Guid­ing el­derly care

Group calls for in­te­grated care, com­mu­ni­ca­tion

Modern Healthcare - - THE WEEK IN HEALTHCARE - Julie Ja­cob Julie Ja­cob is a free­lance writer in Racine, Wis.

Health­care pro­fes­sion­als car­ing for el­derly Amer­i­cans with three or more chronic health con­di­tions should min­i­mize the num­ber of med­i­ca­tions they pre­scribe to those pa­tients, as well as talk at length with them and their fam­i­lies to de­ter­mine their treat­ment pref­er­ences and out­come goals, ac­cord­ing to the Amer­i­can Ge­ri­atrics So­ci­ety’s new guid­ing prin­ci­ples on car­ing for older adults with mul­ti­ple mor­bidi­ties.

“There re­ally is a strik­ing preva­lence of peo­ple who have mul­ti­ple chronic con­di­tions … yet much of the way we prac­tice health­care is re­ally sort of one dis­ease at time. There is in­creas­ing recog­ni­tion that we need to think about how to in­te­grate the treat­ments for all th­ese con­di­tions,” said Dr. Cyn­thia Boyd, cochair of the panel that de­vel­oped the guid­ing prin­ci­ples, and an as­so­ciate pro­fes­sor of medicine at Johns Hop­kins Medicine.

The ques­tion, how­ever, is how med­i­cal prac­tices and hos­pi­tals will be able to put th­ese guid­ing prin­ci­ples into prac­tice on tight bud­gets and with busy clin­i­cians.

“It sounds great on pa­per,” said Lor­raine Ryan, se­nior vice pres­i­dent for le­gal, reg­u­la­tory, and pro­fes­sional af­fairs for the Greater New York Hos­pi­tal As­so­ci­a­tion. “It is a mat­ter of pri­or­i­tiz­ing with limited re­sources.”

In fact, the doc­u­ment notes, the way that clin­i­cians and hos­pi­tals are re­im­bursed does not take into ac­count the time clin­i­cians need to have lengthy dis­cus­sions with pa­tients and their fam­i­lies about treat­ment pref­er­ences. An­other chal­lenge noted in the guid­ing prin­ci­ples is that per­for­mance-based pay­ment sys­tems usu­ally mea­sure pa­tient out­comes for a sin­gle dis­ease, which may en­cour­age health­care providers to over­pre­scribe tests and pro­ce­dures for el­derly pa­tients.

Yet still an­other ob­sta­cle to im­ple­ment­ing the guide­lines is that car­ing for older adults with many health con­di­tions re­quires the co­or­di­na­tion of ser­vices in var­i­ous in­pa­tient and out­pa­tient set­tings, and all of th­ese providers should fol­low the guid­ing prin­ci­ples, said Dr. Michael Mal­one, med­i­cal di­rec­tor for se­nior ser­vices at Aurora Health Care, a 14-hos­pi­tal sys­tem based in Mil­wau­kee. For ex­am­ple, he said, Aurora al­ready has a pro­gram in place for hos­pi­tal­ized el­derly pa­tients in which mul­ti­dis­ci­plinary teams as­sess the pa­tients’ con­di­tion daily and iden­tify the pa­tient’s most im­por­tant con­cern. The chal­lenge is ap­ply­ing that in­ten­sive, mul­ti­dis­ci­plinary ap­proach in other set­tings where el­derly pa­tients are treated, he said.

“There are a lot of mov­ing parts in the care of se­niors with com­plex con­di­tions—their med­i­cal needs, their med­i­ca­tion needs, how they are func­tion­ing, how they are able to take care of them­selves and their links to com­mu­nity ser­vices,” Mal­one said.

De­spite th­ese com­plex­i­ties in car­ry­ing out the Amer­i­can Geri­atric So­ci­ety’s prin­ci­ples, Mal­one wel­comes their “re­fresh­ing fo­cus on pa­tient pref­er­ences and on the kind of holis­tic ap­proach to pa­tients with mul­ti­ple ill­nesses.”

This ap­proach may pay off in lower costs in car­ing for el­derly pa­tients. Ac­cord­ing to a study pub­lished in the April 22 on­line is­sue of JAMA In­ter­nal Medicine, a mul­ti­dis­ci­plinary ap­proach to car­ing for hos­pi­tal­ized el­derly pa­tients re­sulted in lower aver­age hos­pi­tal­iza­tion costs and fewer 30-day read­mis­sions than stan­dard care for el­derly pa­tients. An­other study in the same is­sue con­cluded that spe­cial­ized, mul­ti­dis­ci­plinary care for hos­pi­tal­ized el­derly pa­tients re­duced the in­ci­dence of ad­verse events and short­ened hos­pi­tal stays.

In ad­di­tion to call­ing for less use of med­i­ca­tions and more em­pha­sis on de­ter­min­ing the pref­er­ences of pa­tients and their fam­i­lies, the guid­ing prin­ci­ples also call for bet­ter co­or­di­na­tion of care for el­derly adults with mul­ti­ple mor­bidi­ties, more re­search on best prac­tices in car­ing for older adults with sev­eral chronic health prob­lems and changes to re­im­burse­ment poli­cies to ac­cu­rately re­flect the amount of time that clin­i­cians spend with th­ese el­derly pa­tients.

The AGS pub­lished “Guid­ing prin­ci­ples for the care of older adults with mul­ti­mor­bid­ity: A guide for clin­i­cians” in the Sept. 19, 2012 on­line ver­sion of the Jour­nal of the Amer­i­can Ge­ri­atrics So­ci­ety.

The prin­ci­ples are based on a lit­er­a­ture re­view and rec­om­men­da­tions of a 12-mem­ber ex­pert panel, which in­cluded physi­cians from aca­demic med­i­cal cen­ters, a nurse prac­ti­tioner, a phar­ma­cist and a physi­cian from HHS. They are grouped in five do­mains: pa­tient pref­er­ences, in­ter­pret­ing the ev­i­dence, prog­no­sis, clin­i­cal fea­si­bil­ity and op­ti­miz­ing ther­a­pies and care plans. Within each do­main are sev­eral sug­ges­tions re­gard­ing the care of geri­atric pa­tients, in­clud­ing that clin­i­cians should:

■ In­form el­derly pa­tients about the ex­pected ben­e­fits and risk of treat­ment op­tions us­ing nu­meric data and then de­ter­mine the treat­ment pref­er­ences of the pa­tient and his or her fam­ily.

■ As­sess if ev­i­dence on treat­ment out­comes ap­plies to el­derly pa­tients with mul­ti­ple health prob­lems.

■ Con­sider the timeline of treat­ment ben­e­fits in light of the treat­ment’s side ef­fects, im­pact on qual­ity of life and the pa­tient’s ex­pected life­span.

Boyd, co-chair of the panel that de­vel­oped the prin­ci­ples, said the next step will be to de­velop cur­ricu­lums for health­care pro­fes­sion­als on car­ing for el­derly pa­tients with mul­ti­ple health prob­lems.


The Amer­i­can Ge­ri­atrics So­ci­ety rec­om­mends min­i­miz­ing the num­ber of med­i­ca­tions pre­scribed to el­derly pa­tients with mul­ti­ple health con­di­tions.

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