Study details comprehensive models to decrease care fragmentation in older adults

Three existing comprehensive care models have the most potential to decrease care fragmentation and improve quality of life in older U.S. adults, a new study reports.

Two researchers performed a literature search of trials that examined the performance of comprehensive primary care models in improving care of older U.S. adults with several chronic conditions. Models were evaluated by how well they addressed the following four factors, determined by expert consensus: comprehensive assessment of patients' physical, mental and social conditions; evidence-based care planning and monitoring that considers patients' health needs and care preferences; formal and informal promotion of patients' and caregivers' engagement in care; and communication and coordination of all professionals caring for patients, especially during care transitions. The study results were published in the Nov. 3 Journal of the American Medical Association.

The authors concluded that the Geriatric Resources for Assessment and Care of Elders (GRACE) model, Guided Care, and the Program of All-inclusive Care for the Elderly (PACE) address all four of the predetermined processes and help to improve outcomes of primary care while maintaining or decreasing costs. All three of these models utilize team-based primary care that offers patients comprehensive care, implementation of a care plan over time, proactive monitoring and care coordination, especially at care transitions.

While GRACE and Guided Care are overseen by patients' existing primary care physicians, PACE patients' care is transferred to PACE staff physicians (some of whom are community-based). PACE involves the most frequent contact, with one to five days a week, versus GRACE and Guided Care's monthly visits. Services provided by GRACE and Guided Care, which were established in 2002 and 2006, respectively, are not currently reimbursed by Medicare, Medicaid or private insurance, so these programs are limited to areas with regional pilots or medical home/advanced primary care demonstrations. In PACE, which was established in 1990, each site is considered a managed care plan and receives capitated payments from Medicare and Medicaid.

The authors noted that more research is needed to determine how to identify patients who will benefit from a comprehensive primary care model, how access to such models can be improved, and how such care can be adequately reimbursed. An accompanying editorial examined existing barriers to providing comprehensive care to older U.S. adults and concluded that development of cost-effective care models needs to be expedited. "To move ahead, CMS should establish explicit goals for reforms and ensure that there are robust data from which to draw clear conclusions about current and alternative program success," the editorialists concluded.