Are seniors at greater risk at home or in institutional settings?

August 20, 2014 § Leave a comment

By Adam Burrows, MD, Senior Medical Director for Senior Care Options Program, Commonwealth Care Alliance

A recent study compared the risks faced by seniors living at home with those faced by seniors in nursing homes and hospitals. As reported in Forbes magazine, the study found that rates of preventable and non-preventable hospitalizations were higher for those receiving care in home and community settings.

Because many seniors prefer to remain in their homes, the report raises important concerns. There are certainly risks to seniors who stay at home, including unmet care needs, geriatric syndromes, chronic conditions, and falls and injuries. Many believe that institutional settings can control these risks better than home and community settings.

However, as anyone who takes care of older adults knows, there are plenty of risks associated with institutional settings. Seniors understand that when they enter hospitals and nursing homes they relinquish control over their environment.  Giving up this control might challenge their sense of well being and introduce new risks.

Commonwealth Care Alliance nurse and patient

Reducing risks by changing the way we finance and deliver care
An effective way to reduce risks for seniors is to change the way we structure their care. By moving vulnerable seniors from traditional fee-for-service environments and office-based practices into fully integrated managed care programs, we can apply healthcare dollars to community-based supports and services. Rather than relying on emergency rooms, avoidable hospital stays, referrals to multiple consultants, and expensive testing, we can allocate resources toward direct care workers and ongoing assessment and treatment by multidisciplinary professional staff. By shifting the locus of care, we can address unmet needs, control chronic medical conditions, anticipate and address acute issue, and reduce the risk of falls and injuries.

We may never be able to eliminate risk with fully integrated models. However, we know from our experience with the Commonwealth Care Alliance Senior Care Options program in Massachusetts and with the Program of All-inclusive Care for the Elderly (PACE) nationally that we can mitigate risk and control costs in ways that we cannot with a traditional fee-for-service approach.

The ethics of autonomy
The restructuring of care for high-risk older adults makes it easier for us to honor the preferences of patients and avoid acting on our paternalistic impulses. We may not be able to eliminate risk, but because we can offer strategies that mitigate risk, we can offer real choices to patients and families, rather than purely theoretical ones. We can appreciate that individuals have their personal hierarchies of safety and risk, and they may not prioritize physical safety over all else. For many older adults, familiarity and control are paramount and their loss poses the greater threat.

At Commonwealth Care Alliance, we prioritize autonomy as our preeminent ethical principal. If an individual is willing to accept a level of residual risk to remain in a familiar environment, to retain some control over their environment, and to avoid the loss of control that often accompanies a move to an institutional setting, that’s what we will support.

However, it’s our responsibility to conduct thorough and careful assessments, to understand everything that contributes to risk, and to do whatever we can to address those risks. We must also thoughtfully assess the ability of our members to make informed decisions. If we determine that they understand the situation, the alternative approaches, and the risks and benefits of each, and if they are able to express an informed decision consistently and coherently, we will support their wishes. If we find that they lack the capacity for informed decision-making, we will ask their chosen surrogate decision-makers to decide on their behalf.

Ultimately, it’s in our collective interest to reallocate resources to help older Americans age in their setting of choice. Just as important, health professionals have an ethical duty to prioritize autonomy and respect the wishes of patients. We must accept their willingness to accept risk.

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