Objectives. —To determine (1) the number and proportion of Americans living with chronic conditions, and (2) the magnitude of their costs, including direct costs (annual personal health expenditures) and indirect costs to society (lost productivity due to chronic conditions and premature death). Design. —Analysis of the 1987 National Medical Expenditure Survey for prevalence and direct health care costs; indirect costs based on the 1990 National Health Interview Survey andVital Statistics of the United States. Setting. —US population. Participants. —For the estimate of prevalence and direct costs, the National Medical Expenditure Survey sample of persons who reported health conditions associated with (1) use of health services or supplies or (2) periods of disability. Interventions. —None. Main Outcome Measures. —The number of persons with chronic conditions, their annual direct health care costs, and indirect costs from lost productivity and premature deaths. Results. —In 1987, 90 million Americans were living with chronic conditions, 39 million of whom were living with more than 1 chronic condition. Over 45% of non-institutionalized Americans have 1 or more chronic conditions and their direct health care costs account for three fourths of US health care expenditures. Total costs projected to 1990 for people with chronic conditions amounted to $659 billion—$425 billion for direct health care costs and $234 billion in indirect costs. Conclusions. —The prevalence and costs of chronic conditions as a whole have rarely been estimated. Because the number of persons with limitations due to chronic conditions is more regularly reported in the literature, the total prevalence of chronic conditions has perhaps been minimized. The majority of persons with chronic conditions are not disabled, nor are they elderly. Chronic conditions affect all ages. Because persons with chronic conditions have greater health needs at any age, their costs are disproportionately high.

https://jamanetwork.com/journals/jama/articlepdf/410506/jama_276_18_029.pdf

Persons With Chronic Conditions: Their Prevalence and Costs

Because persons with disabilities (PWDs) use health and social services extensively, both the United States and the United Kingdom have begun to integrate care across systems. Initiatives in these two countries are examined within the context of the reality that personal needs and use of systems differ by age and by type and severity of disability. The lessons derived from this scrutiny are presented in the form of five “laws” of integration. These laws identify three levels of integration, point to alternative roles for physicians, outline resource requirements, highlight friction from differing medical and social paradigms, and urge policy makers and administrators to consider carefully who would be most appropriately selected to design, oversee, and administer integration initiatives. Both users and caregivers must be involved in planning to ensure that all three levels of integration are attended to and that the borders between medical and other systems are clarified.

/pdf/five-laws-for-integrating-medical-and-social-services-4w3gefoeok.pdf

Five laws for integrating medical and social services: lessons from the United States and the United Kingdom.

Objective
To assess the coming challenges of caring for large numbers of frail elderly as the Baby Boom generation ages.

The 2030 Problem: Caring for Aging Baby Boomers

As people continue to age and receive complex health care services at home, concern has arisen about the availability of family caregivers and their ability to combine employment with caregiving. This article evaluates the international research on unpaid caregivers and their labor market choices, highlighting three conclusions: first, caregivers in general are equally as likely to be in the labor force as noncaregivers; second, caregivers are more likely to work fewer hours in the labor market than noncaregivers, particularly if their caring commitments are heavy; and finally, only those heavily involved in caregiving are significantly more likely to withdraw from the labor market than noncaregivers. Policy recommendations are targeting greater access to formal care for “intensive” caregivers and developing workplace policies for employed caregivers.

Labor Market Work and Home Care’s Unpaid Caregivers: A Systematic Review of Labor Force Participation Rates, Predictors of Labor Market Withdrawal, and Hours of Work

Background

The OECD countries have recently promoted policies of deinstitutionalisation and community-based care for the elderly. These policies respond to common cost pressures associated with population aging, and the challenge of providing improved care for the elderly. They aim to substitute less costly services for institutional ones, to improve patient satisfaction and decrease expenses. However, views concerning their success are mixed. We took a comparative cross-national approach to examine the evidence, to identify common features of an effective system of integrated care, and to examine the potential of such models to positively affect care of the elderly, and public finances.



Methods

We conducted a systematic review of recent demonstration projects testing innovative models of care for the elderly in OECD countries. Projects included aimed to create comprehensive integration of acute and long-term care services, and were evaluated using a comparison group.



Results

For each project, we report available results on rates of hospitalisation, long term care institutionalisation, utilisation and costs, impact on process of care, and health outcomes. In addition, the following common features of an effective integrated system of care were identified: a single entry point system; case management, geriatric assessment and a multidisciplinary team; and use of financial incentives to promote downward substitution.



Conclusions

Community-based care can impact favourably on rates of institutionalisation and costs. Comprehensive approaches to program restructuring are necessary, as cost-effectiveness depends on characteristics of the system of care. Expansion of successful programmes to achieve widespread use remains a critical challenge. Copyright © 2003 John Wiley & Sons, Ltd.

International experiments in integrated care for the elderly: a synthesis of the evidence

For almost three decades researchers have sought to quantify the benefits of home and community care for the elderly, invariably assuming that such care would be an economical substitute for institutionalization. Twenty-seven studies that met rigorous criteria of design, size, and subject were analyzed and the results were synthesized to address the effects on institutional utilization and expenditures, and patient health status and well-being. Home- and community-based health care services are shown to raise overall utilization and costs. Health status effects are limited primarily to patient and caregiver contentment and reduction of unmet needs. Recommendations are made for reaping this considerable benefit more efficiently.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1468-0009.2005.00434.x

James E. Pawelak

Papers

The Past and Future of Home- and Community-Based Long-Term Care