The evidence suggests that medical care for frail, old people should be interdisciplinary, coordinated, and accessible. Analysis of the current system suggests it should begin with comprehensive assessment of the individual, including physical function, emotional state, degree of social engagement, support system, and medical insurance. Next, the ideal interdisciplinary team should determine the person’s goals of care. Finally, a plan of care should be developed, taking both goals and needs into account. Implementing the plan will require a robust home care program as well as family support. Achievement of such a system will necessitate reforming the complex adaptive system that makes up American health care today. The most promising change agent is the Medicare program itself, which could introduce requirements into medical training programs to assure competence in geriatric medicine and communication skills. With appropriate legislative changes, Medicare could also negotiate with drug companies over price and set reimbursement for medical technology based on cost-effectiveness. Medicare could also develop a new benefit plan for frail elders that offered more intensive home care and other services in exchange for decreased coverage of invasive, expensive, and often non-beneficial hospital-based technology.
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