A nurse with a senior female patient in a wheelchair in a hospital

RAND Solution

Improving Health Care Quality for Vulnerable Elders


With people living longer lives and elderly populations growing rapidly, health care for seniors is of growing importance both in the United States—where more than 40 percent of health care spending goes toward individuals 65 or older—and across the globe. However, little is known about health care quality for older patients.


Pharmacist helping a senior woman

Seniors often have numerous medical conditions and are especially vulnerable to the negative effects of low-quality health care. The mix of conditions older patients face includes diseases, syndromes, and physiological impairments. This variety can make measuring quality of care for older patients a very complex undertaking.

Seniors often have numerous medical conditions and are especially vulnerable to the negative effects of low-quality health care.

Project Description

In collaboration with Pfizer, Inc., RAND conducted Assessing the Care of Vulnerable Elders (ACOVE), a project to develop and test quality indicators and create a comprehensive assessment system to help inform both health care providers and consumers.

RAND researchers worked with a panel of the foremost experts in geriatric care to identify 22 conditions that comprise the majority of health care received by elders. The research team then developed a set of approximately 240 quality-of-care indicators for four types of health care: prevention, diagnosis, treatment, and follow-up.

The RAND team used these indicators to assess quality of care for a group of vulnerable elders enrolled in managed care plans. Researchers reviewed each patient's medical charts and interviewed patients or their caregivers to fill any relevant gaps not captured by the charts.

Research Questions

  1. Who are “vulnerable elders” and how can we identify them?
  2. Do the elderly receive the amount of high-quality care recommended for them?
    • How does receipt of high-quality care differ based on type of care (e.g., prevention, treatment) or condition?

Key Findings

  • Vulnerable elders are people 65 years and older who are at high risk for death or functional decline. Researchers developed a simple questionnaire, the Vulnerable Elders Survey, to consistently identify these individuals.
  • The vulnerable elderly received about half of the care recommended for them.
    • Quality of care differs widely between different types of care or conditions.
      • Preventive care suffers the most. Providers give diagnostic and treatment procedures most frequently.
      • Care is worse for geriatric conditions (e.g., incontinence, falls) than for conditions that affect all adults (e.g., hypertension).
      • Physicians often fail to prescribe recommended medications for elderly patients.

“We need to ensure that individual needs are addressed and patients, families and physicians are armed with condition-specific information and assessment tools to improve these deficits in care. Educating consumers about the right questions to ask of their medical providers is a powerful first step in increasing the quality of care for our nation's vulnerable elderly.”

Robin Hertz, Pfizer


By creating the first set of quality indicators developed specifically for the vulnerable elderly, RAND provided clarity to a previously murky area of health care delivery that affects a growing proportion of Americans.

Then, researchers used these measures to evaluate efforts by primary care practices to improve on underperforming areas identified by ACOVE's earlier work.

Later, the team updated the quality indicators to reflect real-world changes in diagnosis and treatment. In particular, researchers considered how to apply indicators to patients with advanced dementia and other poor prognoses—to minimize patient discomfort and care that does not benefit the patient.

ACOVE has also examined problems in medication prescribing, the link between quality of care and patient survival, and the reliability of patient ratings with respect to quality of care.

“[ACOVE] provides more evidence that improving the quality of care for older patients can extend patients' lives.”

Robin Hertz, Pfizer