Overview of Geriatric Care

By Debra Bakerjian

, PhD, APRN, Betty Irene Moore School of Nursing, UC Davis

Last full review/revision February 2018 by Debra Bakerjian, PhD, APRNư

The US Department of Health and Human Services (HHS) updates its strategic plan and defines its mission and goals for the next four years. The Center for Medicare and Medicaid Services (CMS) then builds their strategic goals. Currently, CMS strategy consists of four main goals:

  • Better care and lower costs

  • Prevention and population health

  • Expanded health care coverage

  • Enterprise excellence

Practitioners who provide care to older adults should be aware of these goals and incorporate them into their approach to geriatric care. The overarching goal is to improve the patient experience and provide high quality care at a lower cost. Additionally, geriatric practitioners need to incorporate prevention strategies with a goal of keeping patients and populations healthier.

Because older adults tend to have multiple chronic disorders and may also have cognitive, social, or functional problems, they have higher healthcare needs and use a disproportionately large amount of health care resources.

  • People ≥ 65 yr have the highest rate of inpatient hospital stays, more than 2.5 times higher than those 45-64 yr (1).

  • Medicare has steadily increased its share of cost for non-maternal and non-neonatal inpatient stays to 25.1% for people 45-64 yr and 97% for people 65 yr and older (1).

  • People 65 yr and older have the greatest per capita use of emergency departments (538.3 visits per 1,000 population) (2).

  • Half of traditional Medicare beneficiaries 65 yr or older spent 14% or more of their total income on out-of-pocket health care costs, with an even greater burden for those over 85 yr (3).

  • 88% of older adults take at least one prescription drug and 36% take 5 or more prescription drugs (4).

Because of their multiple chronic illnesses, the elderly are likely to see several health care practitioners and to move from one health care setting to another. Providing consistent, integrated care across specific care settings, sometimes called continuity of care, is thus particularly important for elderly patients. Communication among primary care physicians, specialists, other health care practitioners, and patients and their family members, particularly when patients are transferred between settings, is critical to ensuring that patients receive appropriate care in all settings. Electronic health records may help facilitate communication.

References

  • 1. Sun R, Karaca Z, Wong HS: Trends in hospital inpatient stays by age and payer, 2000–2015. HCUP Statistical Brief #235. Agency for Healthcare Research and Quality, 2018.

  • 2. Moore BJ, Stocks C, Owens PL: Trends in emergency department visits, 2006–2014. HCUP Statistical Brief #227. Agency for Healthcare Research and Quality, 2017.

  • 3. Cubanski J, Neuman T, Damico A, et al: Medicare beneficiaries’ out-of-pocket health care spending as a share of income now and projections for the future. Kaiser Family Foundation, 2018.

  • 4. Qato DM, Wilder J, Schumm LP, et al: Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011. JAMA Intern Med 176(4): 473-82, 2016. doi: 10.1001/jamainternmed.2015.8581.

    Health care settings

    Care may be delivered in the following settings:

    • Physician's office: The most common reasons for visits are routine diagnosis and management of acute and chronic problems, health promotion and disease prevention, and presurgical or postsurgical evaluation.

    • Patient’s home: Home care is most commonly used after hospital discharge, but hospitalization is not a prerequisite. Also, a small but growing number of health care practitioners deliver care for acute and chronic problems and sometimes end-of-life care in a patient's home.

    • Long-term care facilities: These facilities include assisted-living facilities, board-and-care facilities, nursing homes, and life-care communities. Whether patients require care in a long-term care facility depends partly on the patient’s wishes and needs and on the family’s ability to meet the patient’s needs. Because of the trend toward shorter hospital stays, some long-term care facilities are now also providing post-acute care (eg, rehabilitation and high-level skilled nursing services) previously done during hospitalization.

    • Day care facilities: These facilities provide medical, rehabilitative, cognitive, and social services several hours a day for several days a week.

    • Hospitals: Only seriously ill elderly patients should be hospitalized. Hospitalization itself poses risks to elderly patients because of confinement, immobility, diagnostic testing, and treatments.

    • Long-term care hospitals: These facilities provide extended hospital-level recovery and rehabilitative care to patients with severe injuries and clinically complex conditions (eg, severe stroke, severe trauma, multiple acute and chronic problems). These facilities are for patients who are expected to improve and return home but who need a longer period of time.

    • Hospice: Hospices provide care for the dying. The goal is to alleviate symptoms and keep people comfortable rather than to cure a disorder. Hospice care can be provided in the home, a nursing home, or an inpatient facility.

    In general, the lowest, least restrictive level of care suitable to a patient’s needs should be used. This approach conserves financial resources and helps preserve the patient’s independence and functioning.

    Geriatric Interdisciplinary Teams

    Geriatric interdisciplinary teams consist of practitioners from different disciplines who provide coordinated, integrated care with collectively set goals and shared resources and responsibilities.

    Not all elderly patients need a formal geriatric interdisciplinary team. However, if patients have complex medical, psychologic, and social needs, such teams are more effective in assessing patient needs and creating an effective care plan than are practitioners working alone. If interdisciplinary care is not available, an alternative is management by a geriatrician or geriatric nurse practitioner or a primary care physician or nurse practitioner or physician assistant with experience and interest in geriatric medicine.

    Interdisciplinary teams aim to ensure the following:

    • That patients move safely and easily from one care setting to another and from one practitioner to another

    • That the most qualified practitioner provides care for each problem

    • That care is not duplicated

    • That care is comprehensive

    To create, monitor, or revise the care plan, interdisciplinary teams must communicate openly, freely, and regularly. Core team members must collaborate, with trust and respect for the contributions of others, and coordinate the care plan (eg, by delegating, sharing accountability, jointly implementing it). Team members may work together at the same site, making communication informal and expeditious. However, with the increased use of technology (ie, cell phones, computers, internet, telehealth), it is not unusual for team members to work at different sites and use various technologies to enhance communication.

    A team typically includes physicians, nurses, nurse practitioners, physician assistants, pharmacists, social workers, psychologists, and sometimes a dentist, dietitian, physical and occupational therapists, an ethicist, or a palliative care or hospice physician. Team members should have knowledge of geriatric medicine, familiarity with the patient, dedication to the team process, and good communication skills.

    To function effectively, teams need a formal structure. Teams should develop a shared vision of care, identify patient-centered objectives and set deadlines for reaching their goals, have regular meetings (to discuss team structure, process, and communication), and continuously monitor their progress (using quality improvement measures). In general, team leadership should rotate, depending on the needs of the patient; the key provider of care reports on the patient’s progress. For example, if the main concern is the patient’s medical condition, a physician, nurse practitioner, or physician assistant leads the meeting and introduces the team to the patient and family members. The physician, nurse practitioner, or physician assistant often work together and determine what medical conditions a patient has, informs the team (including differential diagnoses), and explains how these conditions affect care.

    The team’s input is incorporated into medical orders. The physician or one of the provider team members must write medical orders agreed on through the team process and discusses team decisions with the patient, family members, and caregivers. Alternatively, if the main concern is related to nursing care, such as wound care, then the nurse should lead the team discussion.

    If a formally structured interdisciplinary team is not available or practical, a virtual team can be used. Such teams are usually led by the primary care physician but can be organized and managed by an advanced practice nurse or physician assistant, a care coordinator, or a case manager. The virtual team uses information technologies (eg, handheld devices, email, video conferencing, teleconferencing) to communicate and collaborate with team members in the community or within a health care system.

    Patient and caregiver participation

    Recent evidence has pointed to the importance of providing person-centered care, which means that providers are highly focused on patient preferences, needs, and values. The key principles of patient-centered care include respect for patient preferences; coordinating care, providing information and education to patient and families, involving family and friends, and providing both physical comfort and emotional support. Practitioner team members must treat patients and caregivers as active members of the team—eg, in the following ways:

    • Patients and caregivers should be included in team meetings when appropriate.

    • Patients should be asked to help the team set goals (eg, advance directives, end-of-life care, level of pain).

    • Patients and caregivers should be included in discussions of drug treatment, rehabilitation, dietary plans, and other therapies.

    • Patients should be asked what their ideas and preferences are; thus, if patients will not take a particular drug or change certain dietary habits, care can be modified accordingly.

    Patients and practitioners must communicate honestly to prevent patients from suppressing an opinion and agreeing to every suggestion. Cognitively impaired patients should be included in decision making provided that practitioners adjust their communication to a level that patients can understand. Capacity to make health care decisions is specific to each particular decision; patients who are not capable of making complex decisions may still be able to decide less complicated issues.

    Caregivers, including family members, can help by identifying realistic and unrealistic expectations based on the patient’s habits and lifestyle. Caregivers should also indicate what kind of support they can provide.

    Sources: https://www.merckmanuals.com/professional/geriatrics/provision-of-care-to-the-elderly/overview-of-geriatric-care