Health Care Programs for Older Adults

It’s been 25 years since The John A. Hartford Foundation dedicated its sole priority to improving the care of older adults. Today, the organization has been credited with playing an instrumental role in creating the field of geriatrics “essentially from scratch.”

Geriatricians specialize in the care of older adults, whether working as consultants or as primary care physicians. Of the many medical specialties at work in the American health care system, geriatrics has been identified as a niche and growth opportunity, according to Terry Fulmer, PhD, RN, FAAN, and president of The John A. Hartford Foundation.

“Boomers are at the forefront of this next age wave, and I think they will fundamentally restructure the opportunities and the expectations of care and the way in which they are viewed by society. We see in Japan already that older people are highly encouraged to stay in the workforce,” Fulmer said.

Those familiar with the intricate system of Medicare benefits and payment structures can attest to the (sometimes) disconnect between an essential for care delivery, e.g. medical necessity, and optimal care. While much has changed and continues to change toward progressive reforms, we still have a way to go in serving and protecting all beneficiaries.

“We see this play out every day,” said Fulmer, who keeps an eye on developments such as the emerging role of privatization in well-established public programs and the debate for and against Medicare for All.

Even though management of multiple chronic conditions has become a central challenge for older adults, politics surrounds Medicare reform. And with Medicare, the primary insurer for what will soon be 70 million Americans turning 65, some are asking what should be Medicare’s role in the broader continuum of care, what parts of guaranteed care should be reengineered first, and how can we reasonably control costs while protecting and serving patients well? Debates continue from Capitol Hill down to the smallest towns in America.

“There’s a lot of conversation in play, but the most important thing we can do as clinicians and as people guiding families and patients is to be their advocate,” Fulmer said, “because there are structures in place that can help people access care in a way that will meet their needs. We need to be real advocates at this time, because it’s confusing.”

These advocates consist of an interprofessional care team that includes nurses, social workers, and physicians of all types, along with the patient and family.

Twenty years ago, the principles of geriatric care were described as an “interdisciplinary team assessment; care management; continuity of and access to care; adequate custodial homecare; appropriate use of medications; assistive devices for mobility, hearing, and vision; and dignity and relief from suffering at all stages of illness.” So wrote Christine Cassel and colleagues, when Cassel was chairman of the Henry L. Schwarz Department of Geriatrics and Adult Development and professor of geriatrics and medicine at New York City-based Mount Sinai Medical Center, which is considered to be the home of geriatric medicine.

The John A. Hartford Foundation is also based in New York, a metro area that has been an early-adopter region of innovative care modeling, such as Hospital At Home and the Foundation’s current national movement, Age-Friendly Health Systems (AFHS). AFHS, in partnership with the Institute for Healthcare Improvement, has been growing. Five pioneering systems are currently in place, Fulmer said, with another 75 coming onboard around the U.S. The foundation’s goal is to have 20 percent of health systems nationwide “Age-Friendly” by 2020.

“We have two segments, experts in geriatrics and gerontology, and we have everybody else who needs to know key concepts around geriatrics and gerontology,” Fulmer said.

Among the many programs funded by The John A. Hartford Foundation is the American Geriatrics Society’s CoCare, or co-management of care where, for example, geriatricians work with orthopedic surgeons. “The surgeon will do a really good job of fixing the hip, but then they will be less well-versed in how to take care of congestive heart failure…how to take care of dementia…how to take care of other common comorbidities that older people have,” Fulmer said. This is only one part of effective geriatric care.

Fulmer also points to the work of the National Institute on Aging (NIA), which is addressing the difficulties of caregivers of people with dementia. Americans, she says, need to monitor the policies and programs essential to caring for older adults—supporting strong funding for the NIA and the Administration for Community Living (ACL), for example, and the passage of legislation, such as the CARE Act for family caregivers.

“We need to make sure that people with serious illness and at the end-of-life get what they need. We must also make sure policies are in alignment with the goals and preferences of older people. We can’t presume to know what people want—we need to get that data,” Fulmer said.

The John A. Hartford Foundation is classified as a private foundation. Its assets are approaching $600 million. Central to The John A. Hartford Foundation’s work involves taking evidence that is funded by the government, usually the National Institutes of Health, and getting it into practice, into spread and scale.

“Early on, we wanted to create the leadership in the field and the models of care in the field. Now we are going downstream to the point of care, making sure we can create Age-Friendly Health Systems from what we have learned,” Fulmer said.

The January 2019 edition of Health Affairs GrantWatch features a paper covering The John A. Hartford Foundation’s work in the growth of geriatrics and its nearly half-billion-dollar investment. The evaluation was conducted through a quantitative assessment of the output and impact of the foundation; a qualitative assessment of its cumulative impact; and a combined quantitative-qualitative assessment, through trends data and interviews with experts. The paper examines the extent to which health care for older adults has improved and how much the foundation has contributed to this.

The Health Affairs article details the foundation’s support for geriatrics training programs and the development of geriatrics as a field, and outlines care models that have been funded (including community-based care team care, transitional care programs for hospitalized older adults, home-based primary and acute care, depression treatment, palliative care and medication management). The Foundation’s impacts are noted, including the incorporation of aging in curricula, accreditation and board certification requirements.

Some 90 percent of bachelor’s level nursing school programs now integrate geriatrics into at least one required course, up from one in five in the late 1970s, the paper reports. In addition, the paper emphasizes changes to geriatrics policy and leadership, through supporting influential reports by the Institute of Medicine. Collaborations with other funders, partners and aging-focused organizations and their vital roles in all this work are highlighted. Geriatrics, the article says, is “now a recognized medical, nursing, and social work specialty.”

Additionally, the foundation supports a coordinating center for the Geriatrics Workforce Enhancement Programs, or GWEPs, which receive funding through the federal Health Services and Resources Administration (HRSA). The GWEPs train interdisciplinary health care team members in primary care settings with a goal of combining the collective strengths of physicians, nurses, social workers and medical social workers, pharmacists, physical therapists, occupational therapists, medical students, home health aides, community volunteers, community dwelling older adults and more. And these concepts in team-based care are forging new relationships among a variety of care and service points.

The John A. Hartford Foundation, in partnership with the American Geriatrics Society and HRSA, convenes the GWEPs so they can learn from each other. The latest HRSA funding announcement for the GWEPs—toward which grants are now being written—has Age-Friendly Health Systems and the “four Ms” (what matters, medication, mentation and mobility) imbedded into the application.

Helpful Links
HealthAffairs GrantWatch Article
Isaacs/Jellinek Evaluation Report
Geriatrics Workforce, Health Resources & Services Administration
Recent GWEP Project Profiles
The John A. Hartford Foundation
The HomeCare Podcast Episode 2