1. Recognize that a years-long period of declining capabilities in old age has become the most common path to death, not "terminal illness."
2. Ensure that elders and families have their priorities and possibilities recognized in the plan for therapies and services - an elder-driven care plan
3. Change medical care to adopt geriatric principles - slow changes, astute diagnosis, weighing of the burden of treatments, mobilizing services to the home, avoiding drugs with side effects, and making decisions in light of the elder's priorities.
4. Enhance the ready availability of supportive services - home-delivered food, disability-adapted housing, door-to-door transportation, support for volunteer caregivers, and keeping the elder engaged in the community.
5. Since so much of what matters depends upon the local community (not the payer or medical care provider), we need a new layer of community engagement with monitoring progress and managing their local system, and this includes setting priorities for investments.
6. At this time in the U.S., these reforms can be financed from the savings that prudent medical care will earn, compared with what Medicare now spends. In the long run, we need communities to be proud of their eldercare and comparing performance over time and with other communities, but to start, we just need the will to move ahead.