The Geriatric Floating Interdisciplinary Transition Team

Older adults often receive suboptimal care during hospitalizations and transitions to postacute settings. Inpatient geriatric services have been shown to increase care quality but have not improved patient outcomes consistently. Acute Care for the Elderly units improve patient outcomes but are resource intensive. Transitional care has been shown to reduce hospital readmissions and healthcare costs. This article describes the Geriatric Floating Interdisciplinary Transition Team (Geri‐FITT), a model that combines the strengths of inpatient geriatric evaluation and comanagement and transitional care models by creating an inpatient comanagement service that also delivers transitional care. The Geri‐FITT model is designed to improve the hospital care of older adults and their transitions to postacute settings. In Geri‐FITT, a geriatrician–geriatric nurse practitioner team assesses patients, comanages geriatric syndromes, provides staff education, encourages patient self‐management, communicates with primary care providers, and follows up with patients soon after discharge. This pilot cohort study of Geri‐FITT included hospitalized patients aged 70 and older on four general medicine services (two Geri‐FITT, two usual care) at an academic medical center (N=717). The study assessed the effect of Geri‐FITT on patients' care transition quality (Care Transitions Measure) and their satisfaction with hospital care (four questions). The results indicate that Geri‐FITT is associated with slightly higher, though not statistically significantly so, quality care transitions and greater patient satisfaction with inpatient care. Geri‐FITT may be a feasible approach to enhancing inpatient management and transitional care for older adults. Further study of its effect on these and other outcomes in other healthcare settings seems warranted.     

The first year of a geriatric-orthopaedic liaison service: an alternative to 'orthogeriatric' units?

The use of orthopaedic beds by large numbers of elderly patients with multiple pathology will increase and already exceeds the provision of orthopaedic-geriatric rehabilitation units. A cross-specialty multidisciplinary ward round improved the quality of care of orthopaedic patients without requiring expenditure on equipment, facilities or staff, and abolished the need to transfer patients to geriatric beds for rehabilitation, this being achieved on the orthopaedic unit. The liaison service provided excellent medical training in acute and rehabilitative aspects of geriatric medicine, enhanced the role of other disciplines in the care of the elderly orthopaedic patient and facilitated communication between departments.     

Geriatric syndromes as predictors of adverse outcomes of hospitalization

Aims: The aim of this study was to determine the association between the common geriatric syndromes and predefined adverse outcomes of hospitalization and to identify the most important independent predictors of adverse outcomes using information gained within 24 h of admission in older general medical patients. Methods: A prospective longitudinal cohort study of patients aged ≥75 years admitted to the rapid assessment medical unit in a teaching hospital was carried out. The role of geriatric syndromes in predicting outcomes was examined in univariate and multivariate models. The outcome measures were (i) length of hospital stay (LOS) of 28 days or more, (ii) institutionalization or change in residential care status to a more dependent category at discharge or during 3 months post‐discharge, (iii) unplanned readmissions during 3 months and (iv) mortality in hospital or 3 months post‐discharge. Results: The presence of geriatric syndromes was significantly associated with increased LOS and institutionalization or change in residential care status to a more dependent category. The factors most predictive of these outcomes were impaired pre‐admission functional status in activities of daily living, recurrent falls, urinary incontinence and supported living arrangements. The geriatric syndromes appeared less important in predicting unplanned readmission and death. Conclusion: The presence of geriatric syndromes in older general medical patients is an important determinant of adverse outcomes of hospitalization, particularly of LOS and admission to residential care. The predictors most useful for screening patients for these outcomes, within 24 h of admission, appear to be the presence of certain pre‐existing geriatric syndromes before admission.     

Relationship Between Fear of Falling and Outcomes of an Inpatient Geriatric Rehabilitation Population—Fear of the Fear of Falling

OBJECTIVES: To examine the effects of various risk factors on three functional outcomes during rehabilitation. SETTING: Geriatric inpatient rehabilitation unit. DESIGN: Observational longitudinal study. PARTICIPANTS: One hundred sixty‐one geriatric rehabilitation inpatients (men, women), mean age 82, who were capable of walking at baseline. MEASUREMENTS: Functional status was assessed weekly between admission and discharge and at a follow‐up 4 months later at home using the function component of the Short Form—Late Life Function and Disability Instrument, the Barthel Index, and Habitual Gait Speed. Various risk factors, such as falls‐related self‐efficacy (Falls Efficacy Scale–International), were measured. Associations between predictors and functional status at discharge and follow‐up were analyzed using linear regression models and bivariate plots. RESULTS: Fear of falling predicted functioning across all outcomes except for habitual gait speed at discharge and follow‐up. Visual comparison of functional trajectories between subgroups confirmed these findings, with different levels of fear of falling across time in linear plots. Thus, superior ability of this measure to discriminate between functional status at baseline across all outcomes and to discriminate between functional change especially with regard to the performance‐based outcome was demonstrated. CONCLUSION: Falls‐related self‐efficacy is the only parameter that significantly predicts rehabilitation outcome at discharge and follow‐up across all outcomes. Therefore, it should be routinely assessed in future studies in (geriatric) rehabilitation and considered to be an important treatment goal.     

Description of an orthopedic–geriatric model of care in Australia with 3 years data

Aim:   Orthopedic–geriatric units have been established worldwide to improve the care of older patients admitted with fractures. This study describes one type of orthopedic–geriatric model which has been implemented in Victoria, Australia, named the Orthopedic Aged Care and Rehabilitation Service (OARS) and evaluates patient characteristics and outcomes including inpatient mortality.
Methods:   Eight hundred and thirty-four consecutive admissions under OARS between May 2003 and May 2006 were analyzed.
Results:   Mean age was 76.6 years, the majority of patients were female (73%) and had come from home (77%). Fractured neck of femur represented 51% of all fractures managed by OARS followed by lower limb fractures (20%) and upper limb fractures (13%). The majority of patients required inpatient rehabilitation (49% of patients overall and 61% specifically for fractured neck of femur). Inpatient mortality for all fractures was 2.5% and specifically 3.5% for fractured neck of femur.
Conclusion:   The OARS model involves close liaison between orthopedic and geriatric teams and promotes a multidisciplinary approach. Mortality rate for fractured neck of femur was lower than the state average, suggesting that combined orthopedic–geriatric care can improve outcomes.     

Evaluierung in der geriatrischen Rehabilitation aus der Perspektive des Medizinischen Dienstes der Spitzenverbände der Krankenkassen e.V. (MDS)

There is evidence for the community effectiveness of preventive geriatric intervention programs prior to the need for help or long-term care from a couple of prospective randomized controlled trials (RCTs). For geriatric rehabilitation programs tailored to older people with imminent or manifest need for long-term care analogous--evidence is still lacking. The nationwide leading boards of the FRG's Sickness Insurance Administration in conjunction with its Central Medical Service have formulated guidelines for the formation of a nationwide ambulatory geriatric rehabilitation service to realize the postulate of the long-term care insurance legislation "rehabilitation prior to long-term care". These guidelines must be proven empirically. To prove the effectiveness and efficiency of the foreseen ambulatory geriatric rehabilitation service, the RCT design would be highly desirable. Unfortunately, the prerequisites in the field of methodology are poor since valid, reproducible and feasible criteria for the selection of suitable patients and measurement criteria which meet the requirement of proven medium-term sensitivity to change do not yet exist. Nevertheless, there is a great and urgent need, for the first time, to investigate the cost-effectiveness ratio for this ambulatory geriatric rehabilitation service to be established in the FRG, leaving aside the methodologic desiderata of randomized control-groups.     

Rehabilitation of the elderly patient on dialysis

Rehabilitation for geriatric patients, as well as rehabilitation for patients with a chronic disease, strives to mobilize individuals' residual capacity for optimal function in their usual environment. It is clear from observational studies that chronic dialysis patients often experience marked limitations in physical functioning, and these limitations tend to increase with patients' age. However, both prospective studies and controlled trials conducted with elderly persons demonstrate that muscle strengthening and cardiovascular exercise are related to improved physical functioning, and there is evidence that dialysis patients can also benefit from many of these interventions. Inpatient rehabilitation in a specialized geriatric unit has been shown to be associated with better functional outcomes and decreased need for institutionalization among elderly persons; the process of comprehensive geriatric assessment may also have beneficial outcomes. More controlled studies are needed in order to better specify the effectiveness of various geriatric interventions, for elderly subjects in general and for elderly dialysis patients specifically.     

Interdisciplinary Home Visits for Individuals with Advanced Parkinson's Disease and Related Disorders

Parkinson's disease (PD) is a complex, multisymptom, neurodegenerative disease affecting primarily older adults. With progression, many individuals become homebound and removed from coordinated, expert care, resulting in excess morbidity, mortality, and healthcare expenditures in acute care settings and institutions. Home visit care models have achieved the triple aim of improving individual and population health while reducing costs in many frail, community‐dwelling geriatric cohorts. This study details a novel, interdisciplinary home visit program specifically designed for individuals with PD and related disorders and their family caregivers built upon best practice principles in the care of multimorbid older adults. At each quarterly home visit, a movement disorders–trained neurologist, social worker, and nurse work in parallel with the individual and caregiver to complete a history, physical, detailed medication reconciliation, psychosocial needs assessment, and home safety assessment. A comprehensive, person‐centered plan is agreed upon, referrals to community resources are made, standardized documentation is shared, and follow‐up communication is instituted. In the first 2 years, 272 visits were conducted with 85 individuals who represent one of the oldest, most disabled PD populations reported. Satisfaction with and retention in the program were high. This study represents the first translation of the success of interdisciplinary and home‐based geriatric care models to a population with a specific neurological disease. Preliminary evidence supports the need for such programs in vulnerable populations. Future studies will prospectively assess person‐centered outcomes, the effect of using telemedicine on sustainability, and cost effectiveness.     

An individualized approach to outcome measurement in geriatric rehabilitation

BACKGROUND: The heterogeneity of health problems experienced by frail elderly patients makes it difficult to use a single standard measure to evaluate multiple outcomes of geriatric rehabilitation. Commonly, several measures are used, but an alternative is to use an individualized measure such as Goal Attainment Scaling (GAS). This study investigated the reliability, validity, and responsiveness of GAS as an outcome measure in geriatric rehabilitation. METHODS: We studied 173 consecutive admissions (mean age 81; 77% female; mean length of stay 33 days) to a geriatric rehabilitation unit. Assessment instruments were completed at admission and discharge. Individualized treatment goals were identified for each patient by using GAS; standardized measures included self-rated health, a global clinical assessment, the Barthel Index, the OARS IADL scale, the Folstein Mini-Mental State Examination (MMSE), and the Nottingham Health Profile (NHP). RESULTS: Mobility, future care arrangements, and functional impairment were the most commonly identified GAS goal areas. The interrater reliability of the GAS discharge score was 0.93. The GAS discharge score correlated strongly (r> or =0.50) with the standardized measures, except for self-rated health, the MMSE, and the NHP (r> or =0.31). GAS was more responsive to change than any of the standardized measures. The GAS score was used to derive receiver operating characteristic curves for other measures; this can provide insight into the interpretation of clinically important outcomes. CONCLUSIONS: GAS appears to be a feasible, reliable, valid, and responsive approach to outcome measurement in geriatric rehabilitation.     

Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions

STUDY OBJECTIVE: We sought to synthesize the literature on patterns of use of emergency services among older adults, risk factors associated with adverse health outcomes, and effectiveness of intervention strategies targeting this population. METHODS: Relevant articles were identified by means of an English-language search of MEDLINE, HealthSTAR, CINAHL, Current Contents, and Cochrane Library databases from January 1985 to January 2001. This search was supplemented with literature from reference sections of the retrieved publications. A qualitative approach was used to synthesize the literature. RESULTS: Compared with younger persons, older adults use emergency services at a higher rate, their visits have a greater level of urgency, they have longer stays in the emergency department, they are more likely to be admitted or to have repeat ED visits, and they experience higher rates of adverse health outcomes after discharge. The risk factors commonly associated with the negative outcomes are age, functional impairment, recent hospitalization or ED use, living alone, and lack of social support. Comprehensive geriatric screening and coordinated discharge planning initiatives designed to improve clinical outcomes in older emergency patients have provided inconclusive results. CONCLUSION: Older ED patients have distinct patterns of service use and care needs. The current disease-oriented and episodic models of emergency care do not adequately respond to the complex care needs of frail older patients. More research is needed to determine the effectiveness of screening and intervention strategies targeting at-risk older ED patients.     

To the Future of Ethnogeriatric Research and Publication

The reinstatement of the Journal of the American Geriatrics Society Section on Ethnogeriatrics coincides with more rapid growth in older populations that are classified as ethnic and racial minorities in the United States than those classified as non‐Hispanic white. By 2060, 40% of older Americans are predicted to belong to a minority. Important needs for ethnogeriatric research and publication include: making sure research populations are meaningful and precise rather than using categories that include many unrelated groups; and increasing research among smaller ethnic populations of older adults. Topics in need of attention include epidemiology of common geriatric illness among the smaller populations, and social determinants for those in which disparities have been established; the extent and effectiveness of use of Culturally and Linguistically Appropriate Services Standards in geriatric care; examination of communication strategies used in provider/patient interaction, especially use of interpreters; ethnic differences in treatment of older patients; and models of use of community health workers from older patients' own cultural communities. Stresses related to caregiving in cultures emphasizing the importance of family care are important to understand acceptable models of long‐term care for diverse families. The new Ethnogeriatric Section opens the opportunity for geriatric researchers, especially those from diverse backgrounds, to explore important issues in cross‐cultural geriatric care; their findings can then form the basis of expanded ethnogeriatric curriculum for training future providers for the growing population of diverse older Americans.     

Geriatrie in der ambulanten Versorgung durch haus?rztlich t?tige Internisten

Internal medicine specialists involved in primary care will have a leading part in the treatment of geriatric patients with complex healthcare needs in the future. Approved models like specialized geriatric practices, ambulant or mobile geriatric rehabilitation and special geriatric services for nursing homes are available. Essential is a geriatric qualification that fits with the tasks of an internist in primary care. An incentive payment system has to be created for this purpose to improve the treatment of elderly patients.     

Health Outcomes and Geriatric Assessment: Making Literature Reviews Relevant to Current Programs

The rationale for geriatric assessment programs includes a reduction in nursing home admissions, improved health outcomes and improved physical function. However the evidence for these benefits may not be directly transferable to all models of geriatric assessment programs. This study is a review of published studies of most relevance to aged care assessment teams with regard to one important outcome, nursing home admission. However the conclusions are limited in that no studies are directly comparable to the situation in which aged care assessment teams function. In addition, traditional outcome measures may not be appropriate in considering the effectiveness of similar models of geriatric assessment.     

Clinical effectiveness,cost effectiveness and acceptability of community‐based treatment of hepatitis C virus infection: A mixed method systematic review

Several community‐based models for treating hepatitis C virus (HCV) infection have been implemented to improve treatment accessibility and health outcomes. However, there is a lack of knowledge regarding how well these models achieve the desired goals. We conducted a mixed‐method systematic review of quantitative and qualitative evidence about clinical effectiveness, cost effectiveness and acceptability of community‐based HCV treatment models. Seventeen databases were researched for published and unpublished studies. Methodological quality was assessed using The Joanna Briggs Institute Critical Appraisal tools. Quantitative findings were synthesized in narrative form and qualitative findings were synthesized using meta‐synthesis. Forty‐two quantitative and six qualitative studies were included. No relevant cost effectiveness studies were found. Five categories of community‐based models were identified: telehealth, integration of HCV and addiction services, integration of HCV and HIV services, integration of HCV and primary care, and implementation by a home care and health care management company. The range of reported outcomes included; end of treatment response: 48.7% to 96%, serious side effects: 3.3% to 27.8%, sustained virological response: 22.3% to 95.5%, relapse: 2.2% to 16.7%, and treatment completion: 33.4% to 100%. Inconsistent measures of uptake and adherence were used; uptake ranged from 8.3% to 92%, and 68.4% to 100% of patients received ≥80% of prescribed doses. Patient reported experiences included trusted and supportive care providers, safe and trusted services, easily accessible care, and positive psychological and behavioural changes. The clinical effectiveness and acceptability reported from the included studies are similar to or better than reported outcomes from systematic reviews of studies in tertiary settings. Studies of the cost effectiveness of community‐based models for treating HCV are needed.     

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.     

Future developmental perspectives in rehabilitation and after care of the elderly]

It has now become imperative to organize a differentiated system for geriatric rehabilitation in the Federal Republic of Germany. However, the increasing predominance of diagnostic and therapeutic principles suggests that the holistic vision once associated with "geriatrics" may become of secondary importance as a result of the transfer of treatment strategies from the intensive care sector. The complexity of the everyday person-environment interfaces of chronically ill elderly persons in need of nursing services stands in contrast to the way the success of rehabilitation is still understood in terms of clinical criteria. With respect to future developments, ideas for geriatric rehabilitation and, in particular, follow-up care are being developed that are defined in terms of criteria that have to be newly developed--wide-ranging rather than narrowly conceived criteria--related to rehabilitation objectives that also have to be redefined, namely quality of life, effectiveness and a broad promotion of health. An understanding of geriatric rehabilitation practice defined in this way relating to everyday situations can be expected to yield a high degree of quality assurance in view of the assumed criteria of broadly defined success.     

Impact of population aging on the social and the health care system: need for a new model of long-term care

Population aging is characterized by a marked increase in the number of subjects aged 80 years or more (the oldest old). In this group frailty is extremely common. Frailty is a recently identified condition resulting from a severely impaired homeostatic reserve, that places the elderly at the highest risk for adverse health outcomes, including dependency, institutionalization and death, following even trivial events. Geriatric medicine proposes an original methodology for the management of frail elderly subjects, the so called "comprehensive geriatric assessment", as well as a model of long-term care. These have been shown to reduce the risk of hospitalization and nursing home admission, with a parallel decrease in expenses and an improvement in the patient's quality of life. The effectiveness of the long-term care system depends on: 1) the availability of all the services that are necessary for the frail elderly, both in the hospital and in the community; 2) the presence of a coordinating team, the comprehensive geriatric assessment team, that develops and implements the individualized treatment plans, identifies the most appropriate setting for each patient and verifies the outcomes of the interventions; 3) the use of common comprehensive geriatric assessment instruments in all the settings; 4) the gerontological and geriatric education and training of all the health care and social professionals.     

Hip fracture management and outcomes in Italy

Hip fractures are a major health care problem in Italy since more than 90,000 such fractures per year occur among elderly people. Nowadays, in several boroughs, orthopaedic wards are being restructured, overcoming the traditional model of care towards heterogeneous liaison models between the orthopaedic staff and medical-geriatric staff. However, the care pathway changes considerably from one area to another of the country. Wide differences in the choice of treatment, surgical delays, length of in-hospital stay and the availability of rehabilitation services and intermediate care in the sub-acute period have been reported over the country. The authors described the orthogeriatric model of Arcispedale Santa Maria Nuova (ASMN) Hospital, the main hospital of the province of Reggio Emilia (Emilia-Romagna region), implemented in 2007 for all patients aged 75 years and older admitted with a hip fracture. During hospital stay each patient is comanaged by an orthopedic surgeon and a geriatrician with different responsibility and using a number of evidence-based protocols and standardized procedures. Even without dedicated trauma theatre, comparing data before and after the implementation of the Ortho-Geriatric model, a 50% reduction of waiting time to surgery was observed and the mean hospital stay decreased about 5 days. The Ortho-Geriatric approach should include all those strategies and interventions that have been shown to improve outcomes in well-designed and strictly evidence-based studies and the ASMN model need to be improved in several critical aspects such as standardized approaches in the management of the patients with very high level of comorbidity in the preoperative phase and the coordination of all the medical staff in the presurgical period.     

Transformation of a Geriatric Department in China

China has the world's largest elderly population, and the oldest‐old population, with a current disability rate greater than 50%, will triple in the next 35 years. The field of geriatrics is young, because almost all geriatric departments were established after 2000, and so faces many challenges. Management of diseases and hospital care is the focus. Senior physicians were trained in other subspecialties, such as pulmonary or cardiology, and junior physicians entered geriatrics departments as masters or doctorate students after medical school. The inadequacy of post‐acute and long‐term care facilities has caused long hospital stays. There are no national systematic geriatric training programs, national board examinations, or qualifications in geriatrics. These challenges were used as a framework for guiding changes in the Department of Geriatrics at West China Hospital, Sichuan University. These changes have included international experiences and collaboration for physicians and nurses, revision of departmental conferences, and special training for a unique group of caregivers called hugong (untrained caregivers hired by families to be at the bedside of hospitalized individuals). The most significant yet challenging part of the transformation has been to develop and modify Western‐based geriatric models of care (e.g., Acute Care of the Elderly unit, delirium prevention and management models, palliative care). Lastly, the department established Tianxia (in the sky) Doctors, an internet‐based platform to connect the department's interdisciplinary team to other hospitals, nursing institutions, home‐based care service stations, community health service centers, and pharmacies throughout the region.