S. population is rapidly aging. And its healthcare needs are changing.
By 2050, adults over the age of 65 will make up 20 percent of the U.S. population. The budgetary
and policy implications of this demographic shift represent two of the greatest challenges faced by
federal and state governments today. An aging population will place intense stress on our healthcare
system, its funding sources, and American families. Lack of personal savings for long term-care and a
fragmented and institutionally-dependent delivery system will pose significant risks to the health and
quality-of-life of aging Americans. Our healthcare workforce will need to be re-tooled to manage the
multiple chronic conditions prevalent in this vulnerable population. Addressing the needs of the elderly
will be a top priority of policymakers at every level.
Evidence-based policymaking can improve the cost and quality of care
for the aging.
Meeting the health needs of an aging America requires policy proposals based on the best-available
research evidence about how to improve access, affordability and the quality of health services. Today, for many reasons, health policymaking often fails to fully consider scientific research evidence.
With aging Americans and their loved ones at risk, policymakers have a responsibility to inform their
decisions with rigorous, objective evidence. At the same time, health policy researchers must find a
way to present scientific results in a manner that is relevant to and applicable by policymakers. This
study is the first in a series of efforts to connect research evidence to the set of policy recommendations being made to address the health needs of older adults in the United States.
This study is the first to systematically map health policy recommendations for
the aging to the body of research evidence
In an unprecedented effort to map evidence to health policies, a multidisciplinary team of researchers conducted a two-phase study to identify opportunities for policymakers seeking to improve the
cost and quality of healthcare for the aging. Results of a broad literature search of medical research
evidence were matched and compared to policy recommendations from multiple, cross-cutting healthcare stakeholder groups. From an initial search return of over four hundred thousand literature citations and over 493 health stakeholder organizations, researchers conducted a scoping study and
policy scan to identify unique stakeholder policy recommendations and studies related to the health
of the aging population. An expert panel used these results to organize the information into 10 usable policy categories (further divided for easy reference into 75 subtopic areas), which combine to
present a comprehensive and unbiased view of the best-available evidence and policy activity around
healthcare for older adults. The study intends to inform future policymaking in this critical area with an
easily applied index of evidence-based policy research mapped to the full range of policy options.
Matching these results allows policy makers and the stakeholder community to identify potential areas
of interest:
1)
2)
3)
Where there is significant policy interest and evidence to support proposed changes;
Where policy topics have a strong evidence base but are receiving little attention; and
Where there is policy activity but a lack of scientific evidence.
Addressing the Health Needs of an Aging America | 4
Where Evidence and Policy Meet
The study revealed three areas in which a rich base of research evidence and a high level of
demand for policy change exist:
Prevention and Wellness interventions lower the cost of care and improve health outcomes by
preventing the onset of disease entirely, detecting the early onset of disease through screening, and
slowing or stopping the progression of disease. Within this broad category, the study revealed specific
focus areas where evidence and policy demand strongly converge: screening and early detection;
nutrition and diet; and patient education, empowerment, and physical activity.
The Healthcare and Informal Caregiver Workforce reforms seek to address a significant shortage in the number of professionals who have the necessary skills to treat complex geriatric patients.
Policy interventions could support the use of new models of care to expand the role of family caregivers, leverage the unique skills of nurses and other advanced practice providers, train the workforce in geriatric competencies, coordinate interprofessional teams to manage care, and identify
opportunities for engaging community health workers.
Coordinated Care interventions encourage healthcare payers and providers to move toward a more
accountable system, where a greater portion of reimbursement is tied to patient health outcomes. The
study revealed significant evidence and policy activity on interventions related to care pathways and
bundles, disease management programs, specialized units, discharge coordination and patient navigation, and coordinated delivery of primary and long-term care.
Evidence That Deserves Greater Attention From Policymakers
The following topics had an extensive, rigorously conducted evidence base but received limited attention in the policy arena.
Patient Self-Care and Self-Management initiatives encourage patients to work with their providers
to preserve their health status and minimize avoidable complications. These initiatives utilize strategies such as patient education to encourage healthy decisions and behaviors as well as technology
enabled self-care. Better management of chronic disease can help patients with complex, co-morbid
conditions avoid unnecessary interactions with the healthcare system, such as costly trips to the
emergency room.
Palliative and End-of-Life Care refer to approaches that focus on relieving symptoms for patients
with pain and terminal illnesses and providing support and resources for their family members. Approximately one-third of Medicare dollars are spent on patients in their last two years of life; these
initiatives seek to reduce the suffering of patients at the end-of-life while creating considerable opportunities for healthcare cost reduction. Such initiatives hope to improve patient and caregiver satisfaction.
Addressing the Health Needs of an Aging America | 5
Policy Recommendations That Demand an Evidence Base
Two topics were notable for a large number of policy recommendations within the sampled
stakeholder organizations, but a lack of research evidence to support these recommendations.
Medical Malpractice: A cost-effective, high-value healthcare system would ideally eliminate wasteful
and unnecessary care associated with the practice of defensive medicine. Yet the study found considerable gaps in the evidence base on the potential consequences of malpractice reform on the costs
and quality of care for the aging population
Long-Term Care: While reforming the current long-term care system is a major policy priority for
many stakeholder organizations in the study, the evidence base on the effects of proposals to reform the system for financing and delivering long-term care is limited, particularly at the federal level.
A great deal of policy activity in long term care is happening at the state level, as state leaders use
policy levers such as Medicaid waivers to deliver long-term services and supports in innovative ways.
However, many significant gaps remain and additional evaluation and research are needed to provide
an evidence-base for these policies.
Addressing the Health Needs of an Aging America | 6
Introduction
The U.S. population is rapidly aging. By 2050, older adults, age 65 and older, will make up 20 percent of the total U.S. population, up from 12 percent in 2000 and just 8 percent in 1950. The number
of people age 85 or older will grow the fastest over the next few decades, constituting 4 percent of the
population by 2050, or 10 times its share in 1950 (see Figure 1).
Figure 1. Growth in U.S. Aging Population, 1950-2060 (Projected)
Source: U.S. Census Bureau
Note: * indicates projection 2014 Population Projections
The budgetary and policy implications of this demographic shift represent the greatest challenges faced by the government and the U.S. health system today. While the U.S. population
of adults aged 65 and older currently account for only 13 percent of the population, this cohort consumes more that 34 percent of national health expenditures. On average, the older adult population
spends $18,424 annually per person, with more than one-third of those expenditures occurring after
the age of 85. The Medicaid program accounted for more that 40 percent of overall U.S. nursing
home costs in 2012, and 65 percent of these costs in graying states like Pennsylvania. Together with
Medicare, these programs comprise more that 31 percent of all U.S. health expenditures.1
1
G. Burtless, Trends in the Well-Being of the Aged and Their Prospects through 2030, Brookings Institution Report, June 2015, available from: http://www.brookings.edu/~/media/Research/Files/Papers/2015/06/04-medicare-2030-paper-series/060215BurtlessWell
BeingSeniors.pdf?la=en; U.S. Senate, Commission on Long-Term Care, Report to Congress, September 2013, available from: http://
www.gpo.gov/fdsys/pkg/GPO-LTCCOMMISSION/pdf/GPO-LTCCOMMISSION.pdf.
Addressing the Health Needs of an Aging America | 7
What policy solutions have been advanced to address the challenges of reducing healthcare
costs and improving health outcomes in the elderly population, and are these solutions supported by rigorous scientific evidence? Over the last year, a multidisciplinary team at the Stern
Center for Evidence-Based Policy conducted an unprecedented study that answers these questions.
Researchers systematically analyzed scientific evidence related to the cost and quality of care for the
aging population from across the entire domain of published biomedical literature, as well as health
policy recommendations from a sampled set of stakeholder organizations (advocacy, membership,
and trade organizations) in the United States.
The results of this study provide policymakers with essential insights into the current state of
evidence-based health policy in the United States. The findings will thus drive the future work of
the Stern Center in this politically, economically, and socially critical area of health policy research.
The Challenges of Caring for an Aging America
Meeting the health needs of an aging America requires sizable changes to our existing approach to treatment and service delivery. Unless policymakers take action now, aging Americans and their loved ones will soon experience unsustainably high costs for healthcare coverage as well as significant declines in the access to and quality of care.
Care needs among the U.S. aging population are changing rapidly. An aging America will experience increasingly severe and complex health conditions. Almost half of the U.S. population is expected to have at least one chronic disease by 2020. By 2030, over 40 percent of the 65+ population is
likely to have diabetes; nearly 80 percent will experience hypertension. The number of aging individuals with three or more chronic conditions has also increased significantly within the last ten years, and
this is expected to grow to 40 percent among the 65 and over population by 2030. Complicating the
task of treating multiple chronic conditions is the rising prevalence of age-related functional impairments. This will dramatically expand the number of individuals requiring assistance to perform daily
activities to maintain quality of life and independence. By 2050, the number of Americans needing
long-term services and supports (LTSS) will more than double to 27 million.2
The fragmented U.S. healthcare system is ill-suited to address an expanding aging population’s complex needs. While multiple chronic conditions can be effectively managed through coordinated approaches to treatment, providers rarely coordinate with one another and often lack appropriate incentives for improving the overall health of the patient. This places individuals with multiple
chronic conditions at a significantly higher risk for adverse drug reactions and preventable hospitalizations. Fragmented service delivery also makes it more difficult for aging individuals to navigate their
health choices.3
2
Id.
R. Gijsen, N. Hoeymans, F.G. Schellevis, et al., Causes and consequences of comorbidity: a review, Journal of Clinical Epidemiology
2001;54(7):661-674.
3
Addressing the Health Needs of an Aging America | 8
Gaps in the caregiver workforce will place an increasing number of older adults at risk of losing their health and independence. Less than 3 percent of medical students enroll in geriatrics electives, while less than 1 percent of nurses and pharmacists have gerontological certifications. Training
requirements for direct care workers, which vary from state to state, are often inadequate. Across
health services professions, certification programs fail to emphasize competencies related to caring
for older adults. Finally, surveys of family caregivers also reveal that they have little access to necessary training and skills. These workforce gaps will make it increasingly difficult to provide high-quality
care to aging Americans and will limit access to home or community-based long-term care, which the
vast majority of Americans prefer to nursing homes.4
Though an increasing number of Americans will need long-term care, few will have the capacity to finance that care, shifting the burden to taxpayer-funded programs. Less than 1/3 of Americans 50 and older have begun saving for long-term care. Without such savings and with a diminishing long-term care insurance market, most individuals will be forced to spend down their savings in
order to qualify for Medicaid-provided Long-Term Services and Supports (LTSS). The rise in demand
for LTSS will place a significant burden on Medicaid spending, which is expected to increase by 68
percent between 2015 and 2025, reaching to $576 billion dollars.5 If these present trends continue,
the federal government and the states may be forced to roll back support for other taxpayer priorities,
such as raising school performance, solving the housing crisis, and fixing our decaying transportation
infrastructure.6
Our approach to caring for the aging is fiscally unsustainable for taxpayers and consumers
alike. Absent changes to a fragmented system of care delivery which rewards high-cost rather than
high-quality care, the burden of healthcare spending for the aging population will soon become unsustainable for taxpayer-funded programs like Medicare and Medicaid, as well as individual consumers paying out-of-pocket. Between 2015 and 2025, annual Medicare spending is projected to double
to $1.2 trillion dollars. The median annual out-of-pocket costs for Americans age 65 will rise to $6,200,
nearly double what it was in 2010.7
The Patient Protection and Affordable Care Act (ACA) alone cannot address these
challenges. While the ACA represents the most significant advance in health reform in half a
century, its advances in addressing the challenges of an aging population have been
comparatively modest, limited to several, albeit promising, demonstration programs. As
Medicare and the Older Americans Act reach their fiftieth anniversaries continue to improve aging
America’s access to affordable, high-quality care, it will be necessary to identify, evaluate, and scaleup policy interventions that work.8
4
Institute of Medicine, Retooling for an Aging America: Building the Health Care Workforce, 2008 Report, available from: http://
www.iom.edu/Reports/2008/Retooling-for-an-aging-America-Building-the-Health-Care-Workforce.aspx
5
Updated Budget Projections: 2015 to 2025, Congressional Budget Office, March 2015, available from:
http://www.cbo.gov/sites/default/files/cbofiles/attachments/49973-UpdatedBudgetProjections.pdf
6
U.S. Senate, Commission on Long-Term Care, Report to Congress.
7
Centers for Medicare and Medicaid Services, National Health Expenditure Projections, 2013-2023, Forecast Summary, available
from: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/
Downloads/Proj2013.pdf
8
H. Goldbach, The Affordable Care Act and Older Americans, Stanford Aging Institute, December 8, 2013, available from: https://
aging.stanford.edu/2013/12/affordable-care-act-older-americans/
Addressing the Health Needs of an Aging America | 9
Identifying Opportunities for Evidence-Based Policy Solutions
Addressing the health needs of an aging America will require actionable insights based on the bestavailable research evidence about how to improve the affordability and quality of care for this rapidly
expanding demographic. Policy choices are often made without adequate insights from the full
range of available effectiveness research, and all too often, policy research treats health problems narrowly, ignoring evidence that reveals effective interventions.
With aging Americans and their loved ones at risk, policymakers have a responsibility to base their
decisions on rigorous, objective analysis about which policy proposals work and which do not. Evidence-based health policy should examine the widest array of available research and information to identify actionable recommendations that improve the cost and quality of care. It also
seeks to highlight policy proposals on which additional effectiveness research is necessary.9
To target opportunities for evidence-based policymaking, researchers at the Stern Center
undertook a systematic two-phase study to the map the full landscape of research evidence
and policy ideas. In the first phase, as Figure 2 shows, a multidisciplinary team conducted a Scoping Study, systematically sampling the entire domain of biomedical literature on the cost and quality
of care for the aging (over 24 million citations) to identify areas in which there exists a wide base of
up-to-date research literature. To ensure the search captured the broadest range of current literature, researchers identified systematic reviews, and rigorous, highly cited individual studies published
between 2010 and 2014 that were relevant to older adults and included data on either cost or clinical
outcomes. This resulted in an inventory of 1196 citations, which included 333 systematic reviews and
836 individual studies.
In the second phase, the team conducted a Policy Scan in order to map the universe of existing policy
recommendations related to aging and health in the United States. As Figure 3 shows, researchers
used major databases U.S. organizations to identify 493 health stakeholder groups whose central
purpose is to advocate, research, or lobby in the area of health care, health outcomes, or physical
wellness of older adults. They then targeted all groups producing actionable policy recommendations
and identified 98 health policy organizations from a database. From these organizations, researchers
extracted more than 600 policy proposals.
To identify areas where a significant level of evidence and policy demand existed, researchers categorized all policy recommendations and citations into 10 valid categories and 75 subtopic areas. They
then ranked topics based on the strength of the evidence base and policy demand from multiple,
cross-cutting stakeholder groups.
> See Appendix A for a full description of the methodology.
9
See, among others, Pew-MacArthur Results First Initiative, Evidence-Based Policymaking: A Guide for Effective Government,
November 2014, p. 2, available from:
http://www.pewtrusts.org/~/media/Assets/2014/11/EvidenceBasedPolicymakingAGuideforEffectiveGovernment.pdf
Addressing the Health Needs of an Aging America | 10
The results of this study provide an inventory of areas in which actionable, evidence-based
policy is possible. The study intends to provide a useful inventory of topics on which there exists
sufficient research evidence, along with policy recommendations put forth by multiple stakeholders,
thus improving prospects for meaningful evidence-based reform. Second, the study illustrates evidence-based interventions that deserve more serious attention from policymakers. Finally, the study
highlights areas where policy recommendations require a more substantial evidence base.
> See Appendix B for a full list of the results.
Figure 2. Scoping Study Diagram
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Figure 3. Policy Scan Diagram
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Where Evidence and Policy Meet
Numerous opportunities exist for evidence-based policymaking that will improve the quality and affordability of care for the older adult population in the United States. In particular, the
study found a sizable basis of both research evidence and policy demand on interventions related to
prevention and wellness, the healthcare and informal caregiver workforce, and care coordination (results are summarized in Figure 4). Within each of these major topics, the study also identified focus areas where policymakers and researchers should invest the greatest amount of time and
energy in developing actionable evidence-based policy proposals.
Figure 4. Results of Scoping Study and Policy Scan, by Major Topic
Addressing the Health Needs of an Aging America | 13
Realizing the Value of Prevention and Wellness Services
Prevention activities seek to avoid the onset of disease entirely, detect the onset of disease early
through screening, and stop disease from progressing or worsening. In addition to healthcare services such as cancer screening and vaccinations, patient education to promote nutrition and physical
activity can help prevent the onset or worsening of disease. Within prevention and wellness, the study
revealed three focus areas where there exists an especially strong evidence base and high policy demand: screening and early detection; nutrition and diet; as well as patient education, empowerment, and physical activity.
Focus Area: Screening and early detection
Screening and early detection refer to a broad range of instruments—including exams, tests, and
clinical guidelines—used to identify a disease in individuals who do not have symptoms. While not all
screenings have proven effective, employing evidence-based detection techniques has the potential
to improve health outcomes and lower the cost of treatment by detecting and mitigating the progression of numerous diseases associated with aging, including multiple forms of cancer, cardiovascular
disease, chronic kidney disease, diabetes, hepatitis, as well as Alzheimer’s, dementia, depression,
and alcohol abuse.
Examples of Policy Levers:
• Ensuring that national clinical guidelines adequately include evidence-based screening
procedures for age-related diseases
• Expanding public awareness campaigns to drive early detection
• Eliminating Medicare beneficiary copays for preventive screening procedures
• Expanding community health programs that provide access to screening in low-income
communities
Active Organizations:
American Association of Retired Persons (AARP), Colorectal Cancer Coalition; American Urological Association; Association of Asian Pacific Community Health Organizations; American Society of
Nephrologists; Association of Jewish Aging Services of North America; Alzheimer’s Foundation of
America
Addressing the Health Needs of an Aging America | 14
Focus Area: Nutrition and diet
Research on nutrition and diet has revealed a significant linkage between dietary components and
health risks associated with aging. Randomized controlled trials have shown, for instance, that reducing sodium intake by 3 grams per day is projected to reduce the annual number of new cases of
Coronary Heart Disease by 60,000 to 120,000, stroke by 32,000 to 66,000, and myocardial infarction by 54,000 to 99,000. Other studies illustrate dietary components, such as fiber and Vitamin D,
which reduce age-related health risks and the costs of healthcare. Interventions using oral nutritional
supplements (ONS) have also led to significant reductions in hospital admissions and readmissions,
particularly in older patient groups. Finally, nutritional education or advice about diet has been shown
to contribute to affect physical function and eating habits within the aging population.
Examples of Policy Levers:
• Updating FDA Nutrition Facts Panel to list essential vitamins and minerals of public health
significance, shift daily values (DVs) for sodium, and revise serving sizes
• Updating Dietary Guidelines Advisory Committee (DGAC) recommendations on consumption
of cholesterol, milk products, red and processed meats
• Providing practical advice to consumers on how to follow DGAC recommendations when
eating at restaurants
• Removing federal five-year bar for lawfully present immigrants from Medicaid, the
Supplemental Nutritional Assistance Program, Medicare, and Insurance Exchanges
• Directing additional resources to senior nutrition programs for congregate and
home-delivered meals
• Expanding Commodity Supplemental Food Program (CSFP) to reach seniors in all fifty states
• Supporting programs to encourage purchase of fruits and vegetables
• Incentivizing SNAP use at farmers’ markets
Active Organizations:
Trust for America’s Health, Partnership for Prevention, National Association of Nutrition and Aging
Services Programs, Generations United, Association of Asian Pacific Community Health Organizations
Addressing the Health Needs of an Aging America | 15
Focus Area: Patient Education, Empowerment and Physical Activity
Engaging older adults and their peers to monitor and improve their own health has been shown to
reduce adverse health events in a variety of settings. Randomized controlled trials of peer coaching
for low-income patients with diabetes show substantial improvement in glycemic control. Communitybased risk assessment and education sessions provide evidence of significant declines in hospital
admission for events such as acute myocardial infarction, stroke, and congestive heart failure, among
others. Self-monitoring interventions such as the Cardiovascular Health Awareness Program (CHAP)
has been shown to reduce cardiovascular morbidity at the population level.
Examples of Policy Levers:
• Providing Medicare coverage for patient and caregiver education
• Expanding support for evidence-based intervention campaigns
Active Organizations:
American Society of Clinical Oncology, Association of Jewish Aging Services of North America, American Public Health Association
Adapting the Caregiver Workforce for an Aging Population
Labor accounts for approximately 60 percent of healthcare costs in the United States, making an efficient and effective workforce a critical policy priority, particularly for complex geriatric patients. Policy
interventions that could affect the use of new models of care include: expanding the role of family
caregivers; leveraging the unique skills of the nursing profession; training the workforce in
geriatric competencies; coordinating interprofessional teams to manage care; and identifying
opportunities for engaging community health workers.
Focus Area: Family Caregivers
A significant body of research indicates that informal caregivers – people who spend a great deal of
unpaid time assisting a parent, spouse, or child with personal care and other routine needs – can
play an important role in improving the quality of their loved one’s healthcare and minimizing the need
for costly institutional care. Yet studies have shown that caregiver effectiveness can be measurably
improved with structured training programs, palliative care interventions, and support groups. Educational and behavioral interventions can also help to address knowledge gaps and can also mitigate
caregiver-specific health risks, including higher levels of stress, chronic physical health disease,
depression, and anxiety, which increase the risk of hospitalization, emergency department use, and
other unplanned care that contributes to unnecessary healthcare costs.
Addressing the Health Needs of an Aging America | 16
Examples of Policy Levers:
• Providing Medicare reimbursement to cover survivorship services
• Expanding eligibility for programs such as family and medical leave, which enable
intergenerational caregiving
• Expanding implementation of programs like the Resources for Enhancing Alzheimer’s
Caregiver Health (REACH)
• Developing publicly funded programs that allow participants to hire family members as
caregivers
• Establishing a program to train and compensate family caregivers
Active Organizations:
AARP, Generations United, American Society of Clinical Oncology, national Assocation of Nutrition
and Aging Services Programs, Alzheimer’s Foundation of America, Eldercare Workforce Alliance,
Paraprofessional Healthcare Institute, American Academy of Physician Assistants
Focus Area: Nursing
Nurses bring a unique set of skills to bear in caring for the aged. There exist an array of interventions
that leverage and support nursing practice to improve the affordability and quality of healthcare. Clinical effectiveness research has shown that home-based, nurse-led health promotion can significantly
reduce the cost of care as well as the risk of adverse health events. Nurse-delivered collaborative
care provides effective treatment across a range of long term behavioral and physical health conditions. Nurses with specialized skills, training, and scope of practice can help to reduce hospital visits
and improve outcomes related to chronic conditions like diabetes and coronary artery disease. Finally,
appropriate staffing levels and work environment have been shown to reduce rates of heart failure.
Examples of Policy Levers:
• Permitting non-physician practitioners (NPPs) to practice to the full extent of their training
• Amending the Nurse Reinvestment Act to include educational and financial assistance,
establish a national nursing database, and enhance number of nurse educators
• Expand the public Health Service Act’s Title VIII Geriatrics Nursing Workforce Development
Programs
Addressing the Health Needs of an Aging America | 17
Active Organizations:
American Association of Nurse Life Care Planners, American Holistic Nurses Association, American
Healthcare Association, American Hospital Association, Eldercare Workforce Alliance, Center for Bioethics
Focus Area: Geriatric Competency
The increasing demand for geriatric competencies is well established. Barriers to geriatric training
within the medical field place the supply of trained specialists well behind the demand. Nevertheless,
models of effective geriatric training exist. For instance, since their inception in 1975, the Department of Veterans Affairs (VA)’s Geriatric Research, Education, and Clinical Centers have advanced
geriatric training and clinical care. Elsewhere, programs such as Dementia for Medical Students offer
an inexpensive and ready-to-implement training that has been shown to improve performance on AD
patient-case simulations.
Examples of Policy Levers:
• Congressional and state legislative investigations into the adequacy and appropriateness of
geriatric workforce training and education on content and modalities of delivery
• Modifying standards of state licensing boards to require professional competence or training
in caring for older adults
• Supporting and expanding education and training programs at federal and state level to
develop gerontological workforce, including Titles VII and VIII of the Health Resources and
Services Act.
• Developing CMS requirements for geriatric competencies and dementia training for primary
care clinicians and staff to improve detection, treatment, and care for individuals with
Alzheimer’s disease
• Funding geriatric training programs for physicians, dentists, and behavioral and mental health
professions
Active Organizations:
American Association for Geriatric Psychiatry, Alzheimer’s Foundation of America, American Public
Health Association, Eldercare Workforce Alliance
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Focus Area: Interprofessional Teams
A diverse range of interprofessional care models bring multiple specialists together to provide services, manage patient health, and share accountability for patient outcomes. Systematic reviews of
the interdisciplinary Acute Care for Elders (ACE) model have shown significant reduction in functional
decline, hospital stay, nursing-home discharges, and costs. Outside unit-based interventions, models in which guided-care nurses work in partnership with patients’ primary care physicians have also
been effective at reducing episodes of home healthcare. Remote physician-pharmacist team-based
care has also proven effective at improving cholesterol levels in diabetes patients. Workforce reforms
that support such interdisciplinary approaches to care show are especially promising for improving
specific health outcomes in patients with multimorbidity.
Examples of Policy Levers:
• Requiring the Secretary of Health and Human Services to make grants to the states to
support the establishment and maintenance of interdisciplinary geriatric mental health outreach
teams in community settings where older adults reside or receive social services.
• Requiring training programs certified by state licensure boards to place a greater emphasis
on communication and interpersonal problem-solving skills in order to strengthen caregiving
relationships
• Incentivizing workforce training focused on unique social, physical, and mental healthcare
needs of older adults.
Active Organizations:
American Holistic Nurses’ Association, Society for Post-Acute and Long-Term Care Medicine, Eldercare Workforce Alliance, Paraprofessional Healthcare Institute
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Focus Area: Community Health Workers
In a fragmented health system, older adults—especially those with multiple, complex conditions—
could benefit substantially from the support of community health workers who serve as “system navigators.” Navigator roles for aging and chronically ill patients have developed relatively recently, yet
they show promise in helping to patients to manage their health, from serving as peer health coaches
and assisting with transitions across care settings. Randomized controlled trials have also shown
significant reductions in glycemic control for low-income patients with diabetes.
Examples of Policy Levers:
• Ensure seniors have adequate access to community-based supports and services that keep
enable aging-in-place
• Using authority of public health agencies to make evidence-based musculoskeletal programs
and resources available to public health and healthcare workers
Active Organizations:
American Association of Service Coordinators, American Public Health Association
Coordinating Care to Improve Age-Related Health Outcomes
Fragmentation in the healthcare system between settings and even between professional groups has
been proven as an indicator for poor quality, higher costs, and lower health outcomes. Lack of coordination can result in the failure to deliver necessary services and overtreatment that exposes patients
to unnecessary risks and costly hospital readmissions. Care coordination, in its most basic form,
involves deliberately integrating the activities of two or more participants involved in a patient’s care to
provide appropriate and timely care. Typically, care coordination activities fall within the clinical domain, but there are many policy levers that can influence how clinicians provide services to improve
the patients’ value of care.
The study revealed several strong opportunities for evidence-based policy related to care
pathways and bundles, disease management programs, specialized units, discharge coordination and patient navigation, and coordinated delivery of primary care. Learning from the evidence base what interventions improve care coordination, including the results of ongoing demonstration programs, will inform which policy levers could be most effective.
Addressing the Health Needs of an Aging America | 20
Focus Area: Care Pathways and Bundles
Care pathways are detailed, evidence-based, multidisciplinary plans for the treatment of a particular patient over time and in multiple settings towards an anticipated outcome. For geriatric patients,
these pathways often emerge from the results of a comprehensive geriatric assessment and can treat
a variety of conditions, such as stroke, colorectal surgeries, hip fractures, and ventilator associated
pneumonia. One example is the enhanced recovery after surgery (ERAS) pathway, which has been
proven a cost effective strategy for treating patients with major colorectal surgeries. Related to care
pathways are bundled payments, which define an “episode of care” and provide a global payment to
cover the costs for the episode. This transfers the risk of care from the payer to the healthcare provider to provide the highest quality care at the lowest cost. The payments can include one setting or
span across multiple healthcare settings, which are jointly at risk for the care. These bundles have
often been developed around identifiable episodes, such as congestive heart failure or knee replacements.
Examples of Policy Levers:
• Expanding effective demonstration programs nationally that employ bundled payments, such
as the Acute Care Episode (ACE) bundled payment demonstration.
• Phasing in alternatives to fee for service payment, such as bundled payments, within
Medicare and Medicaid.
• Exploring new opportunities for demonstration programs to incentivize adoption of
evidence-based care pathways.
Active Organizations:
American Association of Kidney Patients, National Academy of Social Insurance, America’s
Health Insurance Plans
Focus Area: Disease Management Programs
Disease management programs focus on coordinating treatments for one or multiple chronic conditions, such as cancer, COPD, and heart failure in which patient self-care is central for success.
Models such as integrated disease management (IDM) establish an integrated care program of selfmanagement, exercise, and nutrition in which multiple healthcare providers collaborate to provide
care. These programs require both interventions with patients as well as organizational changes to
be effective. When applied to COPD, IDM interventions were proven to significantly improve quality of
life and reduce respiratory-related hospital admission and stay. Disease management programs are
typically implemented through managed health plans or government payers. Policy levers to create
or incentivize effective disease management programs have the potential to improve patient health
outcomes and decrease healthcare spending.
Addressing the Health Needs of an Aging America | 21
Examples of Policy Levers:
• Providing coverage for cancer care planning and coordination under Medicare.
• Development and implementation of national standards for treatment summary and care plan
templates.
• Coordinating and integrating health and long-term services and supports for individuals living
with Alzheimer’s Disease.
• Incentivizing the development of chronic-care system interventions such as Money Follows
the Person that promote patient-centered care.
Active Organizations:
American Society of Clinical Oncology, Alzheimer’s Foundation of America, American Association for
Geriatric Psychiatry
Focus Area: Primary Care Coordination
Improving access to comprehensive primary care has been identified as a model for improving quality
and safety outcomes in the aging population. The research literature suggests that the targeted use
of medical homes for several chronic conditions, including congestive heart failure, major depression,
and diabetes mellitus can be effective for improving health outcomes for the elderly. Collaborative
care management, which is a nurse-delivered model that coordinates physical and mental healthcare
for depression and other multi-morbid conditions, has been proven as another cost-effective approach
to coordinate care.
Examples of Policy Levers:
• Expanding access to patient-centered medical homes in public and private health coverage.
• Aligning requirements for Medicare Shared Savings Program ACOs with current requirements
for medical homes or collaborative care models.
Active Organizations:
America’s Health Insurance Plans, Association of Asian Pacific Community Health Organizations
Addressing the Health Needs of an Aging America | 22
Focus Area: Care Transitions and Patient Navigation
Moving patients from one healthcare setting to another or back into the community is a high risk
situation with great potential for poor quality and outcomes. Care transition programs, including discharge planning, as well as patient navigation programs are designed to help at-risk patients transfer
between levels and settings of care and navigate the complex healthcare system. Randomized controlled trials of transition-oriented interventions have been shown to reduce readmissions for complex
chronic conditions. Particularly successful interventions involve assigning nurses as clinical managers
and providing in-person home visits to discharged patients. Among others, transitional care programs
designed for individuals with heart failure improve quality of life and decrease the number of readmissions and the overall cost of care.
Examples of Policy Levers:
• Expand or fund the use of evidence-based care-transition models through demonstration
programs.
• Setting targeted readmission reduction goal for skilled nursing facilities.
• Eliminating Medicare’s three-day prior hospitalization requirement for coverage of post-acute
skilled nursing facility care.
• Counting all days in the hospital including those spent in observation status towards the
Medicare three-day requirement.
Active Organizations:
American Healthcare Association, Center for Medicare Advocacy, American Medical Association
Addressing the Health Needs of an Aging America | 23
Evidence Searching for Policy Levers
Since 2010, biomedical and health services research has produced a wealth of potentially
effective policy interventions that have received less attention from stakeholders and policymakers. In many cases, the staggering number of research studies, researchers’ ineffective dissemination of findings to policymakers, and policymakers’ limited capacity to routinely scan the evidence
base, have combined to make it difficult to scale these interventions into actionable policy recommendations. The Stern Center research team found this pattern to be particularly evident in the fields of
patient self-care, as well as palliative and end-of-life care. In these areas especially, researchers,
stakeholders, and policymakers should collaborate to identify ways that public policy can better
apply the insights of effective interventions.
Supporting Palliative and End-of-Life Care
Palliative care is a holistic approach to care that focuses on relieving symptoms and easing stress for
patients with serious illness. Hospice care is similar to palliative medicine, in that it focuses on managing the symptoms and reducing the suffering of a patient at the end-of-life. Hospice care can take
place either in an individual’s home or in an institutional setting. About 70 percent of Americans would
prefer to die at home,10 but only about 25 percent actually die at home.11 Approximately one-third of
Medicare spending is on patients in their last two years of life. Conversations about preferences for
end-of-life care are difficult and many Americans do not have an advanced directive expressing their
preferences for care at the end-of-life. As a result, many patients at the end-of-life receive costly and
painful healthcare interventions that do not truly respond to individual needs or wishes.
Focus Area: Palliative Care
A few studies have revealed that integrating palliative care into usual care settings can
result in improved health outcomes, patient satisfaction, and cost. One pilot study of
integrating on-site palliative care advanced practice nurses in the community oncology
setting found significant decreases in hospitalization and mortality. A nationwide study
also revealedthat hospice-provided palliative care results in lower costs for terminal
geriatric hepatocellular carcinoma patients. There is a small but emerging evidence-base
for the effective deployment of palliative care programs in nursing home and community
settings.
Remaining policy challenges include misaligned payment incentives and a lack of insurer
coverage and reimbursement for palliative care, the failure of major quality metrics to
include palliative care, financial barriers to third party payments for such care, and statelevel policies that create barriers to essential pain medications in end-of-life settings.
9
J. Cloud, A Kinder, Gentler Death, Time, September 18, 2000, available from:
http://content.time.com/time/magazine/article/0,9171,997968,00.html
10
National Center for Health Statistics, Health, United States, 2010, With Special Feature on Death and Dying, available from:
http://www.cdc.gov/nchs/data/hus/hus10.pdf
Addressing the Health Needs of an Aging America | 24
Focus Area: Advance Care Planning
Patients often lose their capacity or ability to communicate their preferences on end-oflife care goals. Systematic reviews have suggested that written directives or nonresuscitate orders hold promise for addressing this problem and improving the quality of
end-of-life care. Policies that support patients’ preferences, however, will likely encompass
more than written directives alone, however, and further research is required to evaluate
the effectiveness of interventions that promote shared decision-making.
To date, the Physicians’ Orders for Life Sustaining Treatment (POLST) paradigm has
attempted to address these concerns, yet faces legal and political barriers to
implementation in many states.12
Incentivizing Patient Self-Care and Self-Management
Patients with chronic disease account for a huge portion of healthcare spending in the US. Among
older adults, 80 percent have at least one chronic condition.13 99 perecnt of Medicare spending is
attributable to individuals with at least one chronic condition, and 79 percent is attributable to individuals with 5 or more chronic conditions.14 Better management of chronic disease could help patients
with complex, co-morbid conditions avoid unnecessary interactions with the healthcare system, such
as costly trips to the emergency room. Patient self-care and self-management initiatives encourage
patients to work with their providers to maintain their health status and minimize avoidable complications. These initiatives utilize strategies, such as patient education, to encourage healthy decisions
and behaviors.
Patient Self-Care and Self-Management Interventions
Behavioral Adherence Contracts:
Behavioral contracts are often used to achieve patient adherence to medications or
treatment plans by identifying motivations or positive reinforcements, problems and
barriers that interfere with adherence, social supports to assist in adherence, reminder
strategies, and identification of the consequences for non-adherence. These contracts have
been effective in improving adherence among renal transplant recipients undergoing
immunosuppressant therapy.
12
National POLST Paradigm Task Force, POLST Legislative Guide, Approved February 28, 2014, available from:
http://www.polst.org/wp-content/uploads/2014/02/2014-02-20-POLST-Legislative-Guide-FINAL.pdf
13
Centers for Disease Control, Chronic Disease Overview, available from: http://www.cdc.gov/chronicdisease/overview/
G. Anderson, Chronic Care: Making the Case for Ongoing Care, Robert Wood Johnson Foundation and Johns Hopkins
University Bloomberg School of Public Health Report, 2010, available from:
http://www.rwjf.org/content/dam/farm/reports/reports/2010/rwjf54583
14
Addressing the Health Needs of an Aging America | 25
Supported Self-Management:
Whereas traditional self-management is not typically effective for severe chronic
conditions, such as COPD, supported self-management interventions combine traditional
self-management activities with training, led by a nurse or a facilitator. These techniques
have been shown to improve quality of life in patients managing multimorbidity.
E-Patient Communication Tools:
Participatory interventions using Web 2.0 applications can enable older adults to share
disease management information and receive interactive health advice. While additional
randomized controlled trials are necessary, recent studies have suggested that such
communication tools hold promise for managing some chronic diseases.
Policy Recommendations Searching for an Evidence Base
Numerous policy proposals related to the health of the aging lack a foundation in rigorous evidence. For a variety of reasons, including the difficulty of systematically evaluating or modeling agerelated health policies, policymakers will continue to face obstacles to evidence-based decision-making. Researchers of this study found this to be particularly true for proposals related to malpractice
and the financing of long-term care. In these areas, researchers and policymakers alike should
support efforts to conduct systematic research and rigorous evaluation of pilot interventions
at the local, state, and federal levels.
Malpractice Reform: Can It Safely Eliminate the Costs of Defensive Medicine?
Defensive medicine – a practice in which physicians order excessive or unnecessary tests and treatments out of fear of a potential lawsuit – leads to somewhere between $45.6 to $650 billion per year
in healthcare system spending. Proposals to reform malpractice often focus on creating evidencebased standards of care that would limit the liability of doctors who adhere to these standards.15
A cost effective, high-value healthcare system would ideally eliminate wasteful and unnecessary care
associated with the practice of defensive medicine. However, there are considerable gaps in the
evidence base on the potential consequences of malpractice reform on the costs and quality
of care. To address this problem, some organizations have suggested expanding demonstration and
incentive programs to test alternative medical liability systems following the Patient Protection and Affordable Care Act authorization of $50 million for this purpose. However, the $50 million has yet to be
appropriated. As part of the funding for demonstration projects, the Agency for Healthcare Research
and Quality (AHRQ) has awarded $25 million for pilot programs to improve patient safety and reduce
the number of medical liability lawsuits filed. The results of at least four of these programs are showing initial potential, but comprehensive analysis has yet to be conducted.16
15
Bipartisan Policy Center, What is Driving U.S. Health Care Spending? America’s Unsustainable Health Care Cost Growth, 2012
Report, available from: http://bipartisanpolicy.org/library/what-driving-us-health-care-spending-americas-unsustainable-healthcare-cost-growth/
16
Agency for Healthcare Research and Quality, Patient Safety and Medical Liability Initiative, Summary of Findings, June 2014,
available from:
http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/liability/liability_initiative.html
Addressing the Health Needs of an Aging America | 26
Malpractice Reform Proposals In Need of Rigorous Evaluation
Pre-Dispute Arbitration Agreements: Anecdotal evidence indicates that group-practice
physicians have responded to rising malpractice premiums by increasing the volume and
unit-price of services they perform.17 To address these concerns, several policy
recommendations support the use of written contracts in which healthcare providers and
patients agree to use less-costly arbitration procedures rather than litigation to settle
claims. Yet it remains difficult to identify studies that illustrate a clear relationship between
the usage of arbitration and costs or health outcomes.
Evidence-Based Standards and Liability Exemptions: Another policy option the study
identified was to grant physicians a legal presumption that they have acted appropriately if
their actions adhere to evidence-based clinical standards. Maine’s Medical Liability
Demonstration Project, for instance, adopted 20 practice guidelines in four specialties and
provided physicians adhering to these guidelines an affirmative defense against
malpractice claims. Studies of the project, however, did not show significant reductions in
defensive medicine practice or malpractice claims.18
Health Courts and Neutral Medical Experts: Initially introduced in the 1970s, no-fault
health courts are already in place in Sweden, Denmark, and New Zealand. These courts
employ neutral experts in medicine and epidemiology to review claims before an
administrative law judge. Some models for health courts include a centralized database of
past decisions to improve efficiency. More incremental reform proposals would incentivize
courts to retain their own neutral medical experts at trial. Evidence on the effectiveness of
alternatives to the adversarial system of adjudicating malpractice claims exist in states like
Virginia and Florida, but evidence on the effectiveness of these systems is limited.19
17
M. Mello, A. Chandra, A. Gawande et al., National Costs of the Medical Liability System, Health Affairs 2010; 29(9):1569-1577
T. Mackey and B. Liang, The Role of Practice Guidelines in Medical Malpractice Litigation, AMA Journal of Ethics 2011; 13(1):36-41.
19
L.A. Miller, Health Courts: an Alternative to Traditional Tort Law, Journal of Perinatal and Neonatal Nursing 2011; 25(2):99-102.
18
Addressing the Health Needs of an Aging America | 27
Financing Long-Term Care: Is There an Evidence-Based Paradigm for Reform?
Long-term services and supports (LTSS) encompass a range of services needed by individuals with
cognitive and functional limitations. As the population ages, the number of Americans who need
LTSS will more than double in the coming decades, rising from 12 to 27 million by 2050.20 The impact of this increase for aging individuals and their loved ones will be profound. LTSS care is
often delivered in an institutional setting, which is very costly for patients and families – nursing home
care costs approximately $90,000 annually, and home health aide services cost $21,000 annually.21
Though many individuals in need of LTSS receive care at home from family caregivers, these individuals are often unpaid and untrained.
Taxpayer-funded programs that support LTSS will also experience strain. Currently, Medicaid is
the largest payer for LTSS in the United States. In 2012, the US spent $220 billion on LTSS, approximately 61 percent of which was paid by the Medicaid program.22 Yet whereas Medicaid spending
on LTSS grew by 1 percent per year between 2002 and 2012, the Congressional Budget Office estimates a growth rate of 5.5 percent per year between 2013 and 2023.23
Access to long-term care insurance remains limited. Few individuals have access to the kind of
insurance products that would allow them to pay for the kind of LTSS they are likely to need. Currently, Medicare covers only short-term skilled nursing for 100 days and home healthcare needs after
an acute care episode. Medicaid pays for a majority of long term care in the US and provides a safety
net for those who are impoverished by the cost of long term care. Because of this financing structure,
a great deal of policy activity in long term care is happening at the state level, as state leaders use
policy levers such as Medicaid waivers to deliver LTSS in innovative ways. However, many significant
gaps remain. Few resources are directed toward supports for family caregivers. In the private marketplace, the combination of financial risks and adverse-selection problems has made premiums for
long-term care insurance prohibitively high. Moreover, the poor performance of the short-lived Community Living Assistance Services and Supports (CLASS) program suggests major challenges for
achieving comprehensive long-term care reform at the federal level. Finally, the existence of Medicaid
as a “second payer” for long-term care services has contributed to the crowding out of demand for
long-term care insurance.24
While meaningful LTSS reform is a major policy priority for many organizations in the study,
the evidence base on the effects of proposals to reform the system for insuring long-term care
is limited particularly at the federal level. All states are engaged in some effort to rebalance their
long term care systems to care for beneficiaries at home rather than in an institutional setting.
20
U.S. Senate, Commission on Long-Term Care, Report to Congress.
E. Reaves and M. Musumeci, Medicaid and Long-Term Services and Supports: A Primer, Kaiser Family Foundation, May 2015 Report, available from: http://files.kff.org/attachment/report-medicaid-and-long-term-services-and-supports-a-primer
22
Id.
23
Congressional Budget Office, Rising Demand for Long-Term Services and Supports for Elderly People, June 2013 Report, p. 25,
available from: http://www.cbo.gov/publication/44363
24
W. Yin, Strengthening Risk Protection Through Private Long-Term Care Insurance, Hamilton Project Discussion Paper, June 2015,
available from:
http://www.brookings.edu/~/media/research/files/papers/2015/06/thp-retirement-series/yin_private_long_term_care_insurance.pdf
21
Addressing the Health Needs of an Aging America | 28
In 2012, close to half of all Medicaid LTSS spending was for home and community based services
(HCBS).25 A number of states are using managed care as a strategy to promote greater integration
and efficiency in Medicaid LTSS delivery systems, but evidence on the effectiveness of these programs is limited. Fewer than 10 states have had a managed Medicaid LTSS program in place for over
a decade. Studies of long running, well-established MLTSS program have shown mixed results on
indicators such as cost savings, utilization and quality, though some programs have demonstrated
modest improvements in preventable hospitalizations and emergency room visits.26 To date, over 20
states have implemented or are considering implementation of a Medicaid MLTSS program. Some
evidence indicates that states with a long-running, extensive HCBS programs are able to slow Medicaid long term care spending growth more effectively than states which rely predominantly on institutional services.27
Numerous proposals exist for expanding the availability of long-term care insurance. Yet
further research is needed to determine the costs and benefits of each. In particular, studies
should evaluate the following aspects of each proposal:
• Affordability for Consumers and Taxpayers: How likely is each proposal to generate
affordable coverage for those who require long-term care while reducing the expanding burden
of public spending on long-term care?
• Eligibility: How will each proposal ensure that those who need long-term care can access it?
How many activities of daily living (ADL) should trigger eligibility for tax credits or social
insurance? How long must an individual require assistance prior to eligibility? What should the
standards be for determining individuals’ likely needs for future assistance? How should mental
health status inform eligibility decisions?
• Coverage: How likely is each proposal to ensure that insurance covers an adequate mix of
LTSS? LTSS could include skilled nursing facility care; home health care; personal care
attendants; care management and coordination; adult day centers; and respite options for
family and volunteer caregivers.
• Quality: How will the proposal affect the quality of LTSS delivery? How likely is each
proposal to incentivize coordinated, patient-centered care?
25 S. Eiken et al., Medicaid Expenditures for Long-Term Services and Supports in FFY 2012, CMS and Truven Analytics, April 2014,
available from:
http://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/downloads/ltssexpenditures-2012.pdf
26 R.L. Kane et al. Patterns of utilization for the Minnesota senior health options program. J Am. Geriatr. Soc. 2004; 52(12):2039–
2044; R.L. Kane et al. The quality of care under a managed-care program for dual eligibles. Gerontologist 2005; 45(4):496–504;
R.L. Kane, Outcomes of managed care of dually eligible older persons. Gerontologist 2003; 43(2): 165–174; W.G. Weissert et al.
Cost sav-ings from home and community based services: Arizona’s capitated Medicaid long-term care program. J. Health Polit.
Policy Law 1997; 22(6):1329–1357.
27
H.S. Kaye et al. Do noninstitutional long-term care services reduce Medicaid Spending?, Health Affairs 2009; 28(1):262–272.
Addressing the Health Needs of an Aging America | 29
Long-Term Care Insurance Proposals
Federal Policy Levers
Medicare Part A Expansion: This option, financed through the Medicare payroll tax and
new premiums, would create a comprehensive LTSS benefit that would be triggered when
physicians certify that individuals meet eligibility criteria. One proposal advanced by the
Senate Commission on Long-Term Care would provide benefits to individuals who require
assistance with at least two activities of daily living, have needed assistance for 90 days,
and are likely to continue to need services. These benefits would be financed through the
Medicare payroll tax and new premiums and would include “skilled nursing facility care or
daily skilled care; home healthcare without the need for a skilled service; personal care
attendant services; care management and coordination; adult day center services, respite
care options to support family or other volunteer caregiver; outpatient therapies; and other
reasonable and necessary services.”28
Catastrophic Coverage: This option would create a Medicare Part A benefit that covers
out-of-pocket expenses after a lengthy waiting period defined either in time (beneficiary
has paid for three years of home care services) or expenditures (beneficiary has paid for
$50,000 in home care services). One study found that it took 6.8 years, on average, for
LTSS users to spend down their assets and become Medicaid eligible.29
Medicare Advantage Coverage: Incorporating LTSS coverage as a supplemental benefit
in Medicare Advantage (MA) plans would highlight new methods of organizing care and
emphasize the potential benefits of care integration. An example of an integrated program
is the Program of All-Inclusive Care for the Elderly (PACE), which integrates acute and long
term care for enrollees and is financed through capitated payments from Medicare and
Medicaid. PACE initially demonstrated positive results30 but was slow to expand and remains
small, due to factors such as low awareness about the program and its services, a lack of financing
alternatives to Medicaid, and competition from other service providers.31
Market Reforms: Complementary proposals for reforms aim to empower consumers of
long-term care insurance marketplace by standardizing policies, creating electronic
marketplaces, and developing consumer protections and appeals processes. The Health
Insurance Portability and Accountability Act of 1996 (HIPAA) required some
standardization of LTC insurance plan eligibility triggers as a condition of preferred tax
treatment.32
28
U.S. Senate, Commission on Long-Term Care, Report to Congress, September 2013, pp. 66-67.
J. Wiener et al.,Medicaid Spend Down: New Estimates and Implications for Long-Term Services and Supports Financing Reform,
Prepared for the SCAN Foundation by RTI International, March 2013, available from: http://www.thescanfoundation.org/rti-
29
international-medicaid-spend-down-new-estimates-and-implications-long-term-services-and-supports
30 C. Eng et al., Program of All-inclusive Care for the Elderly (PACE): an innovative model of integrated geriatric care and financing,
Journal of the American Geriatric Society 1997 Feb;45(2):223-32.
G.L. Gross et al., The Growing Pains of Integrated Health Care for the Elderly: Lessons from the Expansion of PACE, Milbank Quarterly 2004 Jun; 82(2): 257–282.
32 M. Cohen et al., The Historical Development of Benefit Eligibility Triggers Underlying the CLASS Plan. The SCAN Foundation,
Spring 2011, available from:
http://www.thescanfoundation.org/sites/default/files/TSF_CLASS_TA_No2_History_Benefit_Eligibility_FINAL.pdf
31
Addressing the Health Needs of an Aging America | 30
State Policy Levers
Tax Credits for Long-Term Care Policies: Organizations like America’s Health Insurance
Plans (AHIP) recommend subsidizing the purchase of long-term care through refundable
tax credits in order to enhance access to private long-term insurance. These credits could
guarantee that assistance is available to individuals, regardless of whether or not they owe
federal taxes. Savings in Medicaid costs could also be used to finance the tax credits.
According to one AHIP study, 75 percent of Americans do not believe that it is “the
government’s responsibility to pay for the long-term care needs of everyone,” and about
half of respondents over 50 supported tax incentives to purchase LTC insurance.33 Nearly
half of states offer some form of tax deduction or credit to purchase LTC insurance, which
results in an average reduction in cost of 5 percent and an estimated increase of 2.7 percent
in the purchase of private LTC plans. However, most of this increase is attributed to
individuals at the upper end of the income distribution who have a minimal risk of spending
down into Medicaid.”35
Long-Term Care Partnership Programs: These programs allow individuals to purchase
long-term care insurance and protect some of their assets if they exhaust their
insurance coverage and spend down into Medicaid eligibility. Over 40 states currently
participate in the Partnership Program, but less than 10 percent of active LTC insurance
policies are partnership plans.36 It is unknown whether the Partnership Program has
increased the purchase of private LTC.37 Connecticut was one of the first four states to
implement that partnership program in the 1990s. Over the first nearly 20 years of the
program in Connecticut, out of 53,064 purchased policies, only 95 claimants used up their
private benefits and spent down into Medicaid.38
Medicaid Carve Out: This approach would give individuals the opportunity to use their
expected Medicaid benefits as a subsidy to purchase permanent long-term care insurance
in exchange for the right to future Medicaid LTSS.
33
America’s Health Insurance Plans, Who Buys Long-Term Care Insurance in 2010–2011? A Twenty Year Study of Buyers and NonBuyers (In the Individual Market), March 2012, available from: https://www.ahip.org/WhoBuysLTCInsurance2010-2011/
35
Id.
36
Department of Health and Human Services, Assistant Secretary for Planning and Evaluation, Long-Term Care Insurance, ASPE
Research Brief, June 2012, available from: http://aspe.hhs.gov/daltcp/reports/2012/ltcinsRB.pdf
37
Id.
38
Id.
Addressing the Health Needs of an Aging America | 31
Conclusion
Unless policymakers take action soon, changes in the care needs of the aging population will likely push our current healthcare system to its breaking point—with significant and negative consequences for older adults and their families.
This study identifies immediate and medium-term opportunities to adapt to this generational
and demographic shift with actionable, evidence-based reforms to:
• Expand prevention and wellness efforts;
• Address gaps in the caregiver workforce; and
• Improve care coordination.
Further collaboration between policymakers and researchers in these focus areas is likely to
yield success in improving the health of our aging population.
There are also opportunities for more long-term investment in policy development and
analysis. In focus areas such as patient self-management and palliative care, policymakers
and researchers alike can work together to generate policy solutions by using and expanding the existing evidence base. Finally, policy recommendations on subjects like malpractice
reform and long-term care reform may require more rigorous analysis prior to implementation.
Building on the results of this study, future research at the Stern Center of Evidence-Based
Policy will focus on:
• Policy-focused systematic reviews to identify timely interventions that effectively
improve the cost and quality of healthcare.
• Pilot Studies of cutting-edge interventions that are likely to reduce healthcare
utilization costs and improve health outcomes;
• Modeling of policy options to demonstrate the effects of evidence-based policy
choices on long-term socioeconomic trends affecting providers and patients; and
• Dissemination of policy recommendations based on rigorous evidence to a broad
range of policy stakeholders at multiple levels of government.
Addressing the Health Needs of an Aging America | 32
Appendix A: Research Methodology
This study resulted from a two-year combined effort of a multidisciplinary research team to identify,
without bias, the universe of scientific evidence and policy recommendations that may reduce healthcare costs and maintain or improve health outcomes in the target older adult population.
Scoping Study
The objective of the scoping study was to use existing systematic review techniques to scan research
articles from across the entire domain of published biomedical and health services literature in order
to capture all possible healthcare interventions that are relevant to older adults and aim to reduce
costs while maintaining or improving quality of care. Our study was comprised of three phases.
1. Researchers used PubMed to identify systematic reviews and individual studies that were
published following passage of the Affordable Care Act (2010-2014). From an initial database
of studies that met age and economic criteria (n=404,472), researchers identified all systematic
reviews (n=3,109) and individual studies (n=60,082). All individual studies in the top 5% of
highly cited articles as well as a random sample of 5% of articles added to PubMed in their
publication year were then identified (n=1,876).
2. All studies that were relevant to older adults, included cost and clinical outcomes, and
contained interventions were included for review (n=1169).
Policy Scan
Building on major studies by the Patient-Centered Outcomes Research Institute (PCORI) and the
Institute of Medicine (IOM) and parallel work by McCabe et al. (2007), the Policy Scan identified actionable policy recommendations relevant to the healthcare of older adults in the United States from a
diverse set of relevant organizations.39 We defined relevant organizations as those whose central purpose is to advocate and/or conduct research, or lobby commercially, in the area of healthcare, health
outcomes, or physical wellness of older adults. This included advocacy organizations (e.g. American
Association of Retired Persons), industry groups (e.g. America’s Health Insurance Plans), professional associations (e.g. American Medical Association) and think tanks or non-government policy
organizations (e.g. Bipartisan Policy Center). Actionable recommendations were those in which organizations explicitly called for government action to achieve goals of efficiency, effectiveness, equity,
and responsiveness. Our study was comprised of four phases.
1. Researchers queried organizations indexed by the Encyclopedia of Associations, DIRLINE,
and OpenSecrets.Org, as well as organizations identified by internal experts, to identify a
unique set of relevant organizations making actionable policy recommendations. An initial
analysis of 493 organizations identified by searching databases of the Encyclopedia of
39
O.L. McCabe, A.K. Page, A.S. Daniels, Improving health care for mental and substance use conditions: A framework for bridging
the quality chasm, International Journal of Mental Health 2007; 36(2): 65-79.
Addressing the Health Needs of an Aging America | 33
Associations, Opensecrets.org, and DIRLINE was supplemented by data provided by internal
experts. After applying inclusion and exclusion criteria, the research team arrived at a final list
of 98 organizations with documented policy recommendations.
2. The sources of documented policy recommendations included publicly available documents
included in downloadable files, webpages, and other written statements made by the
organizations. Saved files were classified by organization and received a document number.
A total of more than 400 documents were placed in a data repository and profiled with basic
descriptive statistics.
3. Policy recommendations were extracted from documents by coders and entered
individually into Excel spreadsheets, which were later exported into IBM SPSS 21 for
statistical analysis. To be included, policy recommendations had to be actionable, relevant to
an older adult population, and health-related. This yielded more than 600 recommendations
that were sorted into different policy categories and subcategories by three independent
coders. Recommendations were then matched with studies identified in the scoping study.
Developing Policy Categories
Because most biomedical and health services studies are not typically conducted with the policy
process in mind, it was necessary to develop broad policy categories in order to sort and match research studies and policy positions. By developing a method to assign biomedical articles and policy
recommendations to the same categories of health policy, it is possible to identify areas where policy
demand is high and the evidence base is broad. For this study, broadly applicable categories were
developed as follows:
1. Researchers used existing research literature to identify 42 potential major topic categories.
2. An expert panel of 3 researchers then iteratively condensed this list of categories to 10
major topics.
3. Within each of the 10 major topics, this procedure was repeated to generate 75
subcategories, which are presented as focus areas in the analysis.
4. On the basis of the scoping study and policy scan the research team developed the set of
focus areas detailed in Appendix B.
Addressing the Health Needs of an Aging America | 34
Appendix B: Results
Section 1. Health Information Technology
Description: Information technology is taking on a larger role in healthcare both in healthcare facilities
and in the homes or patients and caregivers. Policies around HIT include funding for IT capital investment, such as the HITECH Act, reimbursement for services via telehealth by government payers, and
inclusion of IT strategy, particularly EHRs, within demonstration programs, such as the Patient Centered Medical Home (PCMH).
Decision support
•
American Hospital Association: AHA must advocate for a significant national investment
in developing methods to quickly and effectively translate standards and guidelines and
changes as they emerge into the decision support tools embedded in the electronic health
record (EHR).
•
J. Avery, S. Rodgers, J. A. Cantrill, et al. (2012). A pharmacist-led information technology
intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled
trial and cost-effectiveness analysis. Lancet, 379(9823), 1310-9
•
B. Clyne, M. C. Bradley, C. Hughes, et al. (2012). Electronic prescribing and other forms of
technology to reduce inappropriate medication use and polypharmacy in older people: a
review of current evidence. Clinics in geriatric medicine, 28(2), 301-22
•
M. N. Walsh, N. M. Albert, A. B. Curtis, et al. (2012). Lack of association between electronic
health record systems and improvement in use of evidence-based heart failure therapies in
outpatient cardiology practices. Clinical cardiology, 35(3), 187-96
•
J. Kryworuchko, E. Hill, M. A. Murray, et al. (2013). Interventions for shared decisionmaking about life support in the intensive care unit: a systematic review. Worldviews on
evidence-based nursing / Sigma Theta Tau International, Honor Society of Nursing, 10(1),
3-16
Electronic health records
Development incentives for post-acute settings
•
Association of Jewish Aging Services of North America (AJAS): FMAP provisions that
were part of the American Recovery & Reinvestment Act (ARRA PL. 111- 5), included funding
to hospitals and independent physician practice associations for improved health information
technology services such as the introduction of electronic health records (EHRs) into respective health providers. However, several health disciplines, such as aging service providers,
were not eligible to receive grants. AJAS will vigorously support efforts that will lead to the
eligibility of providers of long-term services and supports.
Addressing the Health Needs of an Aging America | 35
•
American Healthcare Association: To provide HIT funding to long term & post-acute settings comparable to the support acute & ambulatory care settings receive, plus direct the HHS
Secretary to use discretionary funding to promote HIT adoption by long term & post-acute care
providers.
•
American Healthcare Association: AHCA/NCAL applauds the provisions in the Health
Information Technology for Economic & Clinical Health (HITECH) Act included in the American
Recovery & Reinvestment Act of 2009 (ARRA, now Public Law 111-5), which promote HIT
adoption. Unfortunately, the HITECH Act leaves out long term and post-acute care providers.
AHCA/NCAL urges Congress to remedy this oversight by providing comparable support for
HIT adoption by long term and post-acute care as was a orded to providers in acute and ambulatory care settings. In the meantime, the Secretary of Health & Human Services (HHS) should
use discretionary funding, perhaps from the Center for Medicare & Medicaid Innovation (CMI),
to promote HIT in long term and post-acute care settings.
•
LeadingAge: We support the Fostering Independence Through Technology(FITT) Act (S. 596)
to promote Medicare savings through home health agencies’ use of technology.
•
Vedel, S. Akhlaghpour, I. Vaghefi, et al.(2013). Health information technologies in geriatrics and
gerontology: a mixed systematic review. Journal of the American Medical Informatics Association, 20(6), 1109-19
Development incentives for providers
•
American Hospital Association: The limited exception to the Stark law and the anti-kickback
law safe harbor that permit hospitals to assist physicians in developing EHRs will expire Dec.
31, 2013. These regulatory provisions should be extended beyond the current expiration date.
•
American Academy of Physician Assistants: The American Academy of Physician Assistants recommends that section 4201(a)(3)(B) of the Health Information Technology for Economic and Clinical Health (HITECH) Act be amended to extend the EHR Medicaid incentive
payment to all physician assistants whose patient volume includes at least 30 percent Medicaid recipients.
•
Bipartisan Policy Center: Assure health IT investments support electronic information sharing
to meet the needs of new delivery and payment models- HHS should provide implementation
support for such information sharing, with a particular focus on the needs of small physician
practices and community hospitals.
Meaningful use
•
Association of Asian Pacific Community Health Organizations: Include explicit alignment with HITECH meaningful use requirements. The HITECH Act provides incentives for
hospitals and physicians to achieve “meaningful use of certified electronic health records.”
There is great potential for health information technology to improve communication and
quality for underserved populations. Accordingly, we support the explicit alignment of the requirements for Medicare Shared Savings Program ACOs with the meaningful use requirements.
•
American Hospital Association: The Stage 2 final rules also assess penalties for those
who do not meet the meaningful use standards. By law, penalties begin in FY 2015; how-
Addressing the Health Needs of an Aging America | 36
ever, CMS will instead base penalties on whether hospitals met the meaningful use requirements two years earlier, or 15 months earlier for those attesting to meaningful use for the
first time. The AHA strongly believes this unfairly accelerates the timeframe under which
hospitals must meet meaningful use to avoid penalties.
•
American Hospital Association: AHA believes that Stage 2 of meaningful use should not
start until at least 75 percent of hospitals and physicians have successfully achieved Stage
1.
•
American Hospital Association: Eligibility for Other Care Settings. The law establishing
EHR incentive programs limited them to hospitals and physicians. As we move toward a
more integrated healthcare system, additional settings of care also should receive support
for transitioning to EHRs.
•
American Hospital Association: AHA’s ongoing advocacy efforts to ensure that the meaningful use and certification standards are within reach for the majority of hospitals and
physicians.
•
American Academy of Physician Assistants: Recommends that section 4201(a)(3)(B)
of the Health Information Technology for Economic and Clinical Health (HITECH) Act be
amended to extend the EHR Medicaid incentive payment to all physician assistants whose
patient volume includes at least 30 percent Medicaid recipients.
•
American Hospital Association: AHA’s ongoing advocacy efforts to ensure that the meaningful use and certification standards are within reach for the majority of hospitals and
physicians.
Privacy
•
American Hospital Association: the code of conduct should discourage vendors from including in their contracts indemnity clauses or non-disclosure language that limit the ability
of users to identify and raise safety concerns.
•
American Association for Geriatric Psychiatry: Assurance of confidentiality is at the
foundation of an effective relationship between doctor and patient, and AAGP urges that
privacy and security of individually identifiable health information—particularly with regard
to mental health, substance abuse, and other sensitive patient information—be a critical
core element on any national HIT system.
•
American Hospital Association: The AHA supports the development of a voluntary code
of conduct for EHR vendors with specific commitments to ensuring and promoting safety.
The code of conduct should make clear that vendors are responsible for safe design and
product development and will support safe use of their products.
Standardization
•
American Hospital Association: AHA must advocate for a significant national investment
in developing methods to quickly and effectively translate standards and guidelines and
changes as they emerge into the decision support tools embedded in the electronic health
record (EHR).
Addressing the Health Needs of an Aging America | 37
•
American Medical Association: Chief among the safeguards outlined in AMA policy is the
need to ensure that these technologies (HIT) are covered to enhance care coordination and
information-sharing between those who provide virtual care and in-person care.
•
American Hospital Association: EHRs hold the promise of providing clinicians and patients with real-time access to medical information, which can improve medical decisionmaking, quality and patient safety. We need to standardize these technologies and achieve
interoperability. Insurers, government and vendors should implement interoperability standards that allow providers to share health information.
Electronic prescibing
•
Society for Post-Acute and Long-Term Care Medicine: Dedicated to Long Term Care
Medicine (AMDA) work with legislators, regulatory agencies, and pharmacy organizations
to promulgate secure, regulatory-compliant electronic means of prescribing controlled substances to ensure ready patient access to needed medications in the post-acute and longterm care (PA/LTC) setting.
Patient portals
•
National Alliance for Caregiving: we encourage CMS to continue to identify ways to
leverage Health Information Technology (“HIT”) as a tool that family caregivers can use to
help patients. The Dept. of Veterans Affairs has found new ways to help families access
patient information, through its Blue Button program and the Family Caregiver Pilot which
equips caregivers with iPads to help manage care. We would urge CMS to look towards
these VA programs as an example of how to transform clinical practice to better support
patients and their caregivers and reduce overall health system costs.
Population health informatics
•
American Hospital Association: The AHA and hospitals must advocate for the development of datasets that allow providers to understand the full picture of care delivery.
•
S. J. Crane, E. E. Tung, G. J. Hanson, et al. (2010). Use of an electronic administrative
database to identify older community dwelling adults at high-risk for hospitalization or emergency department visits: the elders risk assessment index. BMC health services research,
10, 338
•
S. J. Atlas, R. W. Grant, W. T. Lester, et al. (2011). A cluster-randomized trial of a primary
care informatics-based system for breast cancer screening. Journal of general internal
medicine, 26(2), 154-61
•
Bajorek, P. Magin, S. Hilmer, I. Krass (2014). A cluster-randomized controlled trial of a
computerized antithrombotic risk assessment tool to optimize stroke prevention in general
practice: a study protocol. BMC health services research, 14, 55
•
P. Colais, N. Agabiti, D. Fusco, et al. (2013). Inequality in 30-day mortality and the wait for
surgery after hip fracture: the impact of the regional healthcare evaluation program in Lazio
(Italy). International journal for quality in healthcare, 25(3), 239-47
Addressing the Health Needs of an Aging America | 38
•
Willis, M. Davies, T. Yates, K. Khunti (2012). Primary prevention of cardiovascular disease
using validated risk scores: a systematic review. Journal of the Royal Society of Medicine,
105(8), 348-56
Standards, uniformity, and connectivity
•
Society for Post-Acute and Long-Term Care Medicine: Dedicated to Long Term Care
Medicine investigate the current availability of and work with appropriate stakeholders to
help develop ideal bidirectional electronic message and document exchanges (i.e., communicating electronically among nursing homes and other community healthcare providers) for
use in post-acute and long-term care (PA/LTC) settings;
•
American Hospital Association: Create data-sharing mechanisms among the Medicare
and Medicaid programs, health plans, providers and other government programs to collect,
analyze and report data in a timely manner to support care
•
American Urological Association: Oppose or defer implementation of ICD-10
•
AHIP: Develop and implement a national roadmap for HIT that ultimately would lead to
adoption of uniform national standards that allow for interoperable electronic communication across the healthcare system.
•
AHIP: Prioritize the development and adoption of uniform measures and advance electronic data collection to support reporting.
•
AHIP: States should take advantage of the “qualified entities” under the Availability of Medicare Data for Performance Measurement program to link Medicare, Medicaid, and commercial claims data ...We recommend developing mechanisms for providing this information
in a way that avoids adding unnecessary costs to the healthcare system, protects patient
privacy, enables consistent analytic results, and allows for the data aggregation to evolve
with changes in payment models and methodologies
•
American Hospital Association: The regulation also should include additional flexibility,
such as allowing hospitals to share hardware or completely subsidize connectivity and software.
•
American Hospital Association: Require in contracts with vendors that they become
CORE-certified.
•
Bipartisan Policy Center: support of electronic capture of data for measurement through
the use of common standards
•
American Hospital Association: the AHA continues to press for a resolution and recommends the creation of a national unique identifier system to connect records and ensure
that hospitals and physicians have the best information available when providing care for
each patient.
•
American Hospital Association: The AHA supports HIEs and will work with state hospital
associations to ensure that federal efforts do not unintentionally result in state-level systems that cannot be connected.
•
American Hospital Association: The AHA continues to advocate for a uniform system
of identification in order to streamline supply chain efficiencies, reduce costs and improve
patient safety.
Addressing the Health Needs of an Aging America | 39
•
National Medical Association: To ensure that HIT does not become a blunt instrument
in the hands of untrained healthcare providers and regulators, NMA recommends: Discussions on standards, certification, and interoperability must be as robust as possible.
•
M. Hustey, R. M. Palmer (2010). An internet-based communication network for information
transfer during patient transitions from skilled nursing facility to the emergency department.
Journal of the American Geriatrics Society, 58(6), 1148-52
Telehealth and remote telemonitoring
General
•
American Medical Association: Identifying technical solutions and requirements. Telemedicine technology also must facilitate easy information sharing and comply with Health
Insurance Portability and Accountability Act (HIPAA) privacy and security requirements. The
AMA is working with telemedicine stakeholders to identify solutions and establish technical
standards.
•
American Medical Association: Both bills would allow telemedicine to be practiced across
state lines by changing medical licensure laws. Under these bills, licensure would be based
on the state in which the patient is located rather than on the state in which the physician is
licensed to practice.
•
American Medical Association: To ensure proper diagnoses and follow-up care, the principles specify that a valid patient-physician relationship should exist before using telemedicine or the physician should meet the standard of care and other safeguards outlined in the
AMA policy for establishing this relationship using appropriate telecommunication technologies.
•
Association of Asian Pacific Community Health Organizations: Telemedicine and Telehealth Communications We also recommend that organizations or agencies using an automated telephonic system be required to use dedicated language lines or, at a minimum,
add voice prompts in multiple languages. Further, HHS should ensure that the staff providing information is trained to respond appropriately to LEP callers and know how to access
bilingual staff or interpreters.
•
P. Y. Takahashi, J. L. Pecina, B. Upatising, et al. (2012). A randomized controlled trial of
telemonitoring in older adults with multiple health issues to prevent hospitalizations and
emergency department visits. Archives of internal medicine, 172(10), 773-9
•
Steventon, M. Bardsley, J. Billings, et al. (2012). Effect of telehealth on use of secondary
care and mortality: findings from the Whole System Demonstrator cluster randomised trial.
BMJ (Clinical research ed.), 344, e3874
•
N. van den Berg, M. Schumann, K. Kraft, W. Hoffmann (2012). Telemedicine and telecare
for older patients--a systematic review. Maturitas, 73(2), 94-114
Heart failure
•
S. C. Inglis, R. A. Clark, F. A. McAlister, et al. (2010). Structured telephone support or telemonitoring programmes for patients with chronic heart failure. The Cochrane database of
Addressing the Health Needs of an Aging America | 40
systematic reviews, (8), CD007228
•
S. I. Chaudhry, J. A. Mattera, J. P. Curtis, et al. (2010). Telemonitoring in patients with heart
failure. The New England journal of medicine, 363(24), 2301-9
•
Anker, S.D., Koehler, F., Abraham, W.T. (2011) Telemedicine and remote management of
patients with heart failure. The Lancet, 378 (9792), pp. 731-739.
•
F. Koehler, S. Winkler, M. Schieber, et al. (2011). Impact of remote telemedical management on mortality and hospitalizations in ambulatory patients with chronic heart failure: the
telemedical interventional monitoring in heart failure study. Circulation, 123(17), 1873-80
•
G. H. Crossley, A. Boyle, H. Vitense, et al. (2011). The CONNECT (Clinical Evaluation of
Remote Notification to Reduce Time to Clinical Decision) trial: the value of wireless remote
monitoring with automatic clinician alerts. Journal of the American College of Cardiology,
57(10), 1181-9
•
V. M. Conraads, L. Tavazzi, M. Santini, et al. (2011). Sensitivity and positive predictive
value of implantable intrathoracic impedance monitoring as a predictor of heart failure hospitalizations: the SENSE-HF trial. European heart journal, 32(18), 2266-73
•
Clarke, M., Shah, A., Sharma, U. (2011). Systematic review of studies on telemonitoring of
patients with congestive heart failure: A meta-analysis. Journal of Telemedicine and Telecare, 17(1), 7-14.
•
P. Mabo, F. Victor, P. Bazin, et al. (2012). A randomized trial of long-term remote monitoring
of pacemaker recipients (the COMPAS trial). European heart journal, 33(9), 1105-11
•
E. Seto, K. J. Leonard, J. A. Cafazzo, et al.(2012). Mobile phone-based telemonitoring for
heart failure management: a randomized controlled trial. Journal of medical Internet research, 14(1), e31
•
Landolina, M., Perego, G. B., Lunati, M., et al. (2012). Remote monitoring reduces healthcare use and improves quality of care in heart failure patients with implantable defibrillators:
The evolution of management strategies of heart failure patients with implantable defibrillators (EVOLVO) study. Circulation, 125(24), 2985-2992.
•
U. Augustin, C. Henschke (2012). [Does telemonitoring lead to health and economic benefits in patients with chronic heart failure? - a systematic review]. Gesundheitswesen
(Bundesverband der Arzte des Offentlichen Gesundheitsdienstes (Germany)), 74(12),
e114-21
•
R. Xiang, L. Li, S. X. Liu (2013). Meta-analysis and meta-regression of telehealth programmes for patients with chronic heart failure. Journal of telemedicine and telecare, 19(5),
249-59
•
Pandor, A., Gomersall, T., Stevens, et al.(2013). Remote monitoring after recent hospital
discharge in patients with heart failure: A systematic review and network meta-analysis.
Heart, 99(23), 1717-1726.
•
S. C. Inglis, A. Conway, J. G. Cleland, R. A. Clark (2014). Is age a factor in the success or
failure of remote monitoring in heart failure? Telemonitoring and structured telephone support in elderly heart failure patients. European journal of cardiovascular nursing
Addressing the Health Needs of an Aging America | 41
COPD
•
J. Polisena, K. Tran, K. Cimon, et al. (2010). Home telehealth for chronic obstructive pulmonary disease: a systematic review and meta-analysis. Journal of telemedicine and telecare,
16(3), 120-7
•
K. E. Lewis, J. A. Annandale, D. L. Warm, et al. (2010). Does home telemonitoring after pulmonary rehabilitation reduce healthcare use in optimized COPD? A pilot randomized trial.
Copd, 7(1), 44-50
•
O. Karg, M. Weber, C. Bubulj, et al. (2012). [Acceptance of a telemo...
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