Exploring opportunities to provide high-quality, community-based care for high-need patients

In the U.S. today, there are more than six million people aged 65 years or older living with multiple health conditions, such as diabetes, heart disease and chronic obstructive pulmonary disease, and more than five million who suffer from dementia or Alzheimer's disease. Many of these "high-need" individuals are also limited in their ability to perform everyday tasks, which can include bathing, dressing and even walking. This population is also living longer. The last phase of life can be several years, with health on a slower, more extended, decline.

Over the next few decades, the age of the U.S. population will shift dramatically with people 65 years and older reaching nearly 84 million – that is almost double the population as of 2012. From a health care perspective this rapid growth, combined with an increase in health needs for a population that is living longer, will have a tremendous burden on our health care system.

Quality care in the community and at home

One of the greatest challenges, in addition to the cost of care, is coordinating and delivering care based on individual preferences and in places people want to receive it: in their communities and in their homes. This will require building new models that integrate the currently fragmented array of primary, specialty and end-of-life care services. It will also require broadening the scope of palliative care – a field devoted to providing people with expert care that serves their goals – beyond hospitals and into the home. Expanding the use of telehealth, coordinating with social services agencies and providing much needed support to the more than 42 million unpaid family caregivers are also requirements.

We see five mutually reinforcing strategies critical to the success of building, spreading and assessing community-based care programs. Derived in part from the Institute of Medicine report Dying in America, the strategies include:

  • Surveillance system (a way to measure and monitor for quality);
  • Public education; payment and accountability;
  • Workforce development; and
  • Model programs (exemplars of high-quality care).

Recognizing that change will require the support of many, and that we cannot do it alone, we identified two areas we believe the foundation can have the greatest impact: strengthening workforce training and support and building effective quality measurement and accountability programs for community-based services.

The foundation will commit $40 million in these two areas from 2017 to 2019. For efforts to strengthen the “workforce,” we use this term to include both paid and unpaid providers of health services. We place emphasis on training and support for family caregivers, who provide most of the daily care and who are not paid. In 2017 we provided a $5 million grant to UC Davis Betty Irene Moore School of Nursing to create the Family Caregiving Institute. In addition to supporting family caregivers, we also help home health aides, social workers and nurses acquire the requisite skills to practice in new delivery models that rely on high-functioning, inter-professional teams to provide care in the home.

From an accountability standpoint, there is an opportunity to fill a void. Currently a robust consumer-protection system does not exist for community-based serious illness care programs. Such a system might include: performance measures for use in public reports that help people select the best providers, payment programs that encourage and reward the provision of high-quality care and accreditation programs. A path forward for building an accountability system can be read in a report released November 2017 titled “Quality Measurement and Accountability for Community-Based Serious Illness Care.” 

We look forward to collaborating with our many partners in serious illness care and sharing our progress and what we have learned along the way.


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