Comprehensive primary care programs treat older patients with chronic conditions

November 02, 2010

In a review of comprehensive primary care programs for older adults with multiple chronic conditions, authors identified three models that appear to have the greatest potential for improving quality of care and life for these patients, while reducing or not increasing the costs of their health care, according to an article in the November 3 issue of JAMA, a theme issue on aging.

Chad Boult, M.D., M.P.H., M.B.A., of the Johns Hopkins Bloomberg School of Public Health, Baltimore, presented the findings of the study at a JAMA media briefing at the National Press Club.

"Older patients with multiple chronic health conditions and complex health care needs often receive care that is fragmented, incomplete, inefficient, and ineffective," write Dr. Boult and co-author G. Darryl Wieland, Ph.D., M.P.H., of Palmetto Health Richland Hospital, Columbia, S.C. To identify models of care that may be more effective, the authors conducted a search of the medical literature for studies regarding U.S. models of comprehensive primary care for older patients with multiple chronic conditions.

The authors write that, based on expert consensus about the available evidence, there are 4 proactive, continuous processes that can substantially improve the primary care of this patient population: comprehensive assessment, evidence-based care planning and monitoring, promotion of patients' and (family caregivers') active engagement in care, and coordination of professionals in care of the patient--all tailored to the patient's goals and preferences.

Using these criteria, three models of chronic care were identified that include these processes and that appear to improve some aspects of the effectiveness and the efficiency of complex primary care--the Geriatric Resources for Assessment and Care of Elders (GRACE) model, Guided Care, and the Program of All-inclusive Care for the Elderly (PACE).

All 3 models are based on care by teams of health care professionals, including primary care physicians, registered nurses and other health professionals. Teams in all 3 models provide many of the same services to older patients with complex health care needs, including:The authors add that these models do have some significant differences in certain aspects of their structures and operations. In the GRACE model, an advance practice nurse and a social worker collaborate with primary care physicians in community health centers to provide comprehensive care for low-income patients. Care is reviewed regularly by an offsite geriatrics interdisciplinary team. In the Guided Care model, 2 to 5 primary care physicians partner with a registered nurse practicing at the same site to provide comprehensive primary care to 55 to 60 older patients who are at high risk for using extensive health services during the following year. Each PACE site operates as a managed care plan that receives capitated payments from Medicare and Medicaid and uses these funds to pay for all of the health-related services required by its patients.

"As the United States implements new models of chronic care, such as the 3 described here, more research is needed to define the optimal methods for identifying the patients who will benefit most, for providing the essential clinical processes, for disseminating and expanding the reach of these models, and for paying for excellent chronic care. Also necessary will be significant advances in the education of health care professionals and the managerial infrastructure that underlies new models of care," the authors write.

In an accompanying commentary in this issue of JAMA, Arpita Chattopadhyay, Ph.D., and Andrew B. Bindman, M.D., of San Francisco General Hospital, University of California, San Francisco, discuss the barriers to implementing comprehensive primary care programs for frail elderly patients. "With increasing health care costs and an aging population, the United States needs to expedite the development and scaling up of cost-effective models of integrated care," the authors suggest. "Health care reform has given CMS [Centers for Medicare & Medicaid Services] new authority to promote the process."
(JAMA. 2010;304[17]:1936-1943. Available pre-embargo to the media at

Editor's Note: Please see the article for additional information, including author contributions and affiliations, financial disclosures, funding and support, etc.

To contact Chad Boult, M.D., M.P.H., M.B.A., call Tim Parsons at 410-955-7619 or email To contact commentary corresponding author Andrew B. Bindman, M.D., call Karin Rush-Monroe at 415-502-1332 or email

For more information, contact JAMA/Archives Media Relations at 312/464-JAMA (5262) or e-mail

The JAMA Network Journals

Related Aging Articles from Brightsurf:

Surprises in 'active' aging
Aging is a process that affects not only living beings.

Aging-US: 'From Causes of Aging to Death from COVID-19' by Mikhail V. Blagosklonny
Aging-US recently published ''From Causes of Aging to Death from COVID-19'' by Blagosklonny et al. which reported that COVID-19 is not deadly early in life, but mortality increases exponentially with age - which is the strongest predictor of mortality.

Understanding the effect of aging on the genome
EPFL scientists have measured the molecular footprint that aging leaves on various mouse and human tissues.

Muscle aging: Stronger for longer
With life expectancy increasing, age-related diseases are also on the rise, including sarcopenia, the loss of muscle mass due to aging.

Aging memories may not be 'worse, 'just 'different'
A study from the Department of Psychological & Brain Sciences in Arts & Sciences adds nuance to the idea that an aging memory is a poor one and finds a potential correlation between the way people process the boundaries of events and episodic memory.

A new biomarker for the aging brain
Researchers at the RIKEN Center for Biosystems Dynamics Research (BDR) in Japan have identified changes in the aging brain related to blood circulation.

Scientists invented an aging vaccine
A new way to prevent autoimmune diseases associated with aging like atherosclerosis, Alzheimer's disease, and Parkinson's disease was described in the article.

The first roadmap for ovarian aging
Infertility likely stems from age-related decline of the ovaries, but the molecular mechanisms that lead to this decline have been unclear.

Researchers discover new cause of cell aging
New research from the USC Viterbi School of Engineering could be key to our understanding of how the aging process works.

Deep Aging Clocks: The emergence of AI-based biomarkers of aging and longevity
The advent of deep biomarkers of aging, longevity and mortality presents a range of non-obvious applications.

Read More: Aging News and Aging Current Events is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to