Aging Well: Solutions to the Most Pressing Global Challenges of Aging
272
Aging Well: Solutions to the Most Pressing Global Challenges of Aging
272Paperback
-
PICK UP IN STORECheck Availability at Nearby Stores
Available within 2 business hours
Related collections and offers
Overview
Product Details
| ISBN-13: | 9781626346956 |
|---|---|
| Publisher: | Greenleaf Book Group Press |
| Publication date: | 01/07/2020 |
| Pages: | 272 |
| Sales rank: | 512,946 |
| Product dimensions: | 5.90(w) x 8.90(h) x 0.70(d) |
About the Author
Read an Excerpt
CHAPTER 1
Demographics
The commitment of ACCESS Health International to elder care and optimal aging is fueled by the global change in demographics. The population over 60 is expected to double to 22 percent, reaching 2.1 billion from 2000 to 2050. The demographic shift is attributed to increased life span, lower mortality rates, declining immigration rates, and lower fertility rates. Figure 1.1 is an example of the rectangularization process from 1970 to 2060.
The 100-year shift that began in 1950 is only 19 years past its midpoint. By 2060, the pyramid will resemble a dome shape. Some predict that it will morph into the shape of a rectangle because, in many countries, the oldest old (85+) population is growing the fastest. The global population of those 85–99 is projected to increase by 151 percent from 2005 to 2030, while the population of those 100+ is expected to increase by more than 400 percent.
The demographic shift is occurring at varying rates throughout the world (Fig. 1.2). The United Nations reported that, in 2015, almost 25 percent of the world's population 60 and over lived in China and that only four other countries accounted for another 25 percent, including the United States, Japan, India, and the Russian Federation. The projected growth rate for the over 60 population also varies from country to country, but is expected to continue to grow globally until 2060.
Potential Support Ratio
One result of the demographic shift is that there will be substantially more older people who need care and fewer younger people to provide the care. This care conundrum is reflected in the potential support ratio — the number of workers (age 15–65) to the number of retirees (65+). The potential support ratio has been declining substantially from 2000 to 2050 (Fig. 1.3).
With the shrinking potential support ratio, who will care for the growing number of older adults? Immigration is one answer, but the overarching response should be that health care and social support systems become more efficient to meet the significant needs of this cohort. Informal caregivers make invaluable contributions, but they cannot meet the complex care needs of the growing older population. This care gap is further magnified when considering the rates of comorbidity and cognitive and functional limitations of the older population.
We will begin with some facts about health care in the United States and then describe solutions to the challenges we have laid out.
CHAPTER 2Health Care in the United States
United States Health Spending and Outcomes
The health spending of the United States is the highest among the Organisation for Economic Co-oporation and Development (OECD) countries. It was 2.5 times greater than the OECD average in 2013. Health spending accounted for 16.4 percent of the gross domestic product in 2013 and, in 2020, it is projected to represent 20 percent. By 2040 it is estimated that one third of all spending in the US will be on health care. Despite all of the spending, the health of Americans lags behind. This is, in large part, a result of America divesting from prevention and health promotion programs. Another contributing factor to such poor health outcomes is that the US does not invest enough in building robust systems of primary care. Although the US spends close to the same amount as other Western countries on health care and social supports combined, it spends proportionately less on social services and more on health care to treat people after they become ill from what are often preventable diseases. Adults in the US are more likely than adults in other developed nations to forgo necessary health care because they cannot afford the cost. From 2010 to 2012, 54 percent of people with chronic illness reported that cost was a barrier for them to access care. The patients surveyed reported that they skipped medications, treatments, and doctor visits because they could not afford the cost. Life expectancy is shorter in the US than most OECD countries. As of 2013 life expectancy in the US was 78.8, while the OECD average was 80.5. In 2014 the Commonwealth Fund ranked the United States health care last among 11 countries. The measures included access, equity, quality, efficiency, and healthy lives. Because of these findings, the government and many health systems in the US are creating new care models to address the issues of healthcare access, quality (including patient satisfaction), and cost. Many of these innovations are designed to serve older adults because the older cohort interacts with the healthcare system more than others.
Optimal Aging
In the US and internationally, there is a continuing focus on community supports and inclusive societies that allow older adults to remain active and engaged. This focus includes age-friendly cities, inclusive housing, and employment opportunities. Most of the improvement in health care and inclusive environments will positively affect those with dementia, but providers and city planners are also committed to implementing dementia-specific care and support measures.
Geriatric Workforce Shortage
Geriatricians are a critical factor of high-quality care for older adults. The US is already struggling with the ability to care for the older population with the high rates of dementia and other chronic illnesses and is lacking in a workforce with appropriate training. According to the American Geriatrics Society, as of 2015, the US was short 9,500 geriatricians. This shortage threatens to grow as the population ages. The World Health Organization cites that to meet the need of the growing older population, all healthcare providers must be educated in gerontology and geriatrics. Some suggest that having more geriatricians in the hospital setting could reduce costs. This is important because 25 percent of Medicare spending is attributable to inpatient hospital care. Geriatricians are trained to understand and diagnose cognitive problems and functional challenges with activities of daily living. They also are knowledgeable about how drugs act differently in the aging body and are adept at polypharmacy management. Additionally, geriatricians are trained to manage multiple comorbidities and understand that health management is often the primary focus rather than cure.
Prevalence of Chronic Disease
Longevity and lifestyle choices such as smoking, alcohol, and obesity have contributed to people developing more chronic illnesses. The occurrence of multiple chronic conditions increases with age, which compounds the burden of caring for the growing aging population. Almost one half of older adults in America are living with both chronic conditions and functional limitations. Eighty percent have at least one chronic condition, and 50 percent have at least two. Approximately 75 percent of Americans 65 and older are living with multiple chronic conditions and 20 percent are living with five or more chronic conditions. The oldest old population (80 and older) is growing most rapidly and has the highest rates of comorbidity.
The number of people living with dementia is projected to increase by more than 200 percent, from 44 million in 2014 to 135 million by 2050. One in nine people 65 and older has dementia. The statistics, however, do not accurately represent the prevalence of dementia because an estimated 50 to 90 percent of dementia cases go undiagnosed. The global average rate of undiagnosed cases of dementia is 75 percent. The rates of undiagnosed dementia vary from country to country. The highest rates are found in the low- and middle-income countries. It is nearly impossible to separate elder care from dementia care after the age of 75 because that population represents 81 percent of the cases of dementia. As we mentioned, the oldest old is the population that is growing the fastest. Thirty-two percent of that cohort have received a diagnosis of dementia. It is more expensive to meet the complex care needs of people with multiple chronic conditions. Many will also need supportive help because those with multiple chronic conditions experience higher levels of poor functional status. Older adults who are living with five or more chronic illnesses have, on average, 50 prescriptions and 14 different physicians and make 37 office visits annually. Those with multiple chronic conditions account for 71 percent of the total health care spending in the United States. The fee-for-service individuals with multiple chronic conditions, who are beneficiaries of the government-sponsored Medicare, accounts for 93 percent of the total Medicare spending. The unsustainability of medical costs is an incentive for the Centers for Medicare and Medicaid Services to support more efficient, less costly, and better quality systems of care for the sickest people. The financial burden is also borne by people living with multiple chronic conditions through out-of-pocket costs and the high price of prescription medications.
Meeting the healthcare and social needs of the older population is a worldwide public health challenge. To properly and sustainably meet the needs of older adults, providers must challenge fragmented and complex care and social support systems and implement coordinated, person-centered care across a variety of care settings and providers. Providers must also foster chronic disease self-management programs and other forms of patient engagement. Two important concepts that we address throughout the book that serve to promote higher-quality accessible care with greater patient satisfaction at a lower cost are person-centered and value-based care.
Person-Centered Care
One theme that occurs throughout our interviews involving elder care is the concept of person-centered care. Rather than being provider led, person-centered care has the patient in the center of the care team with all care decisions based around the goals and priorities of the patient. Person-centered care has been the focus of global health systems and policy makers. Although beneficial for everyone, person-centered care is especially effective in treating those who are most frail and living with multiple chronic conditions. Person-centered care has the potential to lower the health system utilization of the patient by providing more coordinated care and better self-management support that helps keep patients out of the emergency departments and hospitals.
Person-centered care providers have discussions with their patients about the benefits and side effects of aggressive interventions. They involve the patient and their families in care planning, including advanced directives for late life. In the last years of life, often people who are involved in their care planning will opt out of heroic medical interventions and enjoy life in the way they most prefer. Person-centered care is value-based care because it improves quality of life, reduces healthcare utilization, and lowers the care cost in late life.
Value-Based Care
Value is measured as the ratio of health cost and outcomes. The goal of value-based care is to lower health spending by reducing redundancies and unnecessary care. In a fee-for-service reimbursement arrangement, providers are paid for each service they perform, including office visits, tests, operations, and other medical procedures. The more volume, the more the provider makes, which can be seen as an incentive for too much care. Unnecessary medical tests and procedures cost the American healthcare system an estimated US$200 billion each year and overly aggressive care is responsible for an estimated 30,000 deaths annually. Since the passage of the Affordable Care Act in 2010 and the Medicare and CHIP Reauthorization Act (MACRA) of 2015, the United States has been in the process of a historic change in the way health care is reimbursed. Healthcare providers are reorganizing how they deliver care in the response to reimbursements that incentivize value over volume.
The Centers for Medicare and Medicaid Services, private payers, fully integrated health systems such as managed care organizations, and large employers have led the push toward value-based reimbursement policy. They have built in incentives to provide value because they exist as the payer and the payee of health services. Private insurers including Aetna and Blue Cross Blue Shield are dedicating an increasing amount of their spending toward valuebased care. Large employers such as Intel, Starbucks, Boeing, General Electric, Lowe's, and Walmart have forged their own way to value-based care by negotiating with insurers and medical providers to receive better quality care at a lower cost.
Value care arrangements shift health systems from a medical model to a public health model. There are a variety of value-based reimbursement arrangements or alternate payment models.
SHARED SAVINGS
The provider is given an agreed upon fee that is based on the health profile of the patient. If the provider is able to meet specified outcome benchmarks at a lower cost, that savings is kept by the provider or shared at a predetermined rate with the insurer.
SHARED RISK
If the organization spends more than the agreed upon amount, they are required to repay the insurer for some of the excess spending.
BUNDLED PAYMENTS
The insurer makes one payment for the total care linked to a particular procedure or period of time. This fee covers the cost of care across the continuum. If an organization is efficient and does not spend the total fee they received, they can keep the savings. The Centers for Medicare and Medicaid Services have made bundled payments mandatory for heart attack treatment, bypass surgery, hip and knee replacement, and surgical hip and femur fracture treatment.
GLOBAL CAPITATION
Insurers pay a set monthly fee for each patient. The fee is meant to pay for all of the healthcare services used by the patient.
PAY FOR PERFORMANCE
The provider is compensated based on the evaluation of the physician performance metrics. Those who meet the targets established by the insurer may receive a bonus.
Value-based agreements encourage providers to be committed to coordinated, high-quality care because a trip to the emergency department, complications resulting from medication mismanagement, a readmission after a care transition, and other often preventable adverse health events can increase the cost of care substantially. The agreements also give providers more flexibility in resource allocation. Value-based agreements have set the stage for better care in all settings, including the home and community. With the new president, the US is unsure of future healthcare reimbursement policies, but it is doubtful that we will move away from value-based care. Like the US, all countries who are aligning their healthcare systems and policies to meet the needs of their growing older population will need to maintain a vigilant dedication to value-based care and health system redesign.
Alignment to Meet the Needs of the Older Population
The increase in life expectancy is a public health success, and possibly the greatest achievement of the twentieth century. However, the challenge remains for health systems, private entities, and policy makers, from the community level through the federal level, to ensure that people can live the highest quality of life possible (optimal aging) in their additional years. Optimal aging is not solely about health status; it is being able to live active, engaged, and productive lives due to policies and practices that foster inclusive communities for people of all ages and abilities. This public health challenge presents unprecedented opportunities for innovation and we are pleased to share some of our favorites in the following pages.
This is a book of solutions to some of the most pressing challenges in aging today.
In the following chapters, we will describe organizational cultures of elder care providers that are person-centered, coordinated, and efficient and, therefore, require fewer staff and result in better health outcomes, improved access, and lower care costs. We will also detail innovations that support people with dementia and their caregivers that enable those with dementia to remain safely at home and included in their communities. We will show how some models of care have greatly reduced costs and improved outcomes by providing care in the home and community, while others combine social and health supports to improve function and enable aging in place. We will also present models of illness and injury prevention and chronic disease self-management that reduce healthcare utilization greatly and improve the well-being of older adults. We will begin with long-term care financing and why the long-term care industry is less than vibrant in the US. The next chapter makes a convincing case for the need for universal health coverage to meet the growing global long-term care needs of the aging population.
(Continues…)
Excerpted from "Aging Well"
by .
Copyright © 2019 ACCESS Health International.
Excerpted by permission of Greenleaf Book Group Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Table of Contents
1 Demographics 1
2 Health Care in the United States 5
3 Long-Term Care Financing 15
4 Person-Centered Long-Term Care 23
5 Home-Based Palliative Care and Aging in Place and Community 53
6 Coordinated Primary Care 75
7 Emergency Medicine and Hospital Care in the Home and Community 87
8 Support for Those Living with Dementia and Their Caregivers 109
9 Merging Health and Social Services 131
10 Purpose and Social Inclusion 149
11 Eight Lessons for Social Inclusion and High-Quality Sustainable Elder Care 189
Appendix: Indicators List: Essential Elements of an Elderly Friendly Community 203
End Notes 209
About the Authors 251