Contextualización: reconociendo a los actores.

Chronic care requires an information platform. It is essential to track changes in patients’ status over time and to relate outcomes to treatments. Clinicians’ observations need to be structured and directed to emphasize salient information in the midst of so much data on so many conditions. Information needs to be shared among the variety of involved parties. Duplicate efforts to collect the same data need to be eliminated and care better coordinated.

Computers and electronic networks provide a promising mechanism to achieve these ends. It is now feasible to introduce information systems that can track clinically relevant parameters and indicate when the patient’s course is significantly straying from what is expected (Kane, 2000).

Early indications of deviations from an expected course provide an opportunity for modest mid-course corrections. Patients can actually provide much of the data directly and thus become more actively involved in their own care. Ironically, a substantial body of research has been devoted to testing innovative approaches to providing better chronic care. The results of many randomized clinical trials are shown in Table 1, which is based on an earlier review (Boult et al., 2000).

The paradoxical observation that follows from this review is that despite often strong evidence of efficacy, very few of these innovations have been widely implemented. At the same time, case management, which is the approach with the least supportive evidence, has been actively embraced as a prerequisite for most efforts to integrate medical and social care.

Table 1. Effectiveness of interventions in chronic conditions, as shown in randomized clinical trials

+ + + + + + = + + + + = = - + + + + + + = + = + + + + + + = + = = = = = = =

Adapted from Boult et al., 2000

Satisfaction Function Utilization Costs Mortality

Geriatric evaluation and management Interdisciplinary home care Self management Group care Home hospital Disease management Professional dyads in nursing home Acute care for elderly wards Transitional care Case management Key:

+ : significant increase or significantly greater – : significant decrease or significantly less = : no significant difference

6 Conclusions

Long-term care is basically a social service directed at persons with severe chronic health problems. As such, these people are also likely to require active medical care, which should be closely coordinated with their supportive care. Indeed, nursing-home residents, for example, use on average about three times as much care as non-residents. This difference is due to their disability status rather than their residential location.

If the chronic care model is realized and applied, those providing supportive care – be they paid or unpaid – should do so in conjunction with medical care providers. There should be a shared set of objectives. Each component may emphasize its own particular aspects, but each should be aware of the other’s and neither should conflict. Too often, the two groups exhibit philosophically different approaches to care. The long-term care providers appear to work from a premise that their goal is to compensate for their clients’ deficiencies (primarily functional). Good care produces services that address these inadequacies without incurring any complications. Thus, the well-tended frail older person who is free of pressure sores and urinary infections may be viewed as a success. Medical care providers tend to assume a more aggressive stance. Although most do not expect to achieve cures, they do aim for a change in the client’s clinical trajectory as a result of their efforts. In many cases, the benefit is best expressed as a slowing in the rate of decline.

This same therapeutic orientation can and should become a goal for long-term care. However, demonstrating such success can be difficult. It requires some point of reference, because the only visible evidence is often of decline. The evidence of success lies in comparing the actual course to what can be reasonably expected.

An important component of chronic care is early intervention. Caregivers, both formal and informal, need to be sensitized to detecting early signs of change in status and intervening before a crisis is reached. Such a surveillance system requires systematic collection of information and education of users. At present, substantial effort goes into data collection, especially in nursing homes and home health care, but little of that information is used to direct care. Ironically, while many American nursing-home personnel complain about the burden of data collection from the Resident Assessment Instrument (RAI),1 _{others who}

use the same information system in other countries voluntarily extol it as a great leap forward (Ribbe et al., 1997; Sgadari et al., 1997; Phillips et al., 1997; Fries et al., 1997).

1 _{The RAI has two components: the Minimum Data Set (MDS), which is a standardized set of} observations, and the Resident Assessment Protocols (RAPs), which are lists of items to consider in evaluating a potential problem suggested by the MDS.

Part of the problem may lie with its mandatory imposition from outside, but another part derives from its lack of clinically-useful information to track disease status. It needs to be translated into a simple tracking system that will allow caregivers to focus on relevant items more frequently without being burdened with a comprehensive measure.

Coordination of acute and long-term care is impeded both culturally and programmatically. We have already noted the differences in philosophy between medical and long-term care providers. Often the long-term care professionals see themselves as protecting their clients from overly-aggressive medical activity. Because the price of failure (an untoward event) is higher than the rewards for success, an aura of therapeutic nihilism sets in. Long-term care, especially nursing-home care, is actively regulated. Most of the regulations penalize mistakes; few reward caring.

A major source of schismatic care is payment. In general, acute care (even if it is for chronic problems) is covered by Medicare, whereas long-term care is predominantly paid for either by Medicaid or out-of-pocket. These different payment sources come with different eligibility rules, different measures of success, and different incentives. In general, long-term care payment is based on the client’s level of disability.2 _{Medical care is usually}

paid for on a piece-work basis. Both are increasingly being brought under various forms of prospective payment. Under the long-term care prospective payment models, greater care needs (reflected usually in greater levels of disability) generate greater payments. Hence, the unstated incentive is to create or maintain disability, although everyone vehemently denies that any provider would actually respond to such an enticement.

For both groups, the time horizon is usually short. Prospective payment for nursing homes is calculated on a daily basis. Home care may eventually use episodes as the basis for the calculations but no decisions have yet been made. Neither has built-in incentives to employ some concept of investment, whereby more care at an early stage might produce benefits later.

Coordinating payment is a necessary but not sufficient condition to effect integration of acute and long-term care. Major changes in the infrastructure are required. Before those changes can be even attempted, it is necessary to gain the physicians’ attention. As long as physicians view care of older persons as at best only a modest portion of their practice activity, they will not be receptive to considering the sweep of practice changes needed to effectively address chronic disease.

2 _{Medicaid eligibility first requires a stipulated level of poverty, expressed in terms of income}

However, most physicians have been extremely reluctant to embrace geriatrics. In the United States, for example, some physicians who took and passed the certification for added qualifications examination kept that fact a secret, lest they be expected to see a preponderance of geriatric patients. The answer may lie in redefining the issue, away from geriatrics per se to the broader purview of chronic care.