Predicting the occurrence of adverse outcomes is difficult enough in homogeneous groups, but the substantial variability among high-risk seniors renders this task even more challenging. In particular, systematic identification is difficult because of the wide range of causes, the gradual onset of many cases of frailty, the tendency of many symptoms to fluctuate over time, and the diversity in seniors’ reactions to increasing impairment (Soldo and Manton 1985).
The challenge of identifying frailty was raised in our focus groups. Several physicians mentioned that they struggled to identify high-risk elderly patients and that this difficulty limited their ability to direct care management and home care to frail elders. One physician lamented that his group had thus far been less than successful in their attempts to identify those seniors most at risk for frailty and prevent unfavorable outcomes such as institutionalization:
We’re trying to sort out ahead of time people at risk. It seems that we end up choosing people after they’ve had the ER visits or the fractured hip or whatever and then scrambling for placement like everybody else.
Physicians might have benefited from the new-member screening and assessment efforts conducted by all four MCOs, but that screening information did not appear to be disseminated effectively.11 In fact, some physicians were unaware of these data, such as the primary care physician who reported,
I was shocked by how much information the plan collected about my patients. The assessments they brought to us raised some very important medical issues.
At the two IPA-model MCOs, network physicians reported that they often were overwhelmed by screening data provided by the several managed care plans whose members they treated. Many indicated that they participated in as many as seven plans and received member-screening information from most of those plans. They indicated that the resulting “reams” of paper, all with different formats, made it so difficult to use the screening data that the reports were essentially useless.
Physicians seemed confident that they could identify high-risk seniors better during office visits than through other methods. Even here, though, there were challenges. One physician noted that many issues cannot be identified effectively during an office visit, and that being able to have a nurse make a home visit (even if the patient is not homebound) is important for identifying frailty or risk levels:
Probably one of the more common things that I will ask our home care people to do is a visit to evaluate home safety and patients’ functioning in their home setting. From just an office visit I don’t know what’s going on in that house, and I want somebody to go in and check it out.
Several focus group physicians indicated that part of the difficulty in identifying high-risk seniors is that many seniors’ functioning during an office visit is not indicative of their general level of functioning. That is, some high-risk seniors tended to visit their physician's office when they felt strong enough to make the visits, and would postpone a visit if their functioning was particularly limited. Thus, functioning during office visits provided a biased view of the seniors’ overall functioning level. Also, some seniors who functioned well, nevertheless had substantial hazards in their homes. In one case, a patient who exhibited only minor mobility limitations in the office was found to be at risk for a serious fall because her only shower facilities were in her basement down a steep open staircase.