October 11, 2016

No Man is an Island

The United States produces outstanding reports about just about any health-related topic you can imagine. Some of the reports are produced by branches of government: for example, the CDC issues a series of Vital Statistics Reports that summarize and analyze data about deaths, births, and diseases. Other medically oriented reports are produced privately, and the crème de la crème of such reports stem from the National Academies of Sciences, Engineering, and Medicine. 

Created by congressional charter in 1863 and signed into law by President Lincoln, the National Academy (as it was called until recently) is a private institution charged with providing “independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, technology, and medicine.” Its recent report, Families Caring for an Aging America, is in a long tradition of distinguished monographs. Some of these have gone on to be extremely influential, such as To Err is Human: Building a Safer Health System, the report published in 2000 that triggered a serious campaign to enhance the safety of hospital care), others languish on library shelves. Which category the new report on caregiving will fall into remains to be seen. So far, the response of the most influential newspapers has been resounding silence. It deserves better.

The theme of the report, the drumbeat intoning relentlessly throughout its seven chapters and eight appendices, is that no man—or woman—is an island. We are parts of families, whether defined biologically or otherwise, of neighborhoods, and of communities. In the words of the poet, John Donne:
No man is an island,
Entire of itself,
Every man is a piece of the continent,
A part of the main.
As we age and develop assorted frailties, we rely increasingly on those others in our lives to help sustain us. The truth is that younger people are also parts of families, neighborhoods, and communities, and they, too, depend on others for sustenance, support, and succor. The notion that individuals act and think in isolation is a myth. Americans may be more individualistic and less communal in their attitudes and behavior than any other group in human history, but we are still fundamentally social beings. The collision between myth and reality is starkest, however, for those who are physically or cognitively frail, most commonly due to age-related changes.

In medicine, the relentless focus on the individual results in a paradox: in the words of Families Caring for an Aging America, “care delivery simultaneously ignores and relies heavily on family caregivers to provide ongoing support to older adults with cognitive and/or physical impairments.” According to one national survey, only 1/3 of family caregivers had ever been asked by a doctor, nurse, or social worker what they needed to care for their relative, and in a second survey, only 1/6 of caregivers had been asked what they needed to care for themselves. The evidence that caregivers are important is ample: the availability of a family caregiver is associated with fewer and shorter hospital stays for older adults, that caregivers reduce home health care use generally, and that they delay nursing home entry.

             The facts in the new report are not new.  But Families Caring for an Aging America is unusual in emphasizing the role of family caregivers in medical care as well as personal care, for dwelling on the effect of caregiving on the quality of health care as well as on the mental health and pocketbook of the caregiver. An entire chapter is devoted to “family caregiver integration with health care and long term services and supports.” The report assembles all the evidence demonstrating both the crucial role of family members (in the most generic sense) and the obstacles to their fulfilling that role. Caregivers participate in a wide variety of activities on behalf of their elderly charges, including making decisions about stopping and starting medications, selecting alternative treatment options when confronting a major life event, choosing whether to institute or continue life-support, and opting to move to congregate living, assisted living, or a nursing home. Despite the importance of family in older adults’ decision-making, “little attention has been directed at developing interventions to support older adults and their family member when confronting difficult decisions.” Moreover, caregivers are directly involved in the administration or supervision of a variety of sophisticated medical treatments, ranging from peritoneal dialysis to ventilators. Yet, doctors and nurses do little to provide those caregivers with the knowledge and skills they require to competently perform these tasks.

The report goes further: it outlines a strategy for change.

Change must begin with a “reorientation of care systems to a focus on family-centeredness.” That means health professionals need to listen to and honor the person and family’s needs, values, preferences, and goals of care. It means taking into account the physical and mental health of patients and caregivers, and engagement with their community. It entails developing a plan of care that is based on the patient’s needs and wants as well as what the family needs to provide support. It will require that the patient and family have access to timely, complete, and accurate information as well as the tools necessary to make shared and informed decisions. Overall, families need to be integrated into the care team to provide care and supportive services that are accessible, comprehensive, continuous over time, and coordinated across settings.

Medicare has taken a few small, shaky steps in the direction of implementing this model. CMS introduced a billing code that allows physicians, NPs, and PAs to be paid for time spent coordinating care for patients with multiple chronic conditions, without requiring that the patient be present and a physical exam be performed, the previous sine qua non of a “visit.” New home health agency regulations require that the plan of care developed, say, by a visiting nurse, identify the primary caregiver and assure that individual gets the necessary education and training to play the role required of him or her in the overall plan. But much, much more is needed and the report acknowledges this.

Families Caring urges the next US president to create a National Family Caregiver Strategy. Executive orders and new federal legislation should then “explicitly and systematically” recognize the essential role of family caregivers. This means designing specific assessment measures, programs, and research—and the funding to support them. In particular, the strategy should include mechanisms for Medicare, Medicaid, and the VA to identify family caregivers and assess their needs in the delivery of health care and long term services. It should involve directing CMS to develop, test, and implement payment reforms to motivate providers to engage family caregivers and to provide them with evidence-based supports. It should increase funding for programs that support family caregivers and explore adopting additional policies to provide economic support for working caregivers. And it should both collect data to monitor and track the experience of family caregivers, and also develop a multi-agency research program to evaluate caregiver interventions.

It’s a bold vision. And it will need to expand even further, starting not just with the doctors and nurses who care for older patients, but including the educational and training programs for those nurses and doctors. Medical school and nursing school are critical venues to model the kind of collaborative, team-based decision-making the vision assumes. It will need to go back even further, to high school and college, planting the seeds for the role that we will each play as a caregiver and a health care partner by educating young people about all the stages of human existence.

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