I recently went to my first annual Agency for Healthcare Research and Quality (AHRQ) grantee meeting, entitled Research to Reform: Achieving Health System Change. While the AHRQ is not particularly focused on the care of older people, in many ways it is the NIH “institute” with which the Foundation has the most in common. Its tagline, “Advancing Excellence in Healthcare,” testifies to its engaged, action-oriented approach. It funds health services research projects similar to those in the Foundation’s Integrating and Improving Services portfolio. In fact, we co-fund several projects, including Guided Care (also with NIA) and Care Management Plus.
One of the meeting sessions I most wanted to attend was on connecting primary care medical practices with community-based agencies to provide patients with more comprehensive and powerful services. These services include programs for health promotion, emotional and informational support, and behavior change—services that are difficult to fit into brief medical visits. Such programs are much better fits for community-based agencies that are deeply rooted in the communities they serve.
Unfortunately, the news at the meeting was largely disappointing. It turns out that doctors’ offices are unlikely to make referrals. They feel that community agencies have high rates of staff turnover and variable quality. They also complain about being uncertain about the potential costs to their patients of these services—which is pretty revealing. Since when did doctors begin to worry so much about cost, either to society or to the patient, when they refer someone for treatment? Moreover, I recall a similar finding from a project within the Kaiser system. They tried to get primary care teams to refer families who had a loved one with a dementia for free support from the local Alzheimer’s Association, and the doctors still wouldn’t make referrals.
If we take this feedback seriously, one ingredient to increase the impact of community-based programs is to encourage them to adopt high quality, evidence-based programs. Last week’s post on Nancy Whitelaw, this year’s Elizabeth Fries award winner, talked about her work to make evidence-based programs more widely available. In addition, we also need to strengthen the links among community agencies, medical teams, and people/families. Nancy did two investigations into this linking issue -- one for the late Merck Foundation for Healthy Aging and the other for the Centers for Disease Control.
I hope that these thoughts are getting the attention they deserve. The findings reported at the AHRQ meeting do make me very concerned about the future of far more ambitious proposed innovations such as community health teams and medical homes. People who throw these ideas around don’t seem to recognize all the difficulties implicit in even the most obvious and innocuously beneficial partnerships.