HEALTH AND CARE SERVICES

Health care for older people involves managing chronic illness. In essence, geriatrics represents the intersection of chronic disease care and gerontology. Diseases present differently in older persons, and their treatment is complicated by the presence of impairments in other domains, such as affect, cognition, and economics. In the United States, older persons are the only group covered by a universal health care insurance system. Nonetheless, there remains substantial geographic variation in access to care. In general, older people still suffer from ageism; decisions about what care they should receive is influenced by beliefs about what is age appropriate.  The story of health care for older persons is inexorably linked to chronic disease. Indeed, chronic disease is the dominant factor in health care for all ages, but its predominance is especially high for older persons.If for no other reason than because such conditions accumulate with time, older people are disproportionately heavy users of health care, largely because they have a heavier illness burden. Figure 1 shows the distribution of chronic illness among elderly persons. In the United States, elderly persons are the only demographic group that has virtually universal health coverage, under Medicare. Addressing chronic care effectively implies drastically changing the current health system, which was developed to address primarily acute problems. The implied reformation addresses a wide range of aspects of care, including the definitions of concepts such as prevention, the role of patients, and even time. Prevention is best thought of in terms of avoiding major catastrophes. In effect, good chronic disease care will handle problems proactively to prevent emergency room visits and hospitalizations

 It is unrealistic to think about managing chronic disease without actively involving patients in their own care. They are the ones who must deal with the disease every day. The challenge lies in determining how to create a productive partnership between patients and their clinicians. Programs designed to give patients a greater sense of empowerment have been promising. Another approach encourages patients to record systematic observations on defined parameters that reflect the clinical course of their diseases and to notify their clinicians when the observed course deviates from what had been expected. Time too takes on a new meaning, beyond that implied by the term ‘chronic.’ In effect, chronic care means thinking in terms of investments. One provides active primary care with the expectation of recouping that effort in terms of subsequent care avoided. Focusing attention on high-risk periods, such as immediately after a hospital discharge, can pay dividends. Nurses working with patients in these situations can improve compliance with postdischarge regimens and prevent subsequent readmissions. Scheduling encounters need to be overhauled. Instead of seeing patients on a fixed time schedule based on a loose expectation of when another assessment is needed, visits should be triggered by patients’ actual courses. They need to be seen when their condition deviates from the predicted path; then they need to be seen quickly to treat the problem before it becomes serious.