Thursday, March 15, 2018

Dementia & Driving Resource Center (Part 2)

Reprinted from:

Planning ahead
For people in the early stages of Alzheimer's, it is never too soon to plan ahead for how you will get around when you can no longer drive. Putting a plan in place can be an empowering way to make your voice heard.

Tips for planning ahead
Remember that each situation is unique. What works for one person may be different from what works for another. You can get the information and support you need from the Alzheimer's Association at 800.272.3900.
  • Involve family and close friends in the plan.
  • Confront resistance. Empathize with those who are uncomfortable having the conversation and stress the importance of preparing for the future.
  • Develop an agreement for all to share that includes practical safety steps, such as a periodic driving assessment, a GPS monitoring system for the car, and alternate transportation options.

Transportation options
Driving is not the only transportation option available. There are many options people can explore that will allow them to continue to travel independently and remain in control of their mobility.
  • Transition driving responsibilities to others. Arrange for family members and friends to provide transportation.
  • Arrange a taxi service.
  • Use special transportation services for older adults. Access local resources using the Eldercare Locator at or use our Community Resource Finder to search for transportation services.
  • Reduce the need to drive by having prescription medicines, groceries or meals delivered.

Driving evaluation
At the earliest stages, a person with Alzheimer's disease may begin to have difficulty with complex tasks such as driving. Although family and caregivers can watch for signs of unsafe driving, a proactive strategy would be to get a comprehensive driving evaluation by an occupational therapy driving rehabilitation specialist. The evaluation provides a more objective understanding of the current impact of the disease on driving capacity and results in a plan of options. The goal is always to retain the highest level of independence and mobility in the community. Initial recommendations may include strategies to reduce driving risk during the early part of the disease. The occupational therapist can offer strategies specific to the individual's goals and needs. The American Occupational Therapy Association website includes a national database of driving specialists as well as a wealth of resources for both persons with Alzheimer's disease and their families.  

Thursday, March 1, 2018

Dementia & Driving Resource Center (Part 1)

Reprinted from:

Signs of unsafe driving
Determining when someone can no longer safely drive requires careful observation by family and caregivers.
The following list provides warning signs that it's time to stop driving:
  • Forgetting how to locate familiar places
  • Failing to observe traffic signs
  • Making slow or poor decisions in traffic
  • Driving at an inappropriate speed
  • Becoming angry or confused while driving
  • Hitting curbs
  • Using poor lane control
  • Making errors at intersections
  • Confusing the brake and gas pedals
  • Returning from a routine drive later than usual
  • Forgetting the destination you are driving to during the trip
Driving demands quick reaction time and fast decision making — because of this, a person with Alzheimer's will eventually become unable to drive. Dealing with the issue early on can help ease the transition.

Having the conversation
Losing the independence driving provides can be upsetting. It is important to acknowledge a person's feelings and preserve his or her independence, while ensuring the person's safety and the safety of others.

Starting the conversation
  • Initiate a dialogue to express your concerns. Stress the positive and offer alternatives.
  • Address resistance while reaffirming your unconditional love and support.
  • Appeal to the person's sense of responsibility.
  • Reinforce medical diagnoses and directives. Ask the physician to write a letter stating that the person must not drive. Or ask the physician to write a prescription that says, "No driving." You can then use the letter or prescription to reinforce the conversation.
  • Consider an evaluation by an objective third party.
  • Understand that this may be the first of many conversations about driving

When the conversation does not go well
Some people give up driving easily, but for others this transition can be very difficult. Be prepared for the person to become angry with you, due to the memory and insight issues that are part of Alzheimer's.

  • Be patient and firm. Demonstrate understanding and empathy.
  • Acknowledge the pain of this change and appeal to the person's desire to act responsibly.
  • Ask a respected family authority figure or your attorney to reinforce the message about not driving.
  • If the conversation does not go well, do not blame yourself. The disease can impair insight and judgment, making it difficult for people to understand that their driving is no longer safe. Also the disease can cause mood and personality changes that make reactions more pronounced.
  • As a last resort, take away the car keys, disable the car or remove the car completely. When you do any of these things, be sure to provide safe, reliable alternative transportation.

Thursday, February 15, 2018

One Day Your Mind May Fade. At Least You’ll Have a Plan.

Reprinted from:
By Paula Span

When Ann Vandervelde visited her primary care doctor in August, he had something new to show her.

Dr. Barak Gaster, an internist at the University of Washington School of Medicine, had spent three years working with specialists in geriatrics, neurology, palliative care and psychiatry to come up with a five-page document that he calls a dementia-specific advance directive.

In simple language, it maps out the effects of mild, moderate and severe dementia, and asks patients to specify which medical interventions they would want — and not want — at each phase of the illness.

“Patients stumble into the advanced stage of dementia before anyone identifies it and talks to them about what’s happening,” Dr. Gaster told me. “At what point, if ever, would they not want medical interventions to keep them alive longer? A lot of people have strong opinions about this, but it’s hard to figure out how to let them express them as the disease progresses.”

One of those with strong opinions, it happens, was Ms. Vandervelde, 71, an abstract painter in Seattle. Her father had died of dementia years before, in a nursing home after her mother could no longer care for him at home. Ms. Vandervelde had also spent time with dementia patients as a hospice volunteer.
Further, caring for her mother in her final year, Ms. Vandervelde had seen how family conflicts could flare over medical decisions. “I was not going to leave that choice to my children if I could spare them that,” she said.

So when Dr. Gaster explained his directive, “it just made so much sense,” Ms. Vandervelde said. “While I could make these decisions, why not make them? I filled it out right there.”

Like a growing number of Americans over age 60, she already had a standard advance directive, designating a decision-maker (her husband) to direct her medical care if she became incapacitated.

Not all experts are convinced another directive is needed. But as Dr. Gaster and his co-authors recently argued in the journal JAMA, the usual forms don’t provide much help with dementia.

“The standard advance directives tend to focus on things like a ‘permanent coma’ or a ‘persistent vegetative state,’” Dr. Gaster said. “Most of the time, they apply to a person with less than six months to live.”

Although it’s a terminal disease, dementia often intensifies slowly, over many years. The point at which dementia patients can no longer direct their own care isn’t predictable or obvious.

Moreover, patients’ goals and preferences might well change over time. In the early stage, life may remain enjoyable and rewarding despite memory problems or difficulties with daily tasks.

“They have potentially many years in which they wouldn’t want a directive that says ‘do not resuscitate,’” Dr. Gaster said. But if severe dementia leaves them bedridden, unresponsive and dependent, they might feel differently — yet no longer be able to say so.

Whereas a persistent vegetative state occurs rarely, Dr. Gaster tells his patients, dementia strikes far more commonly.

How commonly? That’s not a simple question to answer.

Researchers often cite the long-term Framingham study, which in 1997 estimated the lifetime risk at age 65 as 10.9 percent for men and 12 percent for women.

But the participants in that study were overwhelmingly white. Among the populations facing higher dementia rates are African-Americans, Dr. Murali Doraiswamy, a neuroscientist at Duke University, pointed out.

Last year, the journal Demography published a more representative model, estimating that for the cohort born in 1940, the lifetime risk at age 70 was 30.8 percent for men and 37.4 percent for women.
Dr. Gaster tells patients that “somewhere between 20 and 30 percent of us will at some point develop dementia.” Over the past year, as patients turn 65 and qualify for Medicare — which covers a visit to discuss advance care planning — he has offered them his dementia-specific directive, intended to supplement their other directives.

For each stage of dementia, the patient can choose among four options. “Full efforts to prolong my life” and “comfort-oriented care only, focused on relieving suffering” represent two ends of the spectrum.

Patients can also opt for lifesaving treatments — except when their hearts stop or they can’t breathe on their own, precluding resuscitation or ventilators.

Or they can opt to receive care where they live but avoid hospitalization. “For someone who doesn’t understand what’s happening, going to an E.R. or being hospitalized can be really traumatic,” Dr. Gaster said. The experience can lead to delirium and other setbacks.

So far, 50 to 60 patients have filled out the form. A few have declined his offer to discuss dementia; others “nod and thank me and take it home and never mail it back.”

But most appreciate the overture, Dr. Gaster said, especially if family members have experienced dementia. “It’s something they think and worry about, and they welcome the idea because they do have clear wishes.” In that case, he adds the completed form to their medical records.

We could debate whether a separate dementia form, on top of the general advance directive everyone should have, makes sense. Already, nurses and doctors lament that paperwork often winds up forgotten in a drawer, a safe deposit box or a lawyer’s office, unavailable in a crisis.

If patients haven’t updated the directive in years, their designated proxies may have moved or died. Proxies may never have learned their loved ones’ preferences in the first place. Will adding another directive clarify this process?

Other leaders in the campaign to persuade Americans to document their end-of-life wishes had questions, too.

Ellen Goodman, founder of The Conversation Project (whose dementia-related kit similarly presents choices at different stages), pointed out that the new form represents a patient-doctor agreement.

“We need to have families involved,” she said. “No checklist on earth is going to cover everything you encounter. Most important is the conversation with the decision-maker. That person has to understand what you value and what’s important to you.”

Dr. Rebecca Sudore, a geriatrician and palliative care specialist at the University of California, San Francisco, agreed. Her effort — Prepare for Your Care, an online guide — encourages users to incorporate their reasons for various decisions. “At the bedside, the ‘why’ is very important,” she said.

Both The Conversation Project and Prepare for Your Care provide links to the advance directive/durable power-of-attorney forms legal in each state.

What’s not in dispute: It’s crucial to talk to family, friends and doctors about the quality of life we find acceptable and unacceptable, which interventions we agree to or don’t — and then to document those decisions and circulate the document to designated decision-makers and everyone else who might be involved.

And yes, we should incorporate decisions about dementia into that process, whether in a separate form or not.

When Ann Vandervelde completed her dementia-specific directive, “I felt great relief,” she said. It gave her a sense of control, “and that’s really important to me, to be in the driver’s seat all the way to the end.”

Thursday, February 1, 2018

Home Care Agencies Often Wrongly Deny Medicare Help To The Chronically Ill

Republished from:

January 17, 2018

Colin Campbell needs help dressing, bathing and moving between his bed and his wheelchair. He has a feeding tube because his partially paralyzed tongue makes swallowing "almost impossible," he says.

Campbell, 58, spends $4,000 a month on home health care services so he can continue to live in his home just outside Los Angeles. Eight years ago, he was diagnosed with amyotrophic lateral sclerosis, or Lou Gehrig's disease, which relentlessly attacks the nerve cells in his brain and spinal cord and has no cure.

Because of his disability, he has Medicare coverage, but he can't use it for home care — as the former computer systems manager has been told by 14 home health care providers.
That's an incorrect but common belief. Medicare does cover home care services for patients who qualify but, according to advocates for seniors and the home care industry, incentives intended to combat fraud and reward high quality care are driving some home health agencies to avoid taking on long-term patients, such as Campbell, who have debilitating conditions that won't get better. Rule changes that took effect this month could make the problem worse.

"We feel Medicare coverage laws are not being enforced and people are not getting the care that they need in order to stay in their homes," says Kathleen Holt, an attorney and associate director of the Center for Medicare Advocacy, a nonprofit, nonpartisan law firm. The group is considering legal action against the government.

Federal law requires Medicare to pay indefinitely for home care — with no copayments or deductibles — if a doctor ordered it and patients can leave home only with great difficulty. They must need intermittent nursing, physical therapy or other skilled care that only a trained professional can provide. They do not need to show improvement.

Those who qualify can also receive an aide's help with dressing, bathing and other daily activities. The combined services are limited to 35 hours a week.

Medicare affirmed this policy in 2013 when it settled a key lawsuit brought by the Center for Medicare Advocacy and Vermont Legal Aid. In that case, the government agreed that Medicare covers skilled nursing and therapy services — including those delivered at home — to maintain a patient's abilities or to prevent or slow decline. It also agreed to inform providers, those who audit bills, and others that a patient's improvement is not a condition for coverage.

Campbell says some home health care agencies told him Medicare would pay only for rehabilitation, "with the idea of getting you better and then leaving," he says. They told him that Medicare would not pay them if he didn't improve, he says. Other agencies told him Medicare simply did not cover home health care.

Medicaid, the federal-state program for low-income adults and families, also covers home health care and other home services, but Campbell doesn't qualify for Medicaid.
Securing Medicare coverage for home health services requires persistence, says John Gillespie, whose mother has gone through five home care agencies since she was diagnosed with ALS in 2014. He successfully appealed Medicare's decision denying coverage, and afterward Medicare paid for his mother's visiting nurse as well as speech and physical therapy.

"You have to have a good doctor and people who will help fight for you to get the right company," says Gillespie, of Orlando, Fla. "Do not take no for an answer."

Yet a Medicare official did not acknowledge any access problems. "A patient can continue to receive Medicare home health services as long as he/she remains eligible for the benefit," says spokesman Johnathan Monroe.

A leading industry group contends that Medicare's home health care policies are often misconstrued. "One of the myths in Medicare is that chronically ill individuals are not qualified for coverage," says William Dombi, president of the National Association for Home Care and Hospice, which represents nearly half of the nation's 12,000 home care providers.

Part of the problem is that some agencies fear they won't be paid if they take on patients who need their services for a long time, Dombi says. Such cases can attract the attention of Medicare auditors who can deny payments if they believe the patient is not eligible, or they suspect billing fraud. Rather than risk not getting paid, some home health agencies "stay under the radar" by taking on fewer Medicare patients who need long-term care, Dombi says.
And those companies may have a good reason to be concerned. Medicare officials have found that about a third of the agency's payments to home health firms in the fiscal year ending last September were improper.

Shortages of home health aides in some areas might also lead an overburdened agency to focus on those who need care for only a short time, Dombi says.

Another factor that may have a negative effect on chronically ill patients is Medicare's Home Health Compare ratings website. It includes grades on patient improvement, such as whether a client got better at walking with an agency's help. That effectively tells agencies who want top ratings "to go to patients who are susceptible to improvement," Dombi says.

This year, some home care agencies will earn more than just ratings. Under a Medicare pilot program, home health firms in nine states will start receiving payment bonuses for providing good care and those who don't will pay penalties. Some criteria used to measure performance depend on patient improvement, Holt says.

Another new rule, which took effect last Saturday, prohibits agencies from discontinuing services for Medicare and Medicaid patients without a doctor's order. But that, too, could backfire.
"This is good," Holt says. "But our concern is that some agencies might hesitate to take patients if they don't think they can easily discharge them."

This article was written with the support of a journalism fellowship from New America Media, the Gerontological Society of America and the Silver Century Foundation. Kaiser Health News (KHN) is a nonprofit news service. It's an editorially independent program of the Kaiser Family Foundation, and not affiliated with Kaiser Permanente. You can find Susan Jaffe on Twitter @susanjaffe.

Monday, January 15, 2018

The Hospital Is No Place for the Elderly (3rd of 3 installments)

The elderly flock to Phoenix, Arizona. Not surprisingly, the city is home to one of the country’s biggest nonprofit hospice organizations, Hospice of the Valley. Better than most people in the medical system, hospice providers understand the trouble with hospitals. In the early 2000s, Hospice of the Valley began experimenting with an in-home program designed to bridge the frailty gap—that is, the gap between hospital and hospice. That experiment led to the development of a team-based approach in which nurses, nurse-practitioners, social workers, and sometimes physicians visit clients’ homes, provide and coordinate care, and observe people outside the context of the medical system. “That face time is what makes the program work,” David Butler, Hospice of the Valley’s executive medical director, told me. Butler says that for the 900 people it serves, the program decreases hospitalizations by more than 40 percent, and ER visits by 25 to 30 percent.

Though the program collects whatever payment it can from Medicare and private insurance, it operates at a loss, and is run as a community service and a form of R&D. But things have changed recently. Insurance companies and other providers have begun asking Hospice of the Valley to contract with them to pick up their caseloads of high-cost, chronically ill patients. At the beginning of this year, the program was earning enough in reimbursements to cover one out of seven patients; today the rate is more like one in three. That is still not enough, but when a few more big contracts come through, Butler says, perhaps in a year or 18 months, enough of the patient base will be covered to tip the program into the black.

This would have been impossible a few years ago. Most people saw in-home care as too expensive and logistically complicated even to think about—and in any case, no one would pay for it. So what’s happened?

A few things, not least among them the Affordable Care Act. Under the new health-care law, Medicare has begun using its financial clout to penalize hospitals that frequently readmit patients. Suddenly, hospitals are not so eager to see Grandma return for the third, fourth, or fifth time. Obamacare has also earmarked money specifically to test new care models, including home-based primary care. Thanks to a $13 million Medicare innovation grant, for example, Sutter is rolling out Advanced Illness Management to its entire health network, to test whether the program can be scaled up. If the results of such tests are good, that would provide impetus—and of course, the very fact that Medicare is investing in the experiment signals its interest. Perhaps most important, Obamacare is changing the business calculus by creating alternatives to fee-for-service payment. It is beginning to set up new provider networks and payment schemes that let health systems and insurers share in what they can save by preventing unneeded treatment (while also requiring them to shoulder some of the risk of cost overruns).

Those reforms are still fledgling, and too technical to garner public attention amid the ballyhoo over insurance mandates and the like, but they have already begun to reinforce what people in the geriatrics world tell me is a change in the culture of health care. “The idea of cost avoidance is no longer categorically rejected,” Butler says.

Stuart speaks of a new receptiveness among health systems’ financial executives, at Sutter and elsewhere. “A few years ago, you couldn’t get a new idea across the desk of a CFO unless it generated revenues. If all you could do was save money, it was like, forget it.” Now, he says, CFOs want to hear about savings, because they expect the old sources of revenue—more treatments with more gadgets at higher costs—to dry up. Jeff Burnich, a vice president at Sutter, told me that the business case for aim is only getting stronger. “Most health providers, if not all of us, lose money on Medicare, so how we make up for that is, we cost-shift to the commercial payers,” he said. But the space for cost-shifting is shrinking. “The way you bend the cost curve now is by focusing on where there’s waste and inefficiency, and that’s the end of life in the Medicare population.” He expects to see a wave of hospitals fail in coming years if they don’t provide better value. “The music has stopped,” he said, “and there are five people standing, and one chair.”

Switching to a home-based model of primary care will be a challenge. Medicare, a bureaucratic behemoth designed in the 1960s, moves slowly and will need a lot of time to adjust. Physicians, a notoriously self-important lot, will need to see themselves as part of a team in which a nurse or a social worker often takes the lead. Nurses will need to see hospitalization as a last rather than a first resort. Patients will need to learn that home care can be as good as hospital care, often better. None of this will happen fast.

Still, the mood among people I’ve talked with in the home-based movement is upbeat. I think of them as mammals skittering beneath the feet of dinosaurs, fragile and vulnerable in a newly established niche but better adapted to the changing ecology. The very fact that change agents like Brad Stuart at Sutter, George Taler at Washington Hospital Center, and David Butler at Hospice of the Valley have found success and built constituencies within big corporate health-care systems speaks volumes. At Sutter, aim has acquired institutional and financial momentum of its own; executives there say they expect to expand their annual patient load from about 2,000 today to between 5,000 and 7,000, which would make it the Sutter network’s standard method of care for the frail. “We can’t staff up fast enough to meet the demand,” Sutter’s Jeff Burnich said. “It would be easier to close a hospital than to close this program.”

Believing that aim’s future is secure, Brad Stuart recently left Sutter and, with a colleague, formed a consulting company called Advanced Care Innovation Strategies, to advise health systems and insurance companies around the country on better ways to cope with frail patients and advanced illness. With his 65th birthday coming up, Stuart will soon qualify for Medicare himself. His wife wishes he would slow down, before his own frailty course sets in. He refuses. “That would be like spiritual suicide right now,” he told me, “because there is so much going on. I’m more hopeful all the time. We’ve rolled the rock all the way to the top of the hill, and now we have to run to keep up as it rolls down the other side.”

Monday, January 1, 2018

The Hospital Is No Place for the Elderly (2nd of 3 installments)

The “frailty course,” a gradual and medically complicated downslide, was once exceptional but is now the likely path for half of today’s elders.

Home-based primary care comes in many varieties, but they share a treatment model and a business model. The treatment model begins from the counterintuitive premise that health care should not always be medical care. “It’s not medical treatment, it’s helping meet personal goals,” Brad Stuart said. “It’s about ‘Who is this person, and what do they want in their life?’ ”

In Sutter’s Advanced Illness Management program, known as aim, each patient is assigned to a team of nurses, social workers, physical and occupational therapists, and others. The group works under the direction of a primary-care physician, and meets weekly to discuss patient and family problems—anything from a stroke or depression to an unexplained turn for the worse or an unsafe home.
I sat in on some of these team meetings. A social worker and a nurse talked over a case and decided they needed to make a home visit together; a doctor suggested a medication change; the various members of the group compared notes on one patient’s hospitalization while discussing whether another’s 911 call might have been averted. Strikingly, patients were presented not as bundles of syndromes—as medical charts—but as having personal goals, such as making a trip or getting back on their feet. The team tries to think about meeting patients’ goals rather than performing procedures. An advantage of the multidisciplinary approach is that over time, as clients’ conditions change, the group can recalibrate the mix of services and providers, to avoid jarring transitions. “Once in aim, always in aim,” one coordinator told a patient’s family. Over several years, a person might move from independence and occasional social-worker visits to hospice care and finally death, all within aim, and mostly at home.

One recent morning, while I was waiting at Sutter to accompany a nurse and a social worker on a home visit, the phone rang. It was a panicked caregiver whose charge had rectal bleeding. A case manager alerted the patient’s regular nurse so that she could make a visit right away, almost certainly averting a 911 call, and possibly an ambulance/ER/hospitalization ordeal. Later, in Washington, D.C., accompanying George Taler on house calls, I met a 92-year-old man afflicted with hypertension, blindness, gout, and diabetes, who had been in and out of the hospital before entering Washington Hospital Center’s home-care program in 2007, and who has not been back since—a fact that pleased him. (“I hate the hospital.”) I also met a 75-year-old woman who had recently had a massive stroke; her daughter said Taler’s program had averted at least two ambulance calls since then.

Sutter figures that the program, by keeping patients out of the hospital whenever possible, saves Medicare upwards of $2,000 a month on each patient, maybe more. The VA, for its part, says its program reduces hospital days for its patients by more than a third and reduces combined costs to the VA and Medicare by about 13 percent.

But now we come to the business model, which has been problematic. For doctors, nurses, health systems, and insurers, providing in-home service costs money. Medicare pays for hospitalization, but it does not pay for much by way of in-home care, or for social workers, or for time spent coordinating complex cases and traveling to homes and talking with caregivers. Where in-home primary care has existed, it has tended to be a foundation-funded experiment, or a charitable project, or part of a vertically integrated system like the VA, which can capture any savings. The home-care program at Washington Hospital Center runs at a 30 percent loss. Meanwhile, hospitals lose “heads in beds,” and therefore revenue. Medicare—which is to say, taxpayers—may save money, but it has no mechanism either to track savings or to pay providers and insurers for hospitalizations that do not happen.

This is why Brad Stuart was frustrated for so many years. He could see the path forward, and others could see it, but it was blocked. Today, though, he’s feeling optimistic. The path is clearing.

Friday, December 15, 2017

The Hospital Is No Place for the Elderly (1st of 3 installments)

Medical treatment for aging, chronically ill patients is costly and often ineffective. Can they get better care at home?


It is 1976. Brad Stuart is in his third year of medical school at Stanford, doing his first clinical rotation. He is told to look at an elderly man with advanced lymphoma. The patient is feeble and near death, his bone marrow eviscerated by cancer. The supervising oncologist has ordered a course of chemotherapy using a very toxic investigational drug. Stuart knows enough to feel certain that the treatment will kill the patient, and he does not believe the patient understands this. Like a buck private challenging a colonel, he appeals the decision, but a panel of doctors declines to intervene. Well, Stuart thinks, if it must be done, I will do it myself. He mixes the drug and administers it. The patient says, “That hurts!” A few days later, the man’s bed is empty. What happened? He bled into his brain and died last night. Stuart leaves the room with his fists clenched.

To this day, he believes he killed the patient. “I walked out of that room and said, ‘There has got to be a better way than this,’ ” he told me recently. “I was appalled by how we care for—or, more accurately, fail to care about—people who are near the end of life. We literally treat them to death.”

Here is a puzzling fact: From 1970 until 2009, spending on health care in this country rose by more than 9 percent annually, creating fiscal havoc. But in 2009, 2010, and 2011, health-care spending increased by less than 4 percent a year. What explains the change? The recession surely had something to do with it. But several recent studies have found that the recession is not the whole story. One such study, by the Harvard University economists David Cutler and Nikhil Sahni, estimates that “structural changes” in our health-care system account for more than half of the slowdown.

In a sense, Brad Stuart is one of those changes. He is a leader in a growing movement advocating home-based primary care, which represents a fundamental change in the way we care for people who are chronically very ill. The idea is simple: rather than wait until people get sick and need hospitalization, you build a multidisciplinary team that visits them at home, coordinates health-related services, and tries to nip problems in the bud. For the past 15 years, at Sutter Health, a giant network of hospitals and doctors in Northern California, Stuart has devoted himself to developing home-based care for frail, elderly patients.

For years, many people in medicine have understood that late-life care for the chronically sick is not only expensive but also, much too often, ineffective and inhumane. For years, the system seemed impervious to change. Recently, however, health-care providers have begun to realize that the status quo is what Stuart calls a “burning platform”: a system that is too expensive and inefficient to hold. As a result, new home-based programs are finally reaching the market, such as one launched about five years ago at Sutter, called Advanced Illness Management. “It’s much more feasible now to make a program like this work than it was a few years ago,” Stuart told me. “There are a lot of new payment schemes in the pipeline that are going to make this kind of program much easier to support.”

This is good news. Generalizing from a small sample is always perilous, but if what is happening at Sutter is any indication, a more humane, effective, and affordable health-care system is closer than we think.

The problem that home-based primary care addresses has been well understood for years. Thanks to modern treatment, people commonly live into their 70s and 80s and even 90s, many of them with multiple chronic ailments. A single person might be diagnosed with, say, heart failure, arthritis, edema, obesity, diabetes, hearing or vision loss, dementia, and more. These people aren’t on death’s doorstep, but neither will they recover. Physically (and sometimes cognitively), they are frail. Joanne Lynn, the director of the Altarum Institute’s Center for Elder Care and Advanced Illness, says that this “frailty course,” a gradual and medically complicated downslide, was once exceptional but is now the likely path for half of today’s elders.

Seniors with five or more chronic conditions account for less than a fourth of Medicare’s beneficiaries but more than two-thirds of its spending—and they are the fastest-growing segment of the Medicare population. What to do with this burgeoning population of the frail elderly? Right now, when something goes wrong, the standard response is to call 911 or go to the emergency room. That leads to a revolving door of hospitalizations, each of them alarmingly expensive. More than a quarter of Medicare’s budget is spent on people in their last year of life, and much of that spending is attributable to hospitalization. “The dramatic increase in costs in the last month of life is largely driven by inpatient hospital stays,” Helen Adamopoulos recently reported on “On average, Medicare spends $20,870 per beneficiary who dies while in the hospital.”

Hospitals are fine for people who need acute treatments like heart surgery. But they are very often a terrible place for the frail elderly. “Hospitals are hugely dangerous and inappropriately used,” says George Taler, a professor of geriatric medicine at Georgetown University and the director of long-term care at MedStar Washington Hospital Center. “They are a great place to be if you have no choice but to risk your life to get better.” For many, the worst place of all is the intensive-care unit, that alien planet where, according to a recent study in the Journal of the American Medical Association, 29 percent of Medicare beneficiaries wind up in their last month of life. “The focus appears to be on providing curative care in the acute hospital,” an accompanying editorial said, “regardless of the likelihood of benefit or preferences of patients.”

Taler can attest to one of the more peculiar elements of this situation, which is that a better model—namely, providing care and support at home—has been known and used for decades. Taler himself pioneered an interdisciplinary house-call model in Baltimore in 1980, and in 1999 he co-founded a home-based primary-care program at Washington Hospital Center that has served almost 3,000 people. In the 1970s, the Veterans Administration (now the Department of Veterans Affairs) began building a home-based primary-care program, which now operates out of nearly every VA medical center and serves more than 31,000 patients a day. This is not newfangled, untested stuff.