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Uncovering a "New" Clinical Niche for the Geriatrician
Affiliations:
1Department of Internal Medicine, College of Medicine, University of Central Florida; Orlando VA Medical Center, Orlando, FL
2Miami GRECC, Bruce W. Carter VA Medical Center; Miller School of Medicine, University of Miami, Miami, FL
3West Palm Beach VA Medical Center, West Palm Beach, FL
Abstract: The fragmented nature of the modern healthcare system frequently gives way to inappropriate care by providers who do not fully understand older patients’ complex medical histories. Studies show that uncoordinated care increases the risk of poor patient outcomes, including unnecessary hospitalizations and premature long-term institutionalization, all of which drain healthcare resources and put patients at increased risk of morbidity and mortality. The authors of this article argue that until new care models, such as accountable care organizations, demonstrate their ability to decrease cost and risk to older adults, maintenance of physician-patient relationships is increasingly more important. As medical decision-making becomes evermore complex for older adults, geriatricians are poised to play a unique and valuable role in securing coordinated care in the ever-changing healthcare system.
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The traditional model of the general physician who follows elderly patients across home, hospital, and long-term care (LTC) settings has transformed into a seemingly impersonal and fragmented model in which medically complex older adults are handed off between hospitalists, primary care physicians, and physicians at subacute and LTC facilities.1 The fragmented nature of the modern healthcare system results in vulnerable older adults receiving care from healthcare professionals who often have an incomplete understanding of these patients’ complex medical histories and psychosocial issues. In addition, unnecessary hospitalizations and subacute admissions waste limited resources and may expose older adults to a host of underrecognized geriatric syndromes, nosocomial infections, and an increased risk of long-term institutionalization.
Unfortunately, there is no clear evidence-based consensus as to the proper “carrot and stick” approach to provide care coordination to vulnerable older adults. Recent systematic reviews of transitional care interventional studies have failed to identify best practice strategies.2-4 Best practices of disease management may not be applicable to those older adults with multiple comorbidities, or to those with cognitive, functional, and sensory impairments.5 New care models, such as the patient-centered medical home (PCMH) and accountable care organizations (ACO) have not yet demonstrated consistent savings or decreased risk of rehospitalization in vulnerable older adults.6-8
These new practice models also represent a far different vision of customer service compared with what older adults encountered only a “few” years ago. With medical care and treatment decisions becoming evermore complex, the importance of the physician–patient relationship remains as great as ever. The segregation of physicians to “dedicated” practice venues weakens the bond that many elderly patients previously had with their personal physician. An understanding of the patient’s unique psychosocial issues takes time to develop and may not occur in the fragmented and hurried pace of the modern healthcare system. Similarly, it may take time for patients and their families to develop a sense of trust in their physician and healthcare team. The relationship with the physician has important psychosocial benefits for elderly patients, especially those with limited family support.
With a single primary physician no longer providing inpatient, outpatient, and LTC services, older patients are often confused as to which physician has personal accountability for the coordination of their transitional care needs. The outpatient physician often becomes a bystander in the medical evaluation process and in key decisions that occur during an acute/subacute care episode. Given the current financial disincentives facing the primary care physician, having a connection with patients is one of the few remaining incentives for physicians seeking a career in general medicine and geriatrics.
While PCMHs and ACOs may train care managers (eg, nurses and social workers) to help coordinate care, the anchor of interdisciplinary care for frail older adults needs to be a physician with geriatric expertise. Geriatricians already have 3 years of postgraduate clinical training that focuses on both inpatient and outpatient care. In addition, they have at least an additional year of training in the assessment and management of geriatric syndromes and in the delivery of home-based care and LTC services. Geriatricians acquire expertise working in interdisciplinary teams and developing patient-centered plans of care. Furthermore, geriatricians have expertise in end-of-life care and in the assessment and prevention of hospitalization-associated disability.
Geriatricians, as well as many general medicine physicians, already have the unique skill sets to assume the clinical niche of providing true continuity of care for medically complex elderly patients across outpatient, inpatient, and LTC settings. A recent study by Sorbero and colleagues9 using data from 2002 found that elderly patients whose care was managed in the hospital by geriatricians compared with nongeriatricians had a shorter length of stay and lower costs of care, yet had similar clinical outcomes. Whether physician longitudinal care would involve an inpatient role as the primary attending or as a consultant to a hospitalist service remains unclear. The ability of geriatricians to follow patients across the continuum of care is feasible as many specialists continue to provide care across inpatient and outpatient settings. Similarly, concierge physicians follow their patients when they are hospitalized. Defining the ideal patient profile size and level of interdisciplinary support also needs to be determined.
By providing longitudinal outpatient care and following patients through care transitions, geriatricians could “lead” interdisciplinary teams to deliver concierge-like service to those patients most in need of coordinated care. To provide this level of service will require substantial changes to the relative value units (a measure of value used by Medicare reimbursement formulas for physician services), payments for care coordination (MD and non-MD services), and cost-sharing incentives. Defining a clinical niche for the geriatrician may help to stem the declining interest in the subspecialty of geriatric medicine.10 Such a model would also provide the level of customer satisfaction and personal accountability that elderly patients fondly remember and continue to expect.
References
1. Stefanacci RG. Care coordination today: what, why, who, where, and how? Annals of Long-Term Care. 2013;21(3):38-42.
2. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155(8):520-528.
3. Prvu Bettger J, Alexander KP, Dolor RJ, et al. Transitional care after hospitalization for acute stroke or myocardial infarction. Ann Intern Med. 2012;157(6):407-416.
4. Hesselink G, Shoonhoven L, Barach P, et al. Improving patient handovers from hospital to primary care: a systematic review. Ann Intern Med. 2012;157(6):417-428.
5. Golden AG, Tewary S, Dang S, Roos BA. Care management’s challenges and opportunities to reduce the rapid rehospitalization of frail community-dwelling older adults. Gerontologist. 2010;50(4):451-458.
6. Jackson GL, Powers BJ, Chatterjee R, et al. The patient-centered medical home: a systematic review. Ann Intern Med. 2013;158(3):169-178.
7. Correia EW. Accountable care organizations: the proposed regulations and the prospects for success. Am J Manag Care. 2011;17(8):560-568.
8. Peikes D, Zutshi A, Genevro JL, Parchman ML, Meyers DS. Early evaluations of the medical home: Building on apromising start. Am J Manag Care. 2012;18(2):105-116.
9. Sorbero ME, Saul MI, Liu H, Resnick NM. Are geriatricians more efficient than other physicians at managing inpatient care for elderly patients? J Am Geriatr Soc. 2012;60(5):869-876.
10. Golden AG, Silverman MA, Mintzer MJ. Is geriatric medicine terminally ill? Ann Intern Med. 2012;156(9):654-656.
Disclosures: The authors report no relevant financial relationships.
Address correspondence to: Adam Golden, MD, MBA, ACOS, Geriatrics & Extended Care, Orlando VA Medical Center, UCF College of Medicine, 5201 Raymond Street, CLC-136, Orlando, FL 32803; adam.golden@ucf.edu
