Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. 1. Multiple Conditions of High-Risk Seniors Require Organizationally Complex Care


The organizationally complex care of high-risk seniors is illustrated in Table III.5, by the large portion, 29 percent of our sample, who have seen two or more specialists in the past six months. These specialists are just the tip of the iceberg. The seniors also receive care from their primary care physician and the nurses and other staff who work for them. There may also be an occasional visit to a backup primary care physician when the regular physician is unavailable. The set of care providers also includes the family and friends who provide unpaid assistance with ADLs or IADLs. In addition, there are further complications related to polypharmacy and use of assistive devices.

Effective care requires that all this care be coordinated. For example, one senior said,

I require a number of specialists, including a urologist and a heart doctor. I’ve had a double bypass. I felt I should see a heart doctor occasionally. And I’ve had a half-dozen skin cancers, and the primary care doctor can’t cover everything.

Effective care coordination is particularly important with regard to prescription drugs because of the risk of adverse events due to polypharmacy. This issue is especially pertinent for the 18 percent of our sample taking more than 5 prescriptions daily (Thornton et al. 1991).

Continuity of care is especially important and challenging when frail elders receive care from many providers, because problems with any single provider may compromise all the care. The challenge, therefore, is to ensure that all the providers work together. Some examples of coordination problems reported in our focus groups include an instance when a discharge planner wanted a patient to leave the hospital before the case manager was able to establish appropriate living arrangements. Several participants shared stories in which there was a lack of communication among doctors and specialists in the delivery of care. One senior, who was the primary caregiver for his wife, spoke about the difficulty of getting information from one setting to another:

When my wife went back to the clinic, her doctor didn’t have any notes from the doctor that saw her at the hospital. And obviously they hadn’t communicated because her [primary care] doctor had no idea what had transpired at all. I would have expected some kind of communication.

Another senior who was caring for her husband noted similarly that:

When my husband left the nursing home, there should have been better communication with his doctors. The nursing home told me that they were communicating with the clinic doctors. But apparently not, because my husband’s medication should have automatically been switched when he came home. I shouldn’t have to be calling back and explaining this, that, and the other thing. There’s a pharmacist that calls, but he should be in touch with the primary care physician so that when I want to get [the prescription] refilled I don’t have to explain all this.

A physician noted that coordination among specialty providers can also be problematic:

We need more collaboration, as opposed to actions by individual departments such as a mental health department, neurology, and internal medicine. We need to see the patient as a whole, as opposed to having pockets of funding that come out of each of the departments. I have seen these problems in other systems as well.

The physicians in our focus groups also pointed out that comorbidities make it difficult to address all a patient’s problems fully in one office visit, because time is limited or because treating too many problems at once may confuse many seniors. Physicians try to prioritize problems and make sure they address the most important ones during office visits. Sometimes the treatment priorities of patients differ from those of physicians, which can interfere with effective care delivery.

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