The Evolving Paradigm for Healthcare of the Aging

As our population continues to live longer, it is no surprise that the challenge for providing effective and value-based healthcare is increasing.  

​An older population, which is more susceptible to chronic diseases and general frailty, requires a different paradigm of healthcare than our current system had been optimized for.  Traditional paradigms for medical treatment are focused on specific illnesses, with well-established protocols to address symptoms.  These clinical guidelines, “if x then y”, are linear, developed by specialists who optimize for one disease, but generally do not consider the totality of a person’s condition. Optimizing for one disease often exacerbates issues with another.  With an older population, we need to look at multiple diseases and comorbidity in a new way, customized for each person’s condition.
With patient populations that have complex health conditions we simply can’t provide the most effective care according to specific disease parameters.  Managing to standard guidelines, such as cholesterol limits and blood pressure expectations, may not fit a person with multiple issues.  When a clinician tries to treat to parameters such as heart rate, blood count, etc. in a person with complex issues, they may find that they are constantly reacting to alarms that become chronic, so as a result they either go crazy, or begin to ignore these alarms completely.  Thus, evolving critical issues with the patient’s health may be missed.  In addition, recommendations developed for controlling a specific issue are aimed towards improving life expectancy, which may not be the appropriate focus for an older population.  With an aging patient, a prognostic treatment may not be as important as treating symptoms and making the patient comfortable.  Thus, we need to move towards a non-traditional path for treatment, that can identify subtle changes in symptoms.

The beauty of an AI-based approach, such as the Senscio Systems’ Ibis platform is that it doesn’t assume set parameters. It learns how each unique patient’s status is in a steady state.  It can then detect relevant deviations.  Thus, the clinicians are not monitoring to an arbitrary goal, but rather to changes from a steady state.  If they see changes from the norm, then they know that biometric parameters are changing, and can recognize the need to intervene appropriately and in a timely manner.

Keeping patients in the home, and out of the hospital is a key to better outcomes. When on their own, often patents engaged in self-management get worried if they feel changing symptoms, and have no other recourse other than to call 911.  When this happens, typically an ambulance is summoned,  an EMT who doesn’t know the history takes the individual to the hospital. In the ER, a doctor who doesn’t know the patient follows standard protocols and admits them.  The outcomes tend to be terrible for this population: It is disruptive and the patient rarely comes out better than they were going in.  For a frail 85 year old,  If the doctor makes a slight mistake in the regiment because they don’t understand the complex nature of a patient’s health, they may bring temporary stability, but the patient may have a hard time recovering from the change in their overall medication balance.  We have clinical experience that shows that better results can be obtained by keeping these patients out of institutions, and helping them maintain their health at home.

In addition to the health maintenance challenge, it is also very expensive to bring patients in and out of acute care, when not necessary to address exacerbations.  If a patent has COPD, for example,  it’s not unusual to have bad days, where they may be short of breath. Rather than creating panic and jumping right into hospitalization, a service such as Senscio’s Ibis identifies the issue, and guides the patient through some easy changes in protocol, such as increasing their oxygen, which very often will solve the problem with minimal stress or cost.

Our health system was designed for acute care.  A 55 heart attack victim has a great chance of survival with our system, as there are proven protocols to treat this effectively.  But that model doesn’t work with the older population.  Conducting a procedure to “cure” an elderly person with complex issues may not be the best solution. Not only is it expensive, but it can exacerbate other issues.  The result can be miss-directed care in the high-risk elderly, that they may not have consented to if they understood the risk, and the doctor may not have recommended if they understood the patients full history.
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Part of the challenge of making this transition is that our health payment system is designed for the acute care paradigm, not the accountable care outcome-driven approach. Fortunately, we are slowly moving to a process which is focused on keeping people stable.  Keeping someone healthy is considerably less expensive than reactive medical treatment. Still, if a patient wants to do everything, we have to let them make that choice.  If you ask a surgeon what to do with a condition, they generally will say to operate, as that is how they know how to cure illness. A primary care doc who is informed, however, may be able to make a different recommendation.

​What do we need to get to the new vision?  One big change that will help is to reorient payment to maintaining health rather than “pay for service”. Once we make this change,  we will see more use of  tools such as Ibis to meet this need appropriately.  We need to continue to drive for medical codes that support innovation, and support paying for better outcomes, rather than for taking clinical and institutional-based action.  As these become implemented we can change the way medicine is practiced, thus aligning financial rewards with the better outcomes we can deliver.  

By Soeren Mattke, Managing Director of RAND Health Advisory Services