Addressing the Community‐Based Geriatric Healthcare Workforce Shortage by Leveraging the Potential of Interprofessional Teams

As Americans live longer lives, we will see an increased demand for quality healthcare for older adults. Despite the growth in the number of older adults, there will be a decrease in the supply of a primary care physician workforce to provide adequately for their care and health needs. This article reviews the literature that explores ways to address the primary care workforce shortage in a community‐based geriatric healthcare setting, with special attention to elevating the role of nurses and caregivers and shifting the way we think about delivery of care and end‐of‐life conversations and planning. The shift is toward a more integrated and collaborative approach to care where medical and nonmedical, social services, and community providers all play a role. Several models have demonstrated promising positive benefits and outcomes to patients, families, and providers alike. The goal is to provide high quality care that addresses the unique attributes of older adults, especially those with complex conditions, and to focus more on care goals and priorities. The many barriers to scaling and spreading models of care across varied settings include payment structures, lack of education and training among all stakeholders, and, at the top of the list, leadership resistance. We address these barriers and make recommendations for a path forward where healthcare providers, policymakers, patients, families, and everyone else involved can play a role in shaping the workforce caring for older adults. J Am Geriatr Soc 67:S400–S408, 2019.     

Geriatric education utilizing a palliative care framework

ABSTRACT

The dramatic growth of persons older than age 65 and the increased incidence of multiple, chronic illness has resulted in the need for more comprehensive health care. Geriatrics and palliative care are medical specialties pertinent to individuals who are elderly, yet neither completely addresses the needs of older adults with chronic illness. Interprofessional faculty developed Geriatric Education Utilizing a Palliative Care Framework (GEPaC) to teach an integrated approach to care. Interactive online modules use a variety of instructional methods, including case-based interactive questions, audio-visual presentations, reflective questions, and scenario-based tests. Modules are designed for online education and/or traditional classroom and have been approved for Continuing Medical Education. Pre- and posttest scores showed significant improvements in knowledge, attitudes, and skills. Participants were highly satisfied with the coursework’s relevance and usefulness for their practice and believed that GEPaC prepared them to address the needs of older adults for disease and symptom management, communicating goals of care, and supportive/compassionate care.     

Effect of Physician Delegation to Other Healthcare Providers on the Quality of Care for Geriatric Conditions

The quality of care of older adults in the United States has been consistently shown to be inadequate. This gap between recommended and actual care provides an opportunity to improve the value of health care for older adults. Prior work from the Assessing Care of Vulnerable Elders (ACOVE) investigators first defined, and then sought to improve, clinical practice for common geriatric conditions. A critical component of the ACOVE intervention for practice improvement was an emphasis on the delegation of specific care processes, but the independent effect of delegation on the quality of care has not been evaluated. This study analyzed the pooled results of prior ACOVE projects from 1998 to 2010. Totaled, these studies included 4,776 individuals aged 65 and older of mixed demographic backgrounds and 16,204 ACOVE quality indicators (QIs) for three geriatric conditions: falls, urinary incontinence, and dementia. In unadjusted analyses, QI pass probabilities were 0.36 for physician‐performed tasks, 0.55 for nurse practitioner (NP)‐, physician assistant (PA)‐, and registered nurse (RN)‐performed tasks; and 0.61 for medical assistant– and licensed vocational nurse–performed tasks. In multiply adjusted models, the independent pass‐probability effect of delegation to NPs, PAs, and RNs was 1.37 (P = .05). These findings suggest that delegation of selected tasks to nonphysician healthcare providers is associated with higher quality of care for these geriatric conditions in community practices and supports the value of interdisciplinary team management for common outpatient conditions in older adults.     

When Air Is Rare: Behind the Scenes of an Asthma Web Site

Objective: The number of medical Web sites has increased tremendously during the past 5 years. While the quality of the content has also been on the rise, some questions are still open: Where are users referred from, how large is the target audience, and how do they behave during their visit? Methods: The Asthma Information Center is an independent Web site for physicians, patients, and other health care professionals providing information about asthma. Besides mirroring electronic documents of the Global Initiative for Asthma, numerous interactive pages have been constructed. Main outcome measures: logfiles of the Web server were analyzed for a 5-year interval for numbers of page views, visitors, visits, and external referring sites. Results: The number of visitors has increased since 1995, up to 100,000 page views at the end of the observation interval. In February 2000 approximately 9000 visitors were recorded per month. 3.4 pages were retrieved per visit, which lasted on average 1:57 min. Users are referred primarily by portal sites and only to a lesser extent by search engines. Conclusions: The audience is large for a specialized medical Web site. Users are usually referred from nonmedical sites. They are seeking fast information, most probably as a second opinion after having consulted their physician.     

Complexities of care: Common components of models of care in geriatrics

As people age, they are more likely to have an increasing number of medical diagnoses and medications, as well as healthcare providers who care for those conditions. Health professionals caring for older adults understand that medical issues are not the sole factors in the phenomenon of this “care complexity.” Socioeconomic, cognitive, functional, and organizational factors play a significant role. Care complexity also affects family caregivers, providers, and healthcare systems and therefore society at large. The American Geriatrics Society (AGS) created a work group to review care to identify the most common components of existing healthcare models that address care complexity in older adults. This article, a product of that work group, defines care complexity in older adults, reviews healthcare models and those most common components within them and identifies potential gaps that require attention to reduce the burden of care complexity in older adults.     

Around the EQUATOR with clinician-scientists transdisciplinary aging research (Clin-STAR) principles: Implementation science challenges and opportunities

The Institute of Medicine and the National Institute on Aging increasingly understand that knowledge alone is necessary but insufficient to improve healthcare outcomes. Adapting the behaviors of clinicians, patients, and stakeholders to new standards of evidence-based clinical practice is often significantly delayed. In response, over the past twenty years, Implementation Science has developed as the study of methods and strategies that facilitate the uptake of evidence-based practice into regular use by practitioners and policymakers. One important advance in Implementation Science research was the development of Standards for Reporting Implementation Studies (StaRI), which provided a 27-item checklist for researchers to consistently report essential elements of the implementation and intervention strategies. Using StaRI as a framework, this review discusses specific Implementation Science challenges for research with older adults, provides solutions for those obstacles, and opportunities to improve the value of this evolving approach to reduce the knowledge translation losses that exist between published research and clinical practice.     

Risk Prediction Models for Postoperative Delirium: A Systematic Review and Meta‐Analysis

Postoperative delirium (POD) is a common neuropsychiatric disorder characterized by inattention, fluctuating levels of consciousness, and disorganized thinking. POD can have serious consequences, including institutionalization and death. Risk stratification may target prevention to individuals at greater risk of POD. The objective of this study was to identify all published POD risk prediction models (RPMs) and to compare them with regard to their clinical practicability and predictive and discriminative performance. PubMed and EMBASE were searched from inception to January 1, 2013, for articles describing POD RPMs. Studies were included if they presented data from a cohort study, examined one or more RPMs, examined POD as an outcome, and assessed the performance of the RPM(s). Thirty of 2,246 articles were included, and 37 RPMs were found. Sixteen and six studies described individuals who had undergone cardiovascular and orthopedic surgery, respectively. The Confusion Assessment Method (CAM) for the intensive care unit checklist was the most often used diagnostic method (65%), followed by the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fourth Edition criteria (16%). Predictors most often used in RPMs were age (20), preoperative Mini‐Mental State Examination score (10), and preoperative increased alcohol use (7). Thirty RPMs were not validated, three were validated internally, and four were validated externally. Size of the models was not associated with their discriminatory performance. Instead of creating steadily new RPMs, existing RPMs should be further tested, improved, and meta‐analytically integrated. It may be too early to implement a particular PODRPM in clinical practice with confidence.     

Assessing the Accessibility of Content for Geriatric Fellowship Programs

The information available on program websites concerning geriatric fellowships in internal medicine and family medicine is a crucial factor in generating applicants' interest in individual programs. Our study aimed to quantify the accessibility and quality of information available on accredited geriatric (family medicine and internal medicine) fellowship program websites and further analyze the implications of the results obtained. A list of geriatric (family medicine and internal medicine) fellowship programs was analyzed through quantified measures after being verified for accreditation. Certain criteria were evaluated for each of these programs, such as website accessibility and whether critical information was available on online program websites. These criteria were centered on academic, administrative, and application-based factors. Hundred and fifty eight Family Medicine and Internal Medicine geriatric fellowship programs were identified in total, of which only 150 were accredited by the Accreditation Council for Graduate Medical Education and considered for analysis. Of these, 20 (13.33%) programs had website links that were nonfunctional and only 145 programs had websites at all. On programs' websites, information regarding aspects such as contact information—including phone number or email for the program—were lacking. Other information regarding past and current fellows, research, and curriculum were also generally lacking. Geriatric Fellowship websites in Family Medicine and Internal Medicine can gain better traction from those interested in applying for their programs by updating information more often and providing more and better information concerning critical aspects of the programs themselves online.     

Co‐creation by the ABIM Geriatric Medicine Board and the AGS – Helping Move Geriatrics Forward

The American board of internal medicine (ABIM) establishes standards for physicians. The American geriatrics society (AGS) is a not‐for‐profit membership organization of nearly 6,000 health professionals devoted to improving the health, independence, and quality of life of all older people. Beginning in 2013, ABIM redesigned its governance structure, including the role of the specialty boards. Specialty boards are charged with responsibilities for oversight in four main areas: (1) the assessments used in initial certification and maintenance of certification (MOC); (2) medical knowledge self‐assessment and practice assessment in the specialty; (3) building relationships with relevant professional societies and other organizational stakeholders; and (4) issues related to training requirements for initial certification eligibility within the specialty. The aim of this paper is to inform the geriatrics community regarding the function of geriatric medicine board (GMB) of the ABIM, and to invite the geriatrics community to fully engage with and leverage the GMB as a partner to: (1) develop better certification examinations and processes, identifying better knowledge and practice assessments, and in establishing appropriate training and MOC requirements for geriatric medicine; (2) leverage ABIM assets to conduct applied research to guide the field in the areas of training and certification and workforce development in geriatric medicine; (3) make MOC relevant for practicing geriatricians. Active engagement of the geriatrics community with ABIM and the GMB will ensure that certification in geriatric medicine provides the greatest possible value and meaning to physicians, patients, and the public.     

Hospital Protocols for the Inpatient Care of Older Adults: Results from a Statewide Survey

OBJECTIVES: To assess the prevalence of protocols or guidelines for selected domains of inpatient care for older adults; to explore associations between hospital characteristics and adoption of these guidelines or protocols. DESIGN: Telephone‐ and Web‐based questionnaire. SETTING: General acute care hospitals in Pennsylvania. PARTICIPANTS: Chief nursing officers, directors of nursing, other hospital executives. MEASUREMENTS: Questionnaire items assessed the presence of written protocols or guidelines for selected processes of inpatient care; written guidelines, protocols, or pathways for hip fracture care; and inpatient geriatric consultation. RESULTS: Responses were obtained from 103 of 147 hospitals (70%) between June 21, 2009, and October 12, 2009. The prevalence of written protocols for general hospital practices (e.g., dosing of preoperative antibiotics, deep venous thrombosis prophylaxis) ranged from 84 of 98 (86%) to 90 of 97 (93%) respondents. Twenty of 95 (21%) and 16 of 94 (17%) respondents reported guidelines for the assessment of risk factors for delirium and for routine screening for delirium. Sixty‐six of 92 respondents (72%) reported the presence of a written protocol, guideline, or pathway for hip fracture, and 61 of 100 respondents (39%) confirmed availability of inpatient geriatric consultation. No systematic differences were found in survey responses between facilities on the basis of geriatric consultation availability, hospital size, or teaching status. CONCLUSION: Hospitals vary in their adoption of protocols and guidelines for the care of older adults. Broad opportunities may exist to improve the quality of inpatient care for older adults through better dissemination and implementation of guidelines and protocols for selected geriatric conditions.     

Harnessing Protocolized Adaptation in Dissemination: Successful Implementation and Sustainment of the Veterans Affairs Coordinated‐Transitional Care Program in a Non‐Veterans Affairs Hospital

The Department of Veterans Affairs (VA) Coordinated‐Transitional Care (C‐TraC) program is a low‐cost transitional care program that uses hospital‐based nurse case managers, inpatient team integration, and in‐depth posthospital telephone contacts to support high‐risk patients and their caregivers as they transition from hospital to community. The low‐cost, primarily telephone‐based C‐TraC program reduced 30‐day rehospitalizations by one‐third, leading to significant cost savings at one VA hospital. Non‐VA hospitals have expressed interest in launching C‐TraC, but non‐VA hospitals differ in important ways from VA hospitals, particularly in terms of context, culture, and resources. The objective of this project was to adapt C‐TraC to the specific context of one non‐VA setting using a modified Replicating Effective Programs (REP) implementation theory model and to test the feasibility of this protocolized implementation approach. The modified REP model uses a mentored phased‐based implementation with intensive preimplementation activities and harnesses key local stakeholders to adapt processes and goals to local context. Using this protocolized implementation approach, an adapted C‐TraC protocol was created and launched at the non‐VA hospital in July 2013. In its first 16 months, C‐TraC successfully enrolled 1,247 individuals with 3.2 full‐time nurse case managers, achieving good fidelity for core protocol steps. C‐TraC participants experienced a 30‐day rehospitalization rate of 10.8%, compared with 16.6% for a contemporary comparison group of similar individuals for whom C‐TraC was not available (n = 1,307) (P < .001). The new C‐TraC program continues in operation. Use of a modified REP model to guide protocolized adaptation to local context resulted in a C‐TraC program that was feasible and sustained in a real‐world non‐VA setting. A modified REP implementation framework may be an appropriate foundational step for other clinical programs seeking to harness protocolized adaptation in mentored dissemination activities.     

Successful Models of Comprehensive Care for Older Adults with Chronic Conditions: Evidence for the Institute of Medicine's “Retooling for an Aging America” Report

The quality of chronic care in America is low, and the cost is high. To help inform efforts to overhaul the ailing U.S. healthcare system, including those related to the “medical home,” models of comprehensive health care that have shown the potential to improve the quality, efficiency, or health‐related outcomes of care for chronically ill older persons were identified. Using multiple indexing terms, the MEDLINE database was searched for articles published in English between January 1, 1987, and May 30, 2008, that reported statistically significant positive outcomes from high‐quality research on models of comprehensive health care for older persons with chronic conditions. Each selected study addressed a model of comprehensive health care; was a meta‐analysis, systematic review, or trial with an equivalent concurrent control group; included an adequate number of representative, chronically ill participants aged 65 and older; used valid measures; used reliable methods of data collection; analyzed data rigorously; and reported significantly positive effects on the quality, efficiency, or health‐related outcomes of care. Of 2,714 identified articles, 123 (4.5%) met these criteria. Fifteen models have improved at least one outcome: interdisciplinary primary care (1), models that supplement primary care (8), transitional care (1), models of acute care in patients' homes (2), nurse–physician teams for residents of nursing homes (1), and models of comprehensive care in hospitals (2). Policy makers and healthcare leaders should consider including these 15 models of health care in plans to reform the U.S. healthcare system. The Centers for Medicare and Medicaid Services would need new statutory flexibility to pay for care by the nurses, social workers, pharmacists, and physicians who staff these promising models.     

The Age‐Friendly Health System Imperative

The unprecedented changes happening in the American healthcare system have many on high alert as they try to anticipate legislative actions. Significant efforts to move from volume to value, along with changing incentives and alternative payment models, will affect practice and the health system budget. In tandem, growth in the population aged 65 and older is celebratory and daunting. The John A. Hartford Foundation is partnering with the Institute for Healthcare Improvement to envision an age‐friendly health system of the future. Our current prototyping for new ways of addressing the complex and interrelated needs of older adults provides great promise for a more‐effective, patient‐directed, safer healthcare system. Proactive models that address potential health needs, prevent avoidable harms, and improve care of people with complex needs are essential. The robust engagement of family caregivers, along with an appreciation for the value of excellent communication across care settings, is at the heart of our work. Five early‐adopter health systems are testing the prototypes with continuous improvement efforts that will streamline and enhance our approach to geriatric care.