Familiar Tools Can Fix Care for Sickest Seniors

By Scott Harris

Though geriatrics is a relatively small segment of the physician population, given America’s aging rates it seems likely to grow. A new study found that well-coordinated geriatrics care can help bend the curve of hospital readmissions, and the keys to that coordination may be hiding in plain sight.

A study appearing in the Jan. 3 edition of the American Journal of Medical Quality found that the unadjusted 30-day rehospitalization rate for adults age 65 and older was 18 percent overall, 21 percent for geriatrics patients cared for by the geriatrics inpatient service, 22 percent for geriatrics practice patients on general medical services, and 17 percent for older patients on general medical services.

The study concluded that “despite greater frailty, patients cared for in an interdisciplinary geriatrics practice were no more likely to be rehospitalized than adults receiving ‘usual care,’ when adjusted for age and disease burden.”

But what makes for a successful interdisciplinary geriatrics practice? Most practitioners at least understand the growing need for greater communication between providers and settings. But according to Daniel J. Oates, M.D., the study’s lead author and an assistant professor of geriatrics at Boston University School of Medicine, the linchpin of good geriatrics care may be the case manager assigned to each patient. Though case managers are never a bad idea, they assume new importance for cases as complex and care-intensive as those that find their way to a geriatrics practice.

“It’s very important that your practice has alignment,” Oates said. “You need to be able to coordinate between outpatient settings, inpatient settings, and the team that cares for the patient after discharge.”

But not all case managers are created equal. The secret weapon to coordinated care? Make nurses the case managers. That is not a new or even viable concept in every practice, but nurses nevertheless bring an inimitable blend of skills to case management. Nurses will be familiar to all parties, can act as a personal patient advocate, and have the medical expertise to provide a critical bridge of communications.

“The nurse provides clinical triage and can give medical advice and do the case management function for the patient and the family,” Oates said. “Others have a social worker or someone who may be effective, but may not know the clinical piece. That’s why the nurse works so well, in our experience. The family knows the nurse, and knows that the nurse and the physician work together as a team in caring for the patient. The family knows you’re all on the same page.”

And there’s another tool that may by lying unused in a growing number of toolboxes: electronic medical records (EMR). Oates said that providers with access to well-developed EMRs don’t always take advantage of the information literally in front of their faces.

“We spend millions and millions of dollars on EMRs, but some people never look at them,” Oates said. “Look at the admission data. Look at the tools that are available. Good communication among providers, across areas of care. A well-developed EMR so all providers can coordinate with one another.”

0 thoughts on “Familiar Tools Can Fix Care for Sickest Seniors

  1. If you take a moment to read the abstract of the study cited, you will learn that the authors state that their hypothesis, i.e., geriatrics patients discharged from a geriatrics service would have fewer re-hospitalizations, was unconfirmed. This doesn’t take away from the value nurse case managers bring to the patients in this practice or the use of EMRs, but Geriatrics has a nearly 30 year history as an elective added credential for Board certified specialists in Internal Medicine and Family Medicine so it would be interesting to know the credentials and experience of the physicians in this study who were categorized as Geriatricians vs. Internists. I doubt that Geriatrics, as a speciality, is as small in numbers as Mr. Harris suggests and since the added credential is elective, there is no telling how many General Internal Medicine specialists actually have substantial geriatrics knowledge, experience, and practices.. The VA, as well as most, if not all, academic medical centers have invested heavily in all aspects of Geriatric Medicine as has the Society of Subspecialty Professors of Medicine with strong foundation support.

  2. Comment Amendment: The subspecialty professors organization is the “Association of Subspecialty Professors.” The John A. Hartford Foundation has funded much of the work in Geriatrics through ASP and, especially through the efforts of William Hazzard, MD, whose dedication to clinical geriatrics followed his career from Johns Hopkins to Bowman Gray to the University of Washington.