Geriatric Care Management

Frail elderly patients (generally those > 75 years with multiple chronic health problems complicated by significant functional and psychosocial impairments) are generally classified as "high risk." Once identified, high-risk patients are assigned by triage to geriatric care management programs.

Traditional case management and geriatric care management programs differ (see Table 16-2). The content, substance, and emphasis of geriatric care management programs vary greatly, affecting their efficacy. For example, most programs primarily use telephone communication, whereas others may use home visits. Also, some programs depend completely on primary care providers, whereas others focus on patient self-management.

Most primary care providers (particularly those in Medicare fee-for-service programs) do not have the financial incentives, time, resources, or, in some cases, knowledge to practice effective geriatric care management. By developing geriatric care management programs that provide knowledge, access to the geriatric continuum of care, and additional personnel and resources, MCOs enable primary care providers to practice better geriatric care. Various risk-sharing capitation arrangements give primary care providers the incentive to prevent iatrogenic problems, functional decline, hospitalization, and institutionalization.

MCOs have the financial incentive and organizational capacity to develop, through contracting, an effective geriatric continuum of care, which is crucial to an MCO's success. An effective geriatric continuum of care enables the MCO to use the site providing the most cost-effective care while maintaining quality. Unnecessary or preventable hospitalization--the most expensive component of health care (generally accounting for about 40% of costs)--is avoided through innovative use of subacute and home care (eg, for community-acquired pneumonia) and through shortening of hospital stays (eg, for hip fractures and strokes).

Most MCO models develop a continuum of care by contracting with preferred physician providers, including geriatricians, and other providers (eg, hospitals, subacute and long-term care facilities, home care agencies). Effective access to the continuum of care may be managed by the geriatric care management program. MCOs that send more patients to a specific facility generally receive better service.

Long-term care is covered by very few MCOs, but it can be incorporated into the continuum of care through network development, facilitating access for Medicare MCO members. In addition, several programs, such as the Program of All-Inclusive Care for the Elderly (PACE), are beginning to create managed care for long-term care. PACE pools Medicaid and Medicare capitation to provide comprehensive geriatric care to nursing home-eligible patients. Other models manage the Medicare portion of long-term custodial care; these models offer medical care primarily through extensive use of nurse practitioners.