Integrating care for the geriatric patient. Examples from the Social HMO (SHMO)

Managing the care of geriatric patients with chronic disease focuses attention on the functional impairments that place these patients at risk in the home environment. Maintaining patients in their preferred home settings requires physicians to coordinate effective discharge planning and long-term community care resources. A service coordinator or case manager can play a key role in coordinating the broad array of services needed, as well as linking the providers involved. A coordinated acute and long-term care service delivery system is described, with examples from the Social HMO (SHMO). Data are presented on SHMO enrollee demographic characteristics, chronic disease conditions and functional levels, as well as data on care plans, utilization and costs. A case example illustrates how ongoing medical and long-term care are integrated. Implications for geriatric care and HMO practice are discussed, with recommendations for improving geriatric care in the next generation of SHMO sites.