Medical Case Reports

Health care of the highest quality promotes successful aging. This paper examines the efforts that have been taken to improve the quality of health care, especially hospital care. Most of these efforts have evaluated conventional treatments of specific diseases; they are critical but underfunded and underused, and many practices persist without much evidence of efficacy. Fewer efforts have attempted to improve care for groups of persons in specific settings, such as the hospital. Three complementary approaches to improving comprehensive outcomes for hospitalized older persons-Geriatric Evaluation and Management, Acute Care for Elders, and the Elder Life Program-demonstrate what has been learned about improving care for older persons by redesigning microsystems of care. A research agenda for advancing successful aging should include specific actions to improve the quality of health care.

In 2018 the US population ages sixty-five and older numbered 52.4 million, with older adults representing 15.6 percent of the population. By 2030, 20 percent of Americans will be age sixty-five or older. The most striking aspect of this population is its heterogeneity. In 2017, 23 percent of older Americans were members of racial and ethnic populations, and this percentage will increase by an estimated 135 percent between 2017 and 2040, compared with 36 percent for the non-Hispanic White population. And although stereotypes portray older people as frail, disengaged, and cognitively impaired, many are industrious, creative, and intelligent into the tenth decade of life.

Because of momentous advances in science and technology, the knowledge and skills exist to provide excellent preventive and clinical care to this cohort. What is now needed is the policy, and the will, to take collective action to ensure that all older adults are engaged in health promotion and disease prevention and receive equitable, person-centered, high-quality care. Effective policies are needed that can bridge the gaps between public health, health care, and other sectors of the economy, focusing on social determinants of health and preventive measures to reduce the burden of chronic disease while also providing person-centered care to those with serious illness. Online appendix exhibit A1 illustrates this approach.

In 2016, as part of the National Academy of Medicine’s Vital Directions for Health and Health Care initiative, an expert panel wrote a paper that provided guidance for preparing the nation for the realities of an aging population.4 Since the publication of Preparing for Better Health and Health Care for an Aging Population: A Vital Direction for Health and Health Care, emerging trends have included more personalized approaches to care; greater elicitation of goals and preferences from those receiving care; and growing sophistication in the use of electronic health records (EHRs) to identify risk, classify subpopulations, and direct appropriate interventions. Alternative payment models and Medicare Advantage have created flexibility that permit innovation in care delivery and promote more efficient and higher-quality health care. The CAPABLE (Community Aging in Place—Advancing Better Living for Elders) model is a good example of this flexibility: Section 1915 Medicaid home and community-based services waiver dollars are used for home repairs and in-home care that improves safety and health outcomes for older adults.

Yet most older people remain insured under traditional fee-forservice Medicare, which incentivizes profit-generating services. Policy changes such as bundled, capitated, and other value-based payments are urgently needed to promote the delivery of care that addresses the social determinants of health, encompasses lifestyle modifications, recognizes the diversity of the older population, and provides needed services for elders with serious illnesses.

The 2016 Vital Directions authors expressed deep concerns regarding health care disparities, inequality, structural racism, and the resulting disproportionate risk for adverse outcomes among those who are disadvantaged and most at risk. In 2020 these concerns are even graver, and they present an opportunity for renewed assessment and policy directions for addressing persistent issues. Further, the coronavirus disease 2019 (COVID-19) pandemic has exposed fundamental problems in the US health care system that specifically affect older people.

Acknowledgement

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Conflict of Interest

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