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This chapter describes and critiques the “system” that provides health care for older Americans. The system comprises many elements, including providers of health care, providers of supportive services, “alternative” healers, patients, families, insurers, regulators, and liaisons among these elements. The health care system is addressed primarily from the perspectives of health care professionals and their older patients, particularly patients with multiple chronic conditions and complex health care needs. Strategies for optimizing care within the system and examples of recent innovations designed to improve the system are described.

Strictly speaking, a system (from the Latin noun systema) is a set of procedures or structures that direct or coordinate the orderly flow of other processes. In the case of complex health care for chronically ill older Americans, however, the fragmentation, lack of coordination, and disorderly flow of information and interactions is not a true system of health care. Nevertheless, this chapter uses the term “health care system” to refer to the aggregate of the many elements involved in providing health care to older patients.

The chapter begins with brief introductory descriptions of individual elements of the current system, many of which are described in greater detail in the chapters that follow, e.g., care in hospitals, emergency departments, subacute facilities, rehabilitation units, and nursing homes; complementary and alternative care; and care during transitions between providers. The next section describes the present system's performance in addressing the multifaceted needs of chronically ill older patients, followed by a section on the roles of primary care clinicians in caring for this population. Later sections examine opportunities for creating a more effective, efficient, and patient-centered system and summarize some recent initiatives designed to improve the system's quality and outcomes.

The pluralistic U.S. health care system consists of five interacting elements: providers, patients and caregivers, insurers, liaisons, and regulators.


Providers include health care professionals, health care organizations, and supportive community services. Among health care professionals are primary care and specialty physicians, nurses, social workers, rehabilitative therapists, pharmacists, dentists, mental health professionals, health care aides, and complementary and alternative medicine (CAM) practitioners. In the past, primary care physicians (PCPs) managed their patients across settings of care, providing valuable continuity and advocacy as their patients moved through emergency departments, hospitals, and rehabilitation facilities. Today, increased specialization by site of care has constrained primary physicians mostly to providing ambulatory care. Hospitalists, emergency physicians, and skilled nursing facility specialists (SNFists) provide much of the care in institutions. Although such specialization may have improved some aspects of care within hospitals, emergency departments, and SNFs, it has also eroded continuity of care and contributed to the further fragmentation of an already fragmented system (see Chapter 16). Unfortunately, no one clinician may know the patient well.

The system's health care organizations include acute care hospitals, long-term care hospitals (LTCHs), emergency departments, rehabilitation units, home care agencies, house call practices, ...

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