Program characteristics and enrollees' outcomes in the Program of All-Inclusive Care for the Elderly (PACE).

The Program of All-Inclusive Care for the Elderly (PACE) is a unique program providing a full spectrum of health care services, from primary to acute to long-term care for frail elderly individuals certified to require nursing home care. The objective of this article is to identify program characteristics associated with better risk-adjusted health outcomes: mortality, functional status, and self-assessed health. The article examines statistical analyses of information combining DataPACE (individual-level clinical data), a survey of direct care staff about team performance, and interviews with management in twenty-three PACE programs. Several program characteristics were associated with better functional outcomes. Fewer were associated with long-term self-assessed health, and only one with mortality. These findings offer strategies that may lead to better care.

Team performance and risk-adjusted health outcomes in the Program of All-Inclusive Care for the Elderly (PACE).

PURPOSE: The Program of All-Inclusive Care for the Elderly (PACE) is a community-based program providing primary, acute, and long-term care to frail elderly individuals. A central component of the PACE model is the interdisciplinary care team, which includes both professionals and non-professionals. The purpose of this study was to examine the association between the team's overall performance and the risk-adjusted health outcomes of program enrollees. DESIGN AND METHODS: The study included interdisciplinary teams in 26 PACE programs and 3,401 individuals enrolled in them. We combined information about individuals' health, functional, and mental status from DataPACE with an overall measure of team performance. We used multivariate regression techniques to test the hypothesis that better team performance is associated with better risk-adjusted health outcomes: survival and short-term (within 3 months of enrollment) and long-term (within 12 months of enrollment) improvements in functional status and in urinary incontinence. RESULTS: Team performance was significantly associated with better functional outcomes (both short and long term) and with better long-term urinary incontinence outcomes. There was no significant association with survival. IMPLICATIONS: This study provides empirical evidence for the relationship between team performance and patient outcomes in long-term care. It suggests that PACE programs can improve patient outcomes by improving the functioning of care teams.

Social support and risk-adjusted mortality in a frail older population.

OBJECTIVE: The objective of this study was to test the hypothesis that social support is an important predictor of mortality in a frail older population receiving formal long-term care services. RESEARCH DESIGN AND METHODS: The analysis is based on 3138 individuals enrolled in 28 Programs of All-Inclusive Care for the Elderly (PACE). Information about the enrollees is obtained from dataPACE. Semiparametric Cox proportional hazards models are estimated to assess the importance of individual risk factors, program effect, and social support. RESULTS: The introduction of the social support variables into the mortality model containing the sociodemographic, health needs, and the PACE-site indicator variables results in a significant improvement of the overall model fit. Several social support variables are statistically significant predictors of mortality. Controlling for all participant and caregiver characteristics, participants whose caregiver is a spouse have a significantly lower risk of mortality (hazard ratio = 0.63) compared with those whose caregiver is not a spouse. Furthermore, caregivers' assistance with meals confers a significantly lower risk of morality (hazard ratio = 0.66) compared with no assistance with meals. CONCLUSIONS: This study shows that certain aspects of informal caregiving are important factors enhancing survival in a population of frail, nursing home-certifiable individuals enrolled in a health program that already provides extensive services, including personal care, chores, and meals. Further research to better differentiate between the affective versus the instrumental dimensions of social support is needed to guide programs on how to balance the use of resources to provide both the necessary formal services and the support for the informal caregivers.

Variations in risk-adjusted outcomes in a managed acute/long-term care program for frail elderly individuals.

OBJECTIVE: To develop and investigate the properties of three performance measures based on risk-adjusted health outcomes for a frail, elderly, community-dwelling population enrolled in a managed, acute, and long-term care program. DESIGN: Retrospective analyses of an administrative dataset containing individual level records with information about socioeconomics, health, functional and cognitive status, diagnoses, and treatments. We estimated risk-adjustment models predicting mortality, decline in functional status, and decline in self-assessed health. Each model includes individual risk factors and indicator variables for the program site in which the individual enrolled. Sites were ranked based on their performance in each risk-adjusted outcome, and the properties of these performance measures were investigated. SETTING: Twenty-eight sites of the Program of All-Inclusive Care for the Elderly (PACE) that provide primary, acute, and long-term care services under capitated Medicare and Medicaid payment to a nursing home certifiable, and functionally and cognitively frail community-dwelling elderly population. STUDY PARTICIPANTS: Three thousand one hundred and thirty-eight individuals who were newly enrolled between 1 January 1998 and 31 December 1999. The average age of these enrollees was 78 years, 27% were male, 50% were diagnosed with dementia, and they had approximately 4 Activities of Daily Living limitations and 7.4 Instrumental Activities of Daily Living limitations. MAIN OUTCOME MEASURES: Risk-adjustment models, performance ranking for each site, and correlations between performance rankings. RESULTS: We present risk-adjustment models for mortality, change in functional status, and self-assessed health status. We found substantial variation across sites in performance, but no correlation between performance with respect to different outcomes. CONCLUSIONS: The variations in outcomes suggest that sites can improve their performance by learning from the practices of those with the best outcomes. Further research is required to identify processes of care that lead to best outcomes.

The current state of geriatric medicine: a national survey of fellowship-trained geriatricians, 1990 to 1998.

The rapid growth of the older population has focused national attention on the need for physicians trained in geriatric medicine. To gain insight into the evolving status of the field, with particular focus on career decision-making and academic career development of trainees, we conducted a survey of physicians recently completing geriatric fellowships. The 107 accredited extant geriatric fellowship programs in the United States and Puerto Rico were contacted to identify trainees from 1990 to 1998. A mailed survey addressed relevant career development and training issues. Four hundred ninety out of 787 (62%) physicians responded; 20% completed 1 year and 80% 2 or more years of training. Half made the decision to pursue a career in geriatrics during residency, 27% decided before/during medical school, and a mentor influenced 48%. Currently, 80% have a Certificate of Added Qualifications in geriatric medicine, 69% hold academic appointments, 78% teach, 39% participate in research, and 44% author publications. Most are doing predominantly clinical work in multiple settings. Further analysis of the 1996-to-1998 cohort revealed that those completing fellowships of 2 or more years are more likely to identify all geriatrics as their professional focus, conduct and author research, work with multidisciplinary teams, and participate in professional geriatric societies. This national survey documents career decision-making and the academic and clinical profiles of physicians completing geriatric fellowship training in the past decade. Longer fellowship training is associated with academic career development. Although there is a national need to train clinical geriatricians, the additional need to train and fund future geriatric academic leaders requires increased attention.

Introductory remarks.

This important topic, aging, is really a woman's issue as things now stand. Someday, it is to be hoped, it will be more a man's issue as well, but that is one of the research challenges.Few features of the human aging process have such enormous personal, economic, social, and cultural consequences as the sex differential in lengevity. Life expectancy at birth for women has increased far more rapidly than for men.By the time a person reaches the age of 85, there are approximately five women for every two men. Many other statistics support and illustrate dramatically the importance of gender differences in aging and the challenge of trying to understand why they exist: It is important also to understand the differences in disability.In a recent issue of the Journal of the American Geriatrics Society William Hazzard looked at the biological basis for the sexual differential in longevity His review is extremely thorough and thought-provoking. Dr. Hazzard recently left the geriatric unit at Johns Hopkins School of Medicine to become Chairman of Medicine at Bowman Gray School of Medicine in Winston-Salem, NC.The discussions that follow will examine many aspects of this important subject.

El desafio cientifico: la atención de la salud del anciano

Dadas las caracteristicas demograficas y epidemologicas de la poblacion de mas de 65 anos de edad, en este informe se exploran las principa les vias hacia las cuales se encaminan la investigación cientifica y los servicios medico-sociales