Late Life Care

The current US health care system is unprepared to meet the needs of the rapidly aging population and, as a result, this period of life can be very stressful. For older adults, remaining independent at home and active in the community, not burdening loved ones financially, and having their wishes for care honored, are top priorities. Instead, however, many receive unwanted care and a great number accumulate substantial debt. In the United States, average annual health care spending in the last year of life is $82,000, not including personal and family spending.

“Late Life” individuals, defined as those aged 65+ with multiple chronic conditions and functional limitations, represent only 7% of the US population but account for 33% of total national health care spending on direct patient care, with an annual health care spend of $277 billion for community-dwelling individuals, and $534 billion when the nursing home population is included. 

Expanded supplemental benefits of Medicare Advantage plans now offer a unique opportunity to invest in innovative methods of care delivery that address the priorities of older adults, improve outcomes, and safely meet the imperative to reduce Medicare spending growth. In January 2019, this expansion included categories such as adult day services, in-home support, caregiver support, and home safety modifications, while an additional expansion on the horizon for 2020 will allow even more flexibility. 

To accelerate adoption of these expanded supplemental benefits by Medicare Advantage plans, CERC recognized the need to quickly test and implement concrete ideas based on the needs of the beneficiaries and their health plans. 

CERC’s Late-Life care model identifies three innovations that could be implemented by Medicare Advantage plans to better meet the needs of older adults and reduce per capita spending. They include 1) community (engaging well-functioning seniors as in-home health workers, 2) capability (improving seniors’ functional capabilities and home environments), and 3) communication (using telemediated behavioral health specialists to help patients articulate their health goals). We propose that these solutions fall within the scope of the recently expanded Medicare Advantage supplemental benefits, and we estimate that the new Care Model would offer substantial annual savings for the Medicare Advantage population and individual plans.

Projects and Outcomes

Given the rising cost of care and low levels of patient satisfaction, there is a unique opportunity to align what people value most with the broader national goals of improving quality and decreasing the costs of care for this population. We estimate the three interventions will lead to substantial savings for the Medicare Advantage population and individual plans. Estimated cost reductions per intervention include:

  1. Community: Reduction of 30-day hospital readmission rates

  2. Capability: Average savings of $922 PMPM to Medicare

  3. Communication: Average savings of $13,956 per member in the last six months of life/li>

Challenges and Solutions

  1. The prevalence of social isolation—a lack or paucity of social networks, interactions and supports—has been directly linked to poor health outcomes, increased risk of mortality, and consistently higher health care costs.

    Solution: Leverage the aging community as both companions and lay health workers.

  2. Functional decline leads to hospitalizations and institutionalization. The majority of older adults would like to stay in their homes, however the burden of increasing functional decline often makes it difficult to do so.
    Solution: A compelling solution addressing this challenge is an interdisciplinary team of a nurse, an occupational therapist and a handyperson who conduct a limited number of in-home visits.

    Solution: A compelling solution addressing this challenge is an interdisciplinary team of a nurse, an occupational therapist and a handyperson who conduct a limited number of in-home visits.

  3. Misaligned care. The medical care delivered at the end of life often does not align with patient wishes. Ongoing conversations about health goals between patients, their medical decision-makers and health care providers are critical to providing goal-concordant care.

    For providers, the primary barriers are 1) fear of removing hope, 2) prognostic uncertainty, and 3) competing clinical and administrative demands, whereas the primary barrier for patients is that they are waiting for their providers to initiate the conversation.

    Solution: Given the many barriers that providers must overcome to initiate these conversations, we chose to focus on an intervention that empowers the patient to define and share their values and health goals.

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