Bringing Primary Care Home: The Medical House Call Program at MedStar Washington Hospital Center

MedStar's program offers round-the-clock access to a care team comprising a geriatrician, nurse practitioner, and social worker. The house calls reveal and address problems that are missed when care is poorly coordinated, enabling team members to identify social supports for patients that can improve quality of life, reduce the burden on caregivers, and head off problems that can lead to high-cost institutional care.Based on the cost savings it achieved, the program became one of the models for the federal Center for Medicare and Medicaid Innovation's Independence at Home Demonstration, which is testing whether providing primary care at home to frail elderly patients with multiple chronic conditions or advanced illnesses improves outcomes and lowers health care spending. MedStar participates in the demonstration as part of a consortium that includes Virginia Commonwealth University and University of Pennsylvania Health System, both of which are implementing an approach similar to MedStar's. The consortium is one of nine participating groups to earn a share of the savings they produced for Medicare

Aging Gracefully: The PACE Approach to Caring for Frail Elders in the Community

Mountain Empire is one of the newest of more than 100 independent PACE organizations across the nation that serve both as health plans and as medical and long-term service providers to elders—offering meals, checkups, rehabilitation services, home visits, and many other supports that enable enrollees to preserve their independence. The model for PACE dates back to 1971, when a public health dentist and social worker from the San Francisco Public Health Department working in Chinatown-North Beach noticed that as their clients aged, many needed extra support but dreaded moving into nursing homes. They founded On Lok Senior Health Services as an alternative to institutional care that would allow elders to "age in place" in their homes; on lokis Cantonese for "peaceful, happy abode."On Lok's founders were particularly concerned about elderly clients who suffered when their various clinicians failed to work together, sometimes leading to complications that necessitated moves into institutional care. They designed On Lok to promote what was then an innovative approach: coordinating care from an interdisciplinary team of professionals who provide all primary care services and oversee specialists' services.A Medicare-funded demonstration spanning 1979 to 1983 found this approach had many benefits. Care teams were able to prevent or quickly address problems, resulting in better health and quality of life and producing 15 percent lower costs than traditional Medicare. In the decades since, the model has spread slowly, though enrollment has grown nearly 40 percent in the past three years. As of January 2016, there were 118 PACE organizations in 31 states serving some 39,000 elders

The Hospital at Home Model: Bringing Hospital-Level Care to the Patient

Presbyterian's Hospital at Home program, launched in 2008, is based on a model developed in the mid-1990s by Bruce Leff, M.D., a geriatrician and health services researcher at Johns Hopkins University, who noticed that many of his patients suffered poor outcomes after hospital stays.1 At Johns Hopkins, teams of physicians, nurses, and other clinical staff make house calls to treat elderly patients, many of whom either refuse to go to the hospital or are at such high risk for adverse events that physicians prefer not to admit them. For select patients, this approach produces superior outcomes at a lower cost than hospital care (see Results).The Hospital at Home model has struggled to gain traction elsewhere in the United States, however, in part because Medicare's fee-for-service program will not pay for its services. Presbyterian is able to secure reimbursement from its health plan, which covers 470,000 Medicare Advantage, Medicaid, and commercially insured members throughout the state and has incentives to reduce costs and improve care.Presbyterian's program fits within a suite of services designed to deliver care in the home. These include home-based primary care, home health, hospice, and Complete Care, a care management program designed to improve coordination of services for patients with advanced illness and, when desired, avoid unwanted aggressive care at the end of life

Religion and Education: Whither the Establishment Clause?

Symposium: Religious Liberty at the Dawn of a New Millennium held at Indiana University School of Law-Bloomington on April 9, 1999