No abstract

An evaluation of medical services for elderly members in the Social Health Maintenance Organization (SHMO) demonstrations is presented. The SHMOs generally failed to offer special geriatric medical services to the frail elderly, and the coordination of SHMO medical services with the special long-term care and case management services offered by the SHMOs was limited. These limitations led to some problems for the elderly in terms of access, continuity of care, and satisfaction. Variations in medical services occurred across sites, but generally the SHMOs established by mature HMO organizations appeared to offer more efficient and effective medical services than newly formed SHMOs.

The Program of All-inclusive Care for the Elderly (PACE) grew out of a small community organization in San Francisco and has been replicated by non-profit organizations in a number of other communities across the country. The authors review the successes of PACE as reported in the literature and discuss reasons for its limited growth as well as its significant influence on state and federal long term care policy. They argue that PACE has significantly changed how we think of long term care through its pioneering work fully integrating medical and long term care. PACE has also provided an influential model for breaking down the funding silos that characterize the medical and long term care services arena. State Medicaid agencies and Medicare have learned from PACE. Health plans and private long term insurers may also still learn from PACE. However, the fact that only a little more than 10,000 elders have enrolled in PACE nationwide prevents the authors from finding that PACE has brought about significant structural change in a long term care industry dominated by for-profit nursing homes.

The authors describe initiatives designed to meet the chronic health needs of the elderly. These programs include demonstration programs such as Program of All-Inclusive Care for Elderly, Social Health Maintenance Organization, and state programs for Medicare-Medicaid-eligible elders that focus on integrating medical care with home and community-based services, diseaseor disability-focused care management/coordination initiatives, and recent population-based disease management programs focused on improving adherence to evidence-based protocols, self-care management, and the use of innovative practices such as group visits to improve health outcomes. These initiatives have the potential to improve outcomes and reduce costs, but also highlight tensions between medical model disease management and functionally oriented home and community service programs. The authors suggest that optimal chronic care for elders would require the integration of advances in medically oriented disease management with the best of home and community-based service programs. Medicare policy should promote such integration.

We compared the healthcare costs associated with an integrated care model to an enhanced referral model for the treatment of depression, anxiety, and atrisk drinking from the randomized Primary Care Research in Substance Abuse and Mental Health for the Elderly study. We examined total healthcare costs and cost components, separately for Veterans Affairs (VA) and non-VA participants. No differences in total health expenditures were detected between study arms. No differences in behavioral health expenditures were detected for non-VA sites, but the VA integrated arm had slightly higher ($38; p<0.05) behavioral health costs. Differences in other types of services use were detected.