One of the most difficult tasks we face is improving the quality of health care for the elderly. Dr. Berwick's account of his father's illness [1] is an unfortunately common story of poor care of an older person. Geriatric syndromes such as polypharmacy, decubiti, and delirium are treatable and avoidable, and their ubiquity demonstrates that more attention should be paid to the special needs of the elderly.

First, we need to emphasize continuity of care. One way to achieve the "integration of experience" Dr. Berwick recommends is to use multidisciplinary teams that provide services across the spectrum of community, acute, rehabilitation, and long-term care. Better continuity may have prevented the sudden cessation of therapy with medicine for Parkinson disease, which adversely affected his father.

Second, we need a better understanding of "best practices" for specific geriatric syndromes and common problems. Programs to reduce the incidence of decubiti are a good start, but how can we distill and disseminate the critical aspects of this program?

Third, the issue of reducing total costs is especially critical for care of the elderly because of growing needs and limited resources. Medicare expenditures on acute care are decreasing, but costs of home care and rehabilitation are skyrocketing [2]. Did Medicare "save" any money when it paid for fewer hospital days but also for a lengthy, ineffective rehabilitation stay for Dr. Berwick's father? Whether managed care programs that rely more heavily on community-based care of the elderly will actually reduce costs is an open question.

The challenge of improving quality of care for the elderly deserves special attention. By improving continuity of care, focusing on common geriatric problems, and examining the total costs of care so that we can better allocate scarce resources, we can improve our practices and avoid tragedies such as the one that befell Dr. Berwick's father.