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Geriatrics can be thought of as the intersection of chronic disease care and gerontology. The latter refers largely to the contents of this book: the syndromes associated with aging, the atypical presentations of disease, and the difficulties of managing multiple, simultaneous, interactive problems. Health care for older persons consists largely of addressing the problems associated with multiple chronic illnesses. However, medical care continues to be practiced as though it consisted of a series of discrete encounters. What is needed is a systematic approach to chronic care that encourages clinicians to recognize the overall course expected for each patient and to manage treatment within those parameters. Chapter 4 traces a number of strategies designed to improve the management of chronic disease.

Several initiatives are under way that may help to address this dilemma. The Patient Protection and Affordable Care Act specifically addresses attention to transitions for patients discharged from hospitals. Payments for rehospitalizations are denied, and penalties for excessive rates are levied. The accountable care organization concept calls for better integration of hospital care, primary care, postacute care (PAC), and nursing home care. It may extend to recognizing the need for better social integration as well. The health care home effort to incent practices for more comprehensive care represents a step in this direction.

Care for frail older persons has been impeded by an artificial dichotomy between medical and social interventions. This separation has been enhanced by the funding policies, such as the auspices of Medicare and Medicaid, but it also reflects the philosophies of the dominant professions. A prerequisite for effective coordination is shared goals. Until the differences in goals are reconciled, there is little hope for integrated care. Medical practice has been driven by what may be termed a therapeutic model. The basic expectation from medical care is that it will make a difference. The difference may not always be reflected in an improvement in the patient's status. Indeed, for many chronically ill patients, decline is inevitable, but good care should at least delay the rate of that decline. Because many patients do get worse over time, it may be difficult for clinicians to see the effects of their care. The invisibility of this benefit makes it particularly hard to create a strong case for investing in such care.

Appreciating the benefits of good care in the context of decline in function over time may require a comparison between what happens and what would have occurred in the absence of that care. In effect, the yield from good care is the difference between what is observed and what is reasonable to expect; but without the expected value, the benefit may be hard to appreciate. Figure 15-1 (which also appears in Chapter 4) provides a theoretical model of these two curves. Both trajectories show decline, but the slope associated with better care is less acute. The area between them represents the effects of good care. Unfortunately, that ...

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