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OUTPATIENT CARE
SYSTEMS
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OBJECTIVES
Know and understand:
• Key features of new models of primary care
• Key features of models of enhanced primary care
• Conditions that lend themselves to disease management
programs
• Methodologic differences between comprehensive
geriatric assessment and geriatric evaluation and
management
• Innovative options for geriatric specialty outpatient care
• Three complementary methods of identifying high-risk
patients who could benefit from an innovative outpatient
intervention
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TOPICS COVERED
• Geriatrics in Primary Care
• Enhanced Primary Care
• Disease Management
• Outpatient Consultation
• Geriatric Specialty Care
• Senior Health Clinic
• Program of All-inclusive Care for the Elderly
• Patient Selection for Outpatient Interventions
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INTRODUCTION
• Traditional outpatient care in the U.S. does not deliver the
recommended standard of care to older adults for preventive
services, chronic disease management, and geriatric
syndromes
• A more proactive, patient-centered, and population-based
approach is needed to improve the overall quality of geriatric
care
• Several innovative outpatient care systems have been
developed over the past two decades
 Integrating geriatrics into primary care
 Involving geriatric specialty care
NEW MODELS OF PRIMARY CARE
(1 of 2)
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• Patient-Centered Medical Home (PCMH)
 Builds on strong evidence showing that higher-quality care and
lower costs can be achieved through greater emphasis on
primary care
 Each patient has an ongoing relationship with a personal
physician and participates in decision making
 Physician directed medical practice, whereby, the practice
adopts a “whole-person orientation” and provides/arranges for
all of the patient’s health care needs
 Care is coordinated across all elements of the complex health
system, enhancing access to care
 Payment recognizes the added value provided to patients who
have a PCMH
NEW MODELS OF PRIMARY CARE
(2 of 2)
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• Accountable Care Organization (ACO)
 Aims to manage the full continuum of care and to be
accountable for the overall quality of care and costs for a defined
population
 Provider-led organization
Large integrated delivery systems
Physician - hospital organizations
Independent practice associations
 Receive fee-for-service payments, if certain quality performance
measures are achieved, the ACO will share in the cost savings
 Need strong primary care foundation to succeed
 Can provide infrastructure beyond the primary care practice to
coordinate care across the continuum of care
GERIATRICS IN PRIMARY CARE:
ENHANCED PRIMARY CARE (1 of 7)
Models of Enhanced Primary Care
 Guided Care
 GRACE Team Care™
 CareMore
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GERIATRICS IN PRIMARY CARE:
ENHANCED PRIMARY CARE (2 of 7)
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• Guided Care
 Designed to improve the quality of life and efficiency of
resource use for older adults with multiple morbidities
 Aims to enhance primary care by:

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



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Disease management
Self-management
Case management
Lifestyle modification
Transitional care
Caregiver education and support
Geriatric evaluation and management
 Specialized RN works with assigned primary care
physicians and office staff to care for older adult patients
GERIATRICS IN PRIMARY CARE:
ENHANCED PRIMARY CARE (3 of 7)
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• Guided Care
– Studies have shown:
 After 8 months of Guided Care:
 Improved quality of chronic care (measured by patient ratings)
 Reduced family caregiver strain
 Increased patient/clinician satisfaction with care
 Trend toward less use of expensive health services
 After 32 months of Guided Care:
 Reduced home health care usage
 Little effect on the use of other health services
 Among a subgroup of patients, Guided Care
 Reduced skilled nursing facility admissions
 Showed a trend toward reduced hospital admissions and
emergency department visits
GERIATRICS IN PRIMARY CARE:
ENHANCED PRIMARY CARE (4 of 7)
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• Geriatric Resources for Assessment and Care of Elders
(GRACE) model: GRACE Team Care™
• An intensive “medical home” for high-risk older patients
• Patients receive home based CGA and long-term care
management by an Interprofessional team (NP and SW)
 The GRACE NP and SW collaborate with the office-based primary
care physician
 GRACE protocols are used to guide evaluation and management or
geriatric syndromes
 Weekly team conferences are led by a geriatrician medical director
and also involve a pharmacist and mental health liaison who provide
care recommendations and help problem solve.
• Each patient receives an individualized care plan developed
around common geriatric conditions
 Care plans are consistent with the patient’s goals and preferences
GERIATRICS IN PRIMARY CARE:
ENHANCED PRIMARY CARE (5 of 7)
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• Geriatric Resources for Assessment and Care of Elders
(GRACE) model: GRACE Team Care™
 An RCT of GRACE demonstrated improvements in healthrelated quality of life, better quality of care for geriatric
conditions, and fewer ED visits; and a reduction in
hospitalizations in the high risk group.
 Cost analysis of the GRACE Intervention showed that in the
high-risk group, increases in chronic and preventive care costs
were offset by reductions in acute-care costs -- intervention
was cost neutral in the first 2 years
 Replication of this model has been successful in Medicare
managed-care and VA health care settings
 The GRACE model has demonstrated consistent improvement
in quality of care and reductions in hospital utilization
GERIATRICS IN PRIMARY CARE:
ENHANCED PRIMARY CARE (6 of 7)
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• CareMore
 Developed to provide intensive management for frail,
chronically ill Medicare Advantage program members who
accounted for 70% of medical costs
 Patients enrolled are:
Assessed for chronic diseases and geriatric conditions
Managed by an outpatient Interprofessional team (NP, nurse care
manager, medical assistant care extenders)
 Employs Hospitalists termed “Extensivists”
Provide care in the inpatient, post-discharge follow-up, SNF and
home settings
 Uses condition-specific protocols, team-based chronic
disease care management programs, and home monitoring
technology
GERIATRICS IN PRIMARY CARE:
ENHANCED PRIMARY CARE (7 of 7)
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• CareMore
 Compared with the overall Medicare population the
CareMore model demonstrates:
Excellent performance on quality, utilization, cost, and patient
satisfaction
 Risk adjusted total per capita health spending is 15% below
the national Medicare average
GERIATRICS IN PRIMARY CARE:
DISEASE MANAGEMENT PROGRAMS
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• Focus health care delivery around a single disease with the
goal of optimizing patient care for that disease
• Most effective when integrated with the patient’s PCP and/or
specialist physician
• Potentially cost-saving
• Programs in heart failure, depression, and Alzheimer disease
have led to better outcomes in older adults
GERIATRICS IN PRIMARY CARE:
OUTPATIENT CONSULTATION (1 of 2)
• Comprehensive Geriatric Assessment (CGA)
 Aimed at determining a patient’s medical, functional, and
psychosocial capabilities and limitations, and developing a plan
for treatment and long-term follow-up
 Typically requires a highly trained interprofessional team, so is
expensive and time consuming
 If the team has a purely consultative role, CGA is unlikely to
improve patient outcomes
 CGA coupled with a strategy to improve PCP and patient
adherence with recommendations has demonstrated improved
outcomes
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GERIATRICS IN PRIMARY CARE:
OUTPATIENT CONSULTATION (2 of 2)
• Geriatric Evaluation and Management (GEM)
 More intensive than CGA
 A geriatrics interprofessional team diagnoses and treats
problems, and provides services such as:
 Adjusting medications
 Providing counseling and health education
 Making referrals to other health professionals and community
services
 The team also provides monitoring and coordination of care
between visits through regular telephone calls
 Trials have shown positive results
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GERIATRIC SPECIALTY CARE:
SENIOR HEALTH CLINIC (1 of 3)
• Specialized ambulatory clinical service center for
older adults
• Referral by primary care clinicians
 They can identify their high risk patients knowing factors not
available in administrative data (eg, functional status)
 They may lack the time, skills or incentive
• Includes hospital, skilled-nursing facility (SNF), assisted
living, and home care
• Links patients with community-based services and
information
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GERIATRIC SPECIALTY CARE:
SENIOR HEALTH CLINIC (2 of 3)
• Core team: geriatrician, NP, social worker
• Extended team: pharmacist, physical therapist,
dietician, home-health nurse, etc.
• Provider teams share a common medical record and
meet at least weekly to review complex care plans and
discuss new or anticipated patient issues
• When SHC patients are admitted to the hospital or
SNF, care is delivered directly and/or coordinated by
SHC providers
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GERIATRIC SPECIALTY CARE:
SENIOR HEALTH CLINIC (3 of 3)
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• Patients in SHCs have better mental health and better healthrelated quality of life over time than patients in traditional care
• SHCs are revenue generators when considered within an
integrated health system because of “downstream” hospital and
professional fees
• But uptake of the SHC model has been limited because:
 Administrators tend to consider SHCs in isolation, which makes them seem
to be cost centers
 A limited number of specialty trained geriatrics professionals are available
to staff such clinics
• SHC model has potential to thrive:
 Focusing on high-risk Medicare Beneficiaries
 Delivering higher-quality care at lower costs
GERIATRIC SPECIALTY CARE:
PACE (1 of 3)
• Program of All-inclusive Care for the Elderly
(PACE)
• Managed care program that provides comprehensive
services to frail community-dwelling older adults by a
single organization
• Goal is to keep patient’s in the community for as long
as is medically, socially, and financially feasible
• Combined Medicare/Medicaid funding allows PACE to
integrate acute and long-term care
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GERIATRIC SPECIALTY CARE:
PACE (2 of 3)
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• Services are provided across the continuum of care by an
interprofessional team (PCP, often a geriatrician, NP, clinic and
home health nurses, social workers, physical therapist,
occupational therapist, recreational therapist, pharmacist,
dietitian, and transportation workers)
• Most enrollees are eligible for Medicaid because otherwise the
program carries high out-of-pocket expenses; few insurance
plans cover PACE
• Enrollment criteria:
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Age 55 or older
Eligible for Medicare
Certified by the state as eligible for care in a nursing home
Lives in the defined geographical catchment area
GERIATRIC SPECIALTY CARE:
PACE (3 of 3)
• Research has shown that PACE provides high-quality
care
• About 3 million older adults in the US might benefit from
PACE, but only a small fraction have enrolled since
PACE was made an Medicare provider
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PATIENT SELECTION FOR
OUTPATIENT INTERVENTIONS (1 of 2)
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• Referral by primary care clinicians
-They may lack the time, skills, and incentives
• Screening questionnaires
 The Probability of Repeated Admission (Pra) survey
Risk score is based on age, sex, perceived health, availability of
informal caregiver, heart disease, diabetes, physician visits, and
hospitalizations
Validated in many different populations of community-dwelling older
adults, including Medicaid, fee-for-service, and managed-care
patients
Because of associated expenses and <100% response rates, an
administrative proxy has been developed
PATIENT SELECTION FOR
OUTPATIENT INTERVENTIONS (2 of 2)
• Screening questionnaires
The Vulnerable Elders Survey-13 (VES-13)
 13-item questionnaire produces a vulnerability score
from 0 to 10 based on age, self-reported health, function
 Patients with a score ≥ 3 are at 4 times the risk of
functional decline or death over the next 2 years
• Predictive modeling
Use of administrative data to identify high-risk older adults
 Typically analyzes health insurance enrollment records and
claims data with predictions based on age, gender,
diagnoses, prior use of health services and associated
costs, and pharmacy data
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SUMMARY
• Outpatient interventions for older adults should be
personalized, provided by an interprofessional team in
accord with best practices, coordinated among all
providers and settings of care, and consider patients’
resources and environment
• For optimal cost-effectiveness, outpatient programs
need to be targeted to patients at high risk of
hospitalization and likely to be active participants
• Broad dissemination of effective models of outpatient
care are limited by current payment mechanisms and
the shortage of geriatrics health care professionals
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CASE 1 (1 of 4)
• An 81-year-old man comes in for follow-up related to
progressive dementia. He is accompanied by his
daughter, who is concerned about her father’s
increasing number of falls and his forgetfulness.
• He is widowed and lives alone.
• He has lost 4.5 kg (10 lb) over the last 6 months; his
daughter suspects he is not eating much.
• He is unable to manage his medications or finances,
and is increasingly isolated because he no longer drives.
• His daughter is overwhelmed by the amount of care that
her father requires. When she raises the possibility of
placement in an assisted-living facility, he insists that he
can manage on his own without additional help.
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CASE 1 (2 of 4)
• Examination
 He appears thin.
 Blood pressure is 128/84 mm Hg sitting and 102/68 mm Hg
standing.
 He uses his arms to rise from a chair and takes short steps,
stumbling as he goes to the exam table.
 MMSE score is 15 of 30.
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CASE 1 (3 of 4)
Which one of the following referrals would be optimal for
the ongoing care of this patient?
A. Home-healthcare services for nursing and physical
therapy
B. Program of All-Inclusive Care for the Elderly (PACE)
C. Nursing home
D. Assisted-living facility
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CASE 1 (3 of 4)
Which one of the following referrals would be optimal for
the ongoing care of this patient?
A. Home-healthcare services for nursing and physical
therapy
B. Program of All-Inclusive Care for the Elderly (PACE)
C. Nursing home
D. Assisted-living facility
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CASE 2 (1 of 3)
• A 68-year-old woman comes in for a follow-up visit, accompanied by
her daughters. They are visiting from out of town and bring up
several concerns.
 Their mother is increasingly forgetful: she forgets her grandchildren’s names at
times, as well as important events, and she has occasionally paid the same bill
twice.
 She is increasingly fatigued and has recently fallen several times.
• The patient lives alone, cooks for herself, and drives without
problem. She states that she is a little more tired than usual, and
does not think her forgetfulness is unusual.
• History: COPD and diabetes, each longstanding and well-controlled
• Physical examination is unremarkable, with no evidence of focal
neurologic deficits.
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CASE 2 (2 of 3)
Which one of the following is the most appropriate referral
for this patient?
A. Program of All-Inclusive Care for the Elderly (PACE)
B. Home-health services
C. Admission to assisted-living facility
D. Comprehensive geriatric assessment
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CASE 2 (3 of 3)
Which one of the following is the most appropriate referral
for this patient?
A. Program of All-Inclusive Care for the Elderly (PACE)
B. Home-health services
C. Admission to assisted-living facility
D. Comprehensive geriatric assessment
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GRS9 Slides Editor:
Mandi Sehgal, MD
GRS9 Chapter Author:
Steven R. Counsell, MD, AGSF
GRS9 Question Writers:
Elizabeth N. Harlow, MD
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2016
American Geriatrics Society