May 142014

The MediCaring team of healthcare providers must reflect and address the array of medical and social services frail elders need. However one labels the team– multidisciplinary, interdisciplinary or trans-disciplinary—its key focus must be to deliver an integrative approach based on a care plan developed in collaboration and with the elder and her family. Such a team is best equipped to manage the long-term needs that evolve as elders shift across settings and functional status.

The Care team can build upon one another’s expertise to achieve the common, shared goals articulated through a shared decision-making process driven by the elder in the development of the care plan. This approach operationalizes a basic tenet of MediCaring: that each frail elder should have reliable, comprehensive, and continuous medical and supportive services. Such a strategy builds on an ongoing, personal relationship with a primary care provider skilled in geriatric care. The entire structure builds on trust that is established between clinicians and elders, and extends to the entire team of caregivers, from home health aides to occupational therapists to volunteers.

Such a team—which functions well and operates in concert–can then provide the range of skills and services frail elders require, and offer these clients a reliable point of contact and entry to the system. In developing strong, trusting personal relationships among key team members, the elder and the family/friend caregivers, the structure offers the potential for enduring and effective care.

Core tem members should include, at the very least, a physician/nurse practitioner, nurse and social worker. Other direct providers such as physical therapists, respiratory therapists, speech pathologists, physician specialists, nutritionists, pharmacists, dentists, home health aides, lawyers, clergy and others can be included on the team as needed. Depending on the elder’s specific need, any member of this core team can respond to the elder’s needs for care, and coordinate treatment and services.

MediCaring builds on and ensures primary care for elders whose needs are complex and challenging. Such care is not the primary care we hear about in discourse that has become so common: a physician who provides routine prevention and screening, offers education about chronic disease self-care, and coordinates services by specialists. Rather, MediCaring is primary care on steroids – necessitating a high-functioning team that can deal with very complicated puzzles of needs and responses.

Core team members would hold biweekly meetings to discuss elders in their care, and review and update plans of care. Care would be delivered accordingly. During each visit with an elder, the visiting provider would conduct a medication review and pain and symptom assessment, as well as to assure that the full range of biopsychosocial needs specified in the care plan were being met.

MediCaring uses geriatric principles and palliative care standards and approaches, but is not limited to the medical aspects of service to the frail elderly population. Indeed, a major part of the endeavor is to shift resources from wasteful and unnecessary medical care toward greatly needed social supports that are mostly provided outside of the medical profession, and even outside of the nursing profession. MediCaring Community teams aim to be all-inclusive in order to meet the unique care needs of frail elders.

key words: Joanne Lynn, Janice Lynch Schuster, Judy Peres, MediCaring book, interdisiplinary team, multidisciplinary team

Sep 262011

AHRQ Innovators Exchange features information and a video about a pilot study to improve care for low-income elderly patients with chronic illnesses.

Conducted by Ohio-based Summa Care under the leadership of Practice Change Fellows and Advisory Board Member Kyle Allen, DO, AGSF, the project reports that 70% of participants reported improved health, and 93% rated their experience as good or excellent one year after participation. The program led to cost savings of approximately $600 to $1000 per patient per month as a result of decreased hospitalizations. Summa Health is now conducting a three-year randomized controlled trial to confirm these results.

Summa Health System developed a program called the Frail Elders Care Management Program. The project involved interdisciplinary teams that provide integrated medical and social care management to low-income elderly in-patients who have chronic illnesses. The program aimed to ease the transition from hospital to home, provide preventive care, identify new and emerging problems, reduce readmissions, and prevent functional decline. Most participants were over the age of 65, had several chronic conditions and impaired activities of daily living, and had one or more problems that required an intervention. For example, nearly 40% of patients took more than 10 prescriptions, and nearly 50% had experienced one or more falls.

The project featured an interdisciplinary team whose members included a geriatrician, an advanced practice nurse, a registered nurse care manager, a social worker, and a geriatric pharmacist. Other clinicians were called on as needed. Primary care physicians, who then received a one-time fee, participated in a consultation with the nurse care manager. Over the course of three years, the Frail Elders Care Management Program served 1,272 patients. Based on promising preliminary results, AHRQ funded a three-year randomized controlled trial.

Key Words: frail elders, care transitions, quality improvement, interdisciplinary teams