3.1 What are the critical elements of geriatricized medical services?
A good geriatricized medical service should have all of the following components.
Always committed to an elder-driven care plan, appropriately comprehensive
As developed above, the point of good geriatric care is not generally to align with professional standards that were established with “average” patients, but to develop and implement the customized plan that helps frail elderly people to live as well as possible, from their own perspectives, despite various disabilities and constraints. For frail elders, a good care plan always includes guidance as to treatments and concerns around the time of death—an advance care plan, for end-of-life care.
Alignment with the elderly person’s goals, and the family’s
Good care requires knowing what matters most to the elderly person and family, and arranging services so that they are confident that their care team is “on my side,” and seeking what is best, as defined by the elderly person and family. For example, this requires awareness of how much the frail elder often loses in strength or cognitive function just by going into the hospital. Furthermore, the elder may lose a well-functioning set of supportive services and home care aides. Thus, deciding to go to the hospital becomes a weighty decision guided by the options for and risks of treatment at home, judged from the perspective of the elder’s priorities.
Providers skilled at working in a team and negotiating care plans, whether as leader or member
Multidisciplinary teams whose focus is frail elders will coordinate elder-driven care in the MediCaring Community. Such teams are already required in PACE and hospice, and are often found in nursing homes also. Effective teams include clinicians and practitioners trained and skilled in a broad array of activities: diagnosis and treatment; medication management; rehabilitation; self-care; nursing care; mental health; caregiver assessment, training, and support; nutrition; community services; and housing. Teams would generally include a physician, nurse, and social worker as core participants with the elderly person and family, and they can rely upon ongoing and reliable access to pharmacists, rehabilitation specialists, mental health experts, housing services staff, caregiver support personnel, and legal advisors. The team’s capabilities and functioning would be measured and certified as meeting standards that reflect well-coordinated care, rather than mainly monitoring adherence to requirements for certain disciplines doing certain tasks. Over time, high functioning teams acquire a great deal of cross-training, so disciplinary boundaries become blurred.
Honest and accurate about prognosis and options
Currently, practitioners do not often have the information needed to characterize the likely futures for the elderly person, and, even when they do, they do not generally share that information with the elderly person and family. Some of this is a polite effort to maintain optimism and hopefulness, and some reflects the general lack of familiarity with making decisions while informed of the likelihood of various outcomes. The lack of accurate information could be addressed with analyses of large data sets as to the course of relevantly similar people who were in the same situation a few years ago. But we still need to generate a shared sense that elderly people and their families deserve the opportunity to make their own decisions as adults, and therefore to have honest information, even if the situation presents a grim or upsetting picture.
Deep empathy with the challenges of loss, cognitive failure, compromises, and death
Providing care for frail elderly people always ends in the person’s death and usually entails a long course of decline. To care for persons who cannot “get better” and who will die requires substantial maturity and dedication, but providing services and support is essential. The loneliness of old age is, perhaps, even more devastating than the loss of muscle strength or the diminishment of hearing. A good community would make it possible for caregivers, neighbors, and friends to know and truly care about the elderly person, not just to accomplish the tasks necessary to mere survival.
On-call 24/7 with a person known to elder and family and with care plan in hand
MediCaring requires continuity of services across time, settings, and providers, with round-the-clock coverage and real-time availability to the elder and his or her caregivers. A MediCaring team would be charged with providing medical and nursing advice and support. In the case of an urgent phone call (or text or email) with a pressing health concern, a team member with appropriate skills for the problem would respond promptly. The team member on call would often know the elder and caregivers personally and would always have immediate access to an up-to-date care plan.
Able to provide routine and urgent services in the elder’s home (including nursing home)
Frail elders and their caregivers can be stressed and overwhelmed by the challenge of simply getting to a physician’s office. Whenever feasible, urgent home visits to assess emerging situations should occur within three hours of a call (or, in rural or otherwise difficult areas, telemedicine should be planned and used). The process of developing care plans for MediCaring elders should include honest and forthright understanding about when and if to call 911 or to go to an emergency department. For frail, homebound elders, many technical and supportive services, guided by a competent physical examination, can be safely done where the elderly person lives, including simple diagnostic x-rays and other imaging, blood and urine tests, skin biopsies, electrocardiograms, and more. This spares frail elders the burdens and risks of being moved to another setting simply to receive good medical care, especially when that care can so effectively be delivered to them where they live. Home visits are a wise, safe, and effective method for preventing or delaying hospitalizations and nursing home placements. For example, preliminary results from the Independence at Home demonstration, which delivers primary care at home, show clear benefits to elders, who have fewer hospitalizations and ED visits, as well as fewer 30-day readmissions.[61] In the interests of prudent spending, any service that works in multiple elderly person’s homes has to consider the possibility of organizing delivery of services geographically, rather than having a large array of providers of the same service competing. The practice of having a large number of competing services is usually justified by a claim that this will hold down prices and improve quality (or at least customer service). In health care for frail elders at home, this claim is a weak one since so much of the productive time of skilled people ends up being spent in transportation, and the clients have so little interest in or accessible information about quality that competition has little effect.
Avoidance of preventable complications—falls, dehydration, medication errors, unwanted CPR
Much of good geriatric care focuses upon prevention – not often prevention of the underlying physical problem, but prevention of the complications. Elders have very little resilience to withstand errors, so medications must be carefully considered and adjusted, for example. Falls are a scourge, both because of injuries and because falling makes the person hesitant to walk around, which reduces capacity for ambulation over time. Many falls are preventable, both by monitoring medications and blood pressure and by arranging the home environment to be protective, e.g., with good lighting, no trip hazards, and hand rails.[62] Of course, one also and obviously wants to avoid aggressive medical interventions like resuscitation, dialysis, and ventilators unless they really offer the person an advantage and the well-informed elderly person wants them used.
Broad knowledge of specialty medicine to be able to integrate specialty perspectives
The geriatric physician or nurse practitioner truly must be a “comprehensivist”—a clinician able to understand and manage the contributions of specialist physicians and therapists and being responsible for forging that all-important care plan with the elderly person and family. Not all clinicians care to take on this role. It requires being able to ask for help often, as well as have well-honed sensibilities as to what works, in what situations, and with what outcomes.
Attention to important disabilities not covered by Medicare
One can readily discern that the scope of Medicare coverage was not established by frail elders—it does not attend to hearing, vision, teeth, or feet. A geriatric approach to medical care has to address these issues, since they cause so much suffering and isolation to elders. The geriatric medical provider needs to be able to screen for problems in these arenas and the team has to know how to obtain services from practitioners who are sensitive to the needs and priorities of frail elders, including dealing with issues about costs and personal finances.
Aware of and engaged with the supportive services in the community
A geriatric clinician will quickly become aware of the strengths and gaps in the community’s supportive services (LTSS). This will help steer care plans toward effective and available services, but it also will call on the geriatrician and the team to be engaged with advocating for optimizing the supply and quality of services in their community. MediCaring teams will monitor quality and supply and will be present at governmental hearings and philanthropic decision-making in order to move their community toward adequate supply and reliable quality.
[61] (Centers for Medicare and Medicaid Services, Independence at Home (IAH) Demonstration: Year 1 Practice Results 2015)
[62] (Tinetti and Kumar 2010)
