Perspectives of Patients, Clinicians, and Health System Leaders on Changes Needed to Improve the Health Care and Outcomes of Older Adults With Multiple Chronic Conditions

Journal of Aging and Health

Volumn 30, Issue 5, 2018, Pages 778-799

  Ferris, Rosie ^a   Blaum, Caroline ^a   Kiwak, Eliza ^b   Austin, Janet ^c   Esterson, Jessica ^b   Harkless, Gene ^d   Oftedahl, Gary ^e   Parchman, Michael ^f,g   Van Ness, Peter H ^b   Tinetti, Mary E ^b  

^a NEW YORK UNIVERSITY SCHOOL OF MEDICINE   (United States)

^b YALE UNIVERSITY SCHOOL OF MEDICINE   (United States)

^c Patient Advocate   (United States)

^d UNIVERSITY OF NEW HAMPSHIRE   (United States)

^e Healthcare Consultant   (United States)

^f GROUP HEALTH RESEARCH INSTITUTE   (United States)

^g Grp Health Cooperative Puget Sound   (United States)

Author keywords

multiple chronic conditions; patient centered metrics; patients health priorities; patient clinician partnership

Indexed keywords

AGED; DECISION MAKING; ELDERLY CARE; FEMALE; HEALTH SERVICE; HUMAN; MALE; MULTIPLE CHRONIC CONDITIONS; ORGANIZATION AND MANAGEMENT; PATIENT PARTICIPATION; STANDARDS; TOTAL QUALITY MANAGEMENT;

AGED; DECISION MAKING; FEMALE; HEALTH SERVICES FOR THE AGED; HEALTH SERVICES NEEDS AND DEMAND; HUMANS; MALE; MULTIPLE CHRONIC CONDITIONS; PATIENT PARTICIPATION; QUALITY IMPROVEMENT;

EID: 85046728469     PISSN: 08982643     EISSN: 15526887     Source Type: Journal    
DOI: 10.1177/0898264317691166     Document Type: Article

References (42)

1. Aronson L., Bautista C. A., Covinsky K., (2015). Medicare and care coordination: Expanding the clinician’s toolbox. Journal of the American Medical Association, 313, 797-798.
2. Atlas-Ti: The Knowledge Workbench. (1996). [Computer software]. Thousand. Oaks, CA: Scolari Publications.
3. Bayliss E. A., (2012). Simplifying care for complex patients. Annals of Family Medicine, 10, 3-5.
4. Boyd C. M., Wolff J. L., Giovannetti E., Reider L., Weiss C., Xue Q.-L... Rand C., (2014). Healthcare task difficulty among older adults with multimorbidity. Medical Care, 52(Suppl. 3), 118-125.
5. Bynum J. P. W., Meara E. R., Chang C. H., Rhoads J. M., Bronner K. K., (2016). Our parents, ourselves: Health care for an aging population. Lebanon, NH: The Dartmouth Institute of Health Policy & Clinical Practice.
6. Case S. M., O’Leary J., Kim N., Tinetti M. E., Fried T. R., (2014). Relationship between universal health outcome priorities and willingness to take medication for primary prevention of myocardial infarction. Journal of the American Geriatrics Society, 62, 1753-1758.
7. Centers for Medicare & Medicaid Services. (2015). CMS finalizes 2016 Medicare payment rules for physicians, hospitals & other providers. Retrieved from https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-10-30.html
8. Centers for Medicare & Medicaid Services. (2016). Quality Payment Program: Delivery system reform, Medicare payment reform, & MACRA. Baltimore, MD: Author.
9. Cheung W. Y., Neville B. A., Cameron D. B., Cook E. F., Earle C. C., (2009). Comparisons of patient and physician expectations for cancer survivorship care. Journal of Clinical Oncology, 27, 2489-2495.
10. Dhruva S. S., Redberg R. F., (2008). Variations between clinical trial participants and Medicare beneficiaries in evidence used for Medicare national coverage decisions. Archives of Internal Medicine, 168, 136-140.
11. Elwyn G., Frosch D., Thomson R., Joseph-Williams N., Lloyd A., Kinnersley P... Rollnick S., (2012). Shared decision making: A model for clinical practice. Journal of General Internal Medicine, 27, 1361-1367.
12. Erdem E., Prada S. I., Haffer S. C., (2013). Medicare payments: How much do chronic conditions matter. Medicare & Medicaid Research Review, 3(2), E1-15.
13. Fried T. R., McGraw S., Agostini J. V., Tinetti M. E., (2008). Views of older persons with multiple morbidities on competing outcomes and clinical decision-making. Journal of the American Geriatrics Society, 56, 1839-1844.
14. Fried T. R., Tinetti M. E., Iannone L., O’Leary J. R., Towle V., Van Ness P. H., (2011). Health outcome prioritization as a tool for decision making among older persons with multiple chronic conditions. Archives of Internal Medicine, 171, 1856-1858.
15. Glaser B. G., Strauss A. L., (2009). The discovery of grounded theory: Strategies for qualitative research: New Brunswick, NJ: Transaction publishers.
16. Greenberg J. O., Barnett M. L., Spinks M. A., Dudley J. C., Frolkis J. P., (2014). The “medical neighborhood”: Integrating primary and specialty care for ambulatory patients. JAMA Internal Medicine, 174, 454-457.
17. Greene J., Hibbard J. H., (2012). Why does patient activation matter? An examination of the relationships between patient activation and health-related outcomes. Journal of General Internal Medicine, 27, 520-526.
18. Ickowicz E., (2012). Guiding principles for the care of older adults with multimorbidity: An approach for clinicians. Journal of the American Geriatrics Society, 60(10), E1-E25.
19. Jackson G. L., Powers B. J., Chatterjee R., Bettger J. P., Kemper A. R., Hasselblad V... Kendrick A. S., (2013). The patient-centered medical home: A systematic review. Annals of Internal Medicine, 158, 169-178.
20. Kamerow D., (2012). How can we treat multiple chronic conditions. British Medical Journal, 344, Article e1487.
21. Lorgunpai S. J., Grammas M., Lee D. S., McAvay G., Charpentier P., Tinetti M. E., (2014). Potential therapeutic competition in community-living older adults in the U.S.: Use of medications that may adversely affect a coexisting condition. PLoS ONE, 9(2), Article e89447.
22. May C. R., Eton D. T., Boehmer K., Gallacher K., Hunt K., MacDonald S... Richardson A., (2014). Rethinking the patient: Using burden of treatment theory to understand the changing dynamics of illness. BMC Health Services Research, 14(1), Article 281.
23. Naik A. D., Martin L. A., Moye J., Karel M. J., (2016). Health values and treatment goals of older, multimorbid adults facing life-Threatening illness. Journal of the American Geriatrics Society, 64, 625-631.
24. Naik A. D., McCullough L. B., (2014). Health intuitions inform patient-centered care. The American Journal of Bioethics, 14, 1-3.
25. Nyweide D. J., Lee W., Cuerdon T. T., Pham H. H., Cox M., Rajkumar R., Conway P. H., (2015). Association of Pioneer Accountable Care Organizations vs traditional Medicare fee for service with spending, utilization, and patient experience. Journal of the American Medical Association, 313, 2152-2161.
26. O’Hare A. M., Hotchkiss J. R., Tamura M. K., Larson E. B., Hemmelgarn B. R., Batten A... Covinsky K. E., (2014). Interpreting treatment effects from clinical trials in the context of real-world risk information: End-stage renal disease prevention in older adults. JAMA Internal Medicine, 174, 391-397.
27. Parekh A. K., Goodman R. A., Gordon C., Koh H. K., (2011). Managing multiple chronic conditions: A strategic framework for improving health outcomes and quality of life. Public Health Reports, 126, 460-471.
28. Pham H. H., O’Malley A. S., Bach P. B., Saiontz-Martinez C., Schrag D., (2009). Primary care physicians’ links to other physicians through Medicare patients: The scope of care coordination. Annals of Internal Medicine, 150, 236-242.
29. Rathert C., Wyrwich M. D., Boren S. A., (2012). Patient-centered care and outcomes: A systematic review of the literature. Medical Care Research and Review, 70, 351-379. doi:10.1177/1077558712465774
30. Ritchie J., Lewis J., Nicholls C. M., Ormston R., (2013). Qualitative research practice: A guide for social science students and researchers. London, England: SAGE.
31. Stange K., (2009). The problem of fragmentation and the need for integrative solutions. Annals of Family Medicine, 7, 100-103.
32. Stange K. C., (2012). In this issue: Challenges of managing multimorbidity. Annals of Family Medicine, 10, 2-3.
33. Tinetti M. E., (2014). The gap between clinical trials and the real world: Extrapolating treatment effects from younger to older adults. JAMA Internal Medicine, 174, 397-398.
34. Tinetti M. E., Esterson J., Ferris R., Posner P., Blaum C. S., (2016). Patient priority–directed decision making and care for older adults with multiple chronic conditions. Clinics in Geriatric Medicine, 32, 261-275.
35. Tinetti M. E., Fried T. R., Boyd C. M., (2012). Designing health care for the most common chronic condition—Multimorbidity. Journal of the American Medical Association, 307, 2493-2494.
36. Tinetti M. E., McAvay G. J., Fried T. R., Allore H. G., Salmon J. C., Foody J. M., Fraenkel L., (2008). Health outcome priorities among competing cardiovascular, fall injury, and medication-related symptom outcomes. Journal of the American Geriatrics Society, 56, 1409-1416.
37. Tinetti M. E., Naik A. D., Dodson J. A., (2016). Moving from disease-centered to patient goals–Directed care for patients with multiple chronic conditions: Patient value-based care. JAMA Cardiology, 1(1), 9-10.
38. Tran V. T., Harrington M., Montori V. M., Barnes C., Wicks P., Ravaud P., (2014). Adaptation and validation of the Treatment Burden Questionnaire (TBQ) in English using an internet platform. BMC Medicine, 12, Article 109.
39. Ubel P. A., (2015). Why it’s not time for health care rationing. Hastings Center Report, 45(2), 15-19.
40. Wasfy J. H., Rao S. K., Kalwani N., Chittle M. D., Richardson C. A., Gallen K. M... Ferris T. G., (2016). Longer-term impact of cardiology e-consults. American Heart Journal, 173, 86-93.
41. Zuchowski J. L., Rose D. E., Hamilton A. B., Stockdale S. E., Meredith L. S., Yano E. M... Cordasco K. M., (2015). Challenges in referral communication between VHA primary care and specialty care. Journal of General Internal Medicine, 30, 305-311.
42. Zuckerman R. B., Sheingold S. H., Orav E. J., Ruhter J., Epstein A. M., (2016). Readmissions, observation, and the hospital readmissions reduction program. New England Journal of Medicine, 374, 1543-1551.