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Why We Are Doomed to Mediocrity in Caring for Seniors!

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The very best part of attending LeadingAge are the conversations. Yesterday’s general session speaker was Atul Gawande who talked about the US healthcare system as it is today and what it could be.

Here are a few snapshots from his talk:

  • The world of aging care and healthcare seem to be separate but they shouldn’t be.
  • Medical care has been about hospitals in the center and home and family on the periphery.   This puts distance between healthcare and the goals people have for their lives.
  • The source of the problem in healthcare and care of seniors is complexity.
  • It is rare when patients really get all the right care they need.  If they are lucky it happens 50% of the time.
  • The most expensive care is not the best care.  Often the best care is the least expensive.
  • Taking a systems approach to healthcare would provide better care, lower costs and happier patients.
  • To make our healthcare system work better, we need to have people who do not normally work together, start working together.
  • We need to go back and look at goals that people have, then  integrate services, housing, homecare, senior housing, hospitals to meet those goals.
  • The goal should be to give people the best possible day they can have that day!

Why We Are Doomed

Over the course of the last two and a half days I have had the opportunity to chat with a number of individuals who play a role in how care and services are delivered to seniors and how those services are paid for. One of the questions I like to ask is this:  Why is it that Assisted Living does not play a role in caring for seniors with significant medical needs?  The short answer is that it is "because Medicare doesn’t pay for it". This is true up to a point, except that once a senior is enrolled in a Medicare Advantage program or a PACE program this no longer true.  Yet, it does not seem to even hold a serious place on radar of any of the payer sources I have talked to.  Even worse, it does not seem to something seriously considered by those who are providing these services.

Imagine these two very real scenarios:

1. A low income senior lives at home in subsidized housing.  Because they live alone, they don’t get adequate nutrition, they don’t do a great job of taking their medications and they are lonely. As a result, of this suboptimal living condition, the negative factors collide and they end in an ambulance to the hospital where they rack up thousands of dollars of charges, paid for with government dollars, or to bring it closer to home, our tax dollars. After a several days in the hospital, they return home until the next episode.   Over the course of a year this one individual will rack up a hundred thousand dollars or more in hospital and physician charges.  Or . . . they could move into a great assisted living community where the social and ADL deficits would be eliminated saving buckets of dollars and improving the resident’s quality of life.   - - - - “Often the best care is the least expensive.”

2.A low income senior has an acute medical event that triggers a legitimate unavoidable hospital stay.  After a week or so, the senior is discharged to skilled nursing where they continue to improve.  After their Medicare days run their course, the patient who still needs supportive care, becomes a custodial patient with their care being paid for by Medicaid still in the nursing home.

The glaring question that never gets asked is this: Would it be possible to place this person in an assisted living community where the quality of life would be better and the cost lower? - - - - “Often the best care is the least expensive.” Ultimately the reason this situation will persist is because it works well for the providers even though it is to the detriment of society and seniors. Steve Moran


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