Gordon and Betty Moore Foundation Patient Care Program: Mid-Course Review of the High-Need Patients Investigation

The Gordon and Betty Moore Foundation has published a report that provides an overview of funder and grantee work in serious illness care, particularly as it relates to the high-need patient population. Available on their website, the document covers accomplishments, impact, durability and lessons learned from grants related to the priority areas in workforce and accountability and payment. The Health Teams for Frail Elders Project is a component of the Moore Foundation’s Workforce portfolio through the grant titled “Aging Patients and Health Professionals: New Roles in a Changing Health System”. Key themes from the report include:
1. The importance of paid and unpaid caregiver inclusion in health care teams
2. Filling the workforce gap in terms of knowledge, skill and supply to best provide serious illness care to an aging population
3. Improving communication skills of providers around late-life and end-of-life care

Screen Shot 2018-11-27 at 9.27.42 AM

National Forum of State Nursing Workforce Centers Annual Conference

The National Forum of State Nursing Workforce Centers was held in Denver CO at the historic Brown Palace Hotel from June 12-14.

Our team was well represented. Karen Donelan presented “Models of Care for Frail Older Adults Living in the Community”, bringing together recent research from two projects on the roles of nurses and social workers in care management. Peter Buerhaus was one of the Conference leaders, and gave the opening plenary address focusing on trends in the nursing workforce. Joanne Spetz’s team from UCSF was well represented with 5 presentations: “Strengthening the Nursing Workforce to Care for People with Serious Illness: Recommendations from a National Summit”, “Describing Workforce Demand: Three States’ Data Collection and Dissemination Approaches and Examples of Uses of the Data”, “Developing Regional Forecasts of Nursing Supply and Demand: Data and Methodological Challenges”, “The Effect of Nurse Practitioner and Physician Assistant Regulations on the Growth of the Opioid Treatment Workforce” and “Nurse Workforce Supply and Demand Projections: How Different Models and Source Data Influence the Results”. Other plenaries included David Cutler from the Department of Economics at Harvard and Lynda Benton from The Johnson&Johnson Campaign for Nursing’s Future, where exciting new initiatives are underway to support nursing innovation and leadership.

2019 Partners Population Health Research Symposium

cmichaelpophealthOn June 10th, we attended the 2019 Partners Healthcare Population Health Research Symposium in Somerville, MA. Posters presented by our team included “Social Work in Health and Aging: Past, Present, & Future” as well as “The Roles of Registered Nurse and Social Work Care Managers in Care Management.” Other projects of interest to our team on display at the symposium were “Implementing a Community Health Worker Intervention at Hospital Discharge” presented by Dr. Jocelyn Carter, director of the Community Care Transitions Initiative at MGH, “Collaborating with an External Vendor to  Implement a Home Based Care Management Program” presented by Maryann Vienneau, Program Director for iCMP and Palliative Care at Partners, and “Home Visits for Our Homebound, Best Care Model”, presented by Jennifer Wright, Population Health Program Director at Newton-Wellesley Hospital.


Introduction: Health Teams for Frail Older Adults Project

The U.S. population is aging and our society will need innovative solutions to provide health care to an increasing population of older adults. As our team thought about the population where innovation in health care delivery was most urgently needed we thought of our family members, colleagues and patients who struggle most with the complexities of our system. Frail older adults challenge us to think about how to make care simpler even when health gets complicated.

Primary care and geriatric health professionals are overworked and in short supply. Family caregivers are expected to take on more and more care.  Are better teams a solution to improving care for older adults? What health professionals and other staff do we need on those teams? What are the best roles for nurses, physicians, and social workers who care for older adults? Are patients and caregivers on those teams?

We asked these questions in site visits conducted in 2017 all over the United States to understand what health professionals do every day to care for an aging population. We invited experts to a professional meeting on health care teams.  In 2018, we conducted national surveys of frail older adults and caregivers, and a national  survey of primary care and geriatric health professionals.

In 2019, we will be sharing our findings.  We invite your questions, comments, and collaboration.

Karen Donelan, Sc.D, Ed.M., Health Policy Research Center, The Mongan Institute