Academic journal article Generations

Experts Answer Five Critical Questions about Integration of Care

Academic journal article Generations

Experts Answer Five Critical Questions about Integration of Care

Article excerpt

In many ways it appears that the next frontier in the care revolution will be in the area of integrating acute and long-term care for older people While the notion that older people will benefit has become almost axiomatic, the real potential value of such integration-and specific, practical ideas about what it would take to achieve it-are not necessarily clear. Here, we've asked leaders in the field togive us their candid answers to five critical questions about integration of care.

For their varying perspectives, we hear from James J Callahan, Jr, Jennie Chin Hansen, Rosalie A. Kane, William Weissert, Thomas E. Brown, Jr, andJoan L. Quinn.


James J. Callahan, Jr., PhD., is director, Policy Center on Aging, Heller School, Brandeis University, Waltham, Mass.

What is the most obvious benefit from the integration of acute- and chroniccare services for frail elders?

This question generates more questions than answers because it does not operationalize integration nor does it identify who is to receive the obvious benefit. In the absence of a specific definition, "integration" becomes a Rorschach test for the responders to the question. Nor is it clear whether the question refers to the integration of acute with chronic-care services or integration within the acute sector and within the chronic-care sector. It certainly would be valuable if primary-care physicians, medical specialists, nurses, mental health staff, therapists, and others on the acute side could get their act together. It would be just as useful, if, within the chronic-care sector, the homemakers, nutrition providers, service coordinators, housing advocates, transportation specialists, and others could get their act together, as well. I suspect, however, that the question is referring to joining those two sectors, whether or not there is any level of integration within them.

Services integration is a topic that's been of interest to me for most of my professional career-particularly integration of social services. A starting point for professional consideration of service integration would be the charity organization societies that sprang into existence in the late nineteenth century. They were designed to ensure that no poor person would get one more resource than what they deemed necessary. They created a technology of investigation using the police, friendly visitors, and, later, social case workers and now their descendants, case managers. Early in the twentieth century, Mary Richmond (I9I7) wrote her famous book Social Diagnosis, which created a structured methodology for integrating services around particular individuals. In the thirties, forties, and fifties, the United Way (called the Community Chest or United Fund) and its affiliates supported social service exchanges, which were an attempt to share information among agencies regarding individuals' use of services. I am old enough to remember reviewing carbon copies of records detailing some poor soul's many and lengthy contacts with a variety of limited-purpose social agencies. These people's experience with the fragmented system led them to be designated "multiproblem families." Social service exchanges added little other than curiosity to the task of meeting an individual's immediate needs. Much of the information they collected was irrelevant and discarded. My experience with this process has made me forever suspicious of communitywide data systems.

Services integration at a programmatic or systems level was a goal of the multiservice centers funded by the War on Poverty and by the coordinating structures created by the Model Cities programs instigated by the federal government in the I96os. Probably the most serious effort at social service integration occurred during the Nixon administration under the leadership of Elliot Richardson, Secretary of Health, Education and Welfare. The department conducted numerous studies documenting the lack of integration among services and supported a variety of service integration projects (Richardson, I976). …

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