Glossary

AAA – Area Agency on Aging. An agency (in a local government or a community-based organization) that provides information on resources in the local area. An AAA is available in every part of the country, funded by the Older Americans Act.

ACL – Administration for Community Living. An agency that is part of the Department of Health and Human Services and manages programs to serve persons in old age and those with disabilities.

ADL – Activities of Daily Living. A term used in healthcare to refer to people’s daily self-care activities.

ADRC – Aging and Disability Resource Center. An agency that provides a consolidated source of information about aging, disability, and the services in the local area.

ACO – Accountable Care Organization. An organization of health care providers that continue to be paid fee-for-service; but, if they can achieve savings (compared with usual care), they share the savings with Medicare and other insurers. CMS has established a few types of ACOs, including Pioneer, Next Generation, and Medicare Shared Savings Plans.

AHRQ – Agency for Healthcare Research and Quality. The federal agency that sponsors health services research.

AoA – Administration on Aging. A Federal agency now incorporated into the Administration for Community Living that focuses on community-based supports and protections for elders.

BPCI – Bundled Payment Care Improvement Program in Medicare, which provides incentives for hospital and post-hospital core efficiencies.

CARE – The Continuity Assessment Record and Evaluation. A group of geriatric patient assessment tools with standardized items that was intended for use across settings where patients receive care and which did serve as the source for much of the latest version of OASIS and MDS.

Caregiver – A person who is providing direct services, supervision, or coordination of services on behalf of a frail elderly person.

CCM – Chronic Care Management code. A new billing code in 2016 for which Medicare pays for ongoing management of health care by a physician practice for persons living with chronic conditions.

CMMI – Center for Medicare and Medicaid Innovation. The part of CMS that administers innovative projects to improve system performance.

CMS – Centers for Medicare & Medicaid Services (cms.gov). The federal agency that administers Medicare and Medicaid programs.

Community Board – The collected group of stakeholders that generate a community’s voice to decide evidence-informed priorities for improving elder care in a MediCaring Community.

CQI – Continuous quality improvement. A set of management tools to guide identifying, testing, and learning from innovations.

CRISP – Chesapeake Regional Information System, or CRISP (crisphealth.org), is a regional health information exchange (HIE) serving Maryland and the District of Columbia.

ED or ER – Emergency Department or Emergency Room. A part of a hospital for receiving newly sick or injured persons.

Frail elders (or frail elderly people, or just “elders”) are people living with disabilities and illnesses that are generally associated with aging and that tend to worsen through to death. Operationally, this category might be defined as having ADL dependencies or poor judgement requiring assistance or supervision by others for most of each day, or having conditions or age likely to come to this point in the near future. Frailty is mainly a lack of reserve so that challenges to health or living circumstances have more severe results than they would in a younger person with more resiliency. See also Component #1: Frail Elders Identified in a Geographic Community.

Family – In this writing, we use “family” to include all those who are bonded to a particular elder by affection, legal relationship, or other operation of the law. The category includes diverse kinds of relationships, so long as the well-being of the frail elderly person is a personal concern.

GRACE – Geriatric Resources for Assessment and Care of Elders. A model of service delivery especially focused on low-income seniors.

HCBS – Home and Community-Based Services. Both a general approach to supporting frail and disabled persons at home rather than in an institution and a specific program such as the one in the Veterans Health System in which an IDT serves persons with advanced illnesses and disabilities at home. See also Component #3: Medical Care Tailored to Frail Elders.

HIE – Health Information Exchange. A regional health care information network implementing connections, data standards, and data management that enable interoperability and interchange of information across health care providers, usually on a regional basis.

HIPAA – Health Insurance Portability and Accountability Act. The statute that, among other things, standardizes the privacy rules for medical records.

IAH – Independence at Home. A Congressionally mandated demonstration program of in-home care by physicians with a geriatric focus. See also Chapter 3

IDT – interdisciplinary team. The team that together provides care planning and service delivery for a frail elderly person. An IDT always includes a physician (or nurse practitioner), nurse, and a person from a social work or psychology background and might also include many other specialists and personal care workers.

IOM – Institute of Medicine, now National Academy of Medicine. Part of the National Academy of Sciences, and often the lead in putting together influential statements of the scientific evidence around policy issues.

IMPACT – Improving Medicare Post-Acute Care Transformation, a federal statute that requires that provider organizations that serve Medicare patients after hospitalization will provide assessments in a required uniform way, to enable comparisons of outcomes with different strategies for services.

LTSS – Long-Term Services and Supports. Basically, all the non-medical elements that go into supporting a frail elder across time, such as assistance with bathing and dressing.

MCO – Managed Care Organization. An organization that receives a monthly capitation (PMPM) and is obligated to provide all covered services that the enrolled population needs.

MDS – Minimum Data Set. The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes.

OASIS – Outcome and Assessment Information Set is the Medicare-mandated standard clinical assessment tool for persons receiving home care.

PACE – Program of All-Inclusive Care for the Elderly. A permanent delivery system and payment arrangement that serves persons living in the community and needing a nursing home level of care. PACE now mostly serves persons who are eligible for both Medicare and Medicaid coverage. See also Chapter 7: Implementation: Start with PACE.

PCP – Primary Care Provider. The physician who takes responsibility for the range of health care needs of a patient, including prevention, rehabilitation, and outpatient diagnosis and treatment. Usually, this category is operationalized as internal medicine, family practice, general practice, pediatrics and geriatrics, though specialist physicians can take on this role as well.

PCORI – Patient-Centered Outcomes Research Institute. Federally chartered funder of research to guide patient and provider decisions with evidence.

Physician – The medical care provider with skills and license to take responsibility for health care of patients, a category which includes nurse practitioners and, in some situations, physician assistants.

PMPM – Per member per month. The amount paid by an insurer (e.g., Medicare or Medicaid) to a capitated provider, or the cost of services when allocated evenly across the relevant patient population.

ROI – A performance measure used to evaluate the efficiency of an investment or to compare the efficiency of a number of different investments. ROI measures the amount of return on an investment relative to the investment’s cost. To calculate ROI, the benefit (or return) of an investment is divided by the cost of the investment, and the result is expressed as a percentage or a ratio.