Prepare for age wave: Assess elderly now
Focus group identifies needs
If you think providing geriatric services is complex and costly in the ’90s, just wait until the baby boomers hit the health care system’s straining resources after the year 2000.
So how do quality improvement professionals find out what elderly patients really need?
Starting a geriatric assessment center now will provide a invaluable focus group to help hospitals prepare for the aging population later, says Sandy Crandall, RN, MSN, CRNP, geriatric nurse practitioner at St. Mary Medical Center in Langhorne, PA.
"It will be the key to the future of your gerontological programs," Crandall stresses. "The other added benefit is that physicians and consumers, as well as the rest of the hospital, will see the program as a quality and market initiative."
Although the assessment program is not yet a money-maker (reimbursement occurs only through Medicare), Crandall says managed care contracts eventually will be negotiated with the program included.
"We didn’t expect immediate returns. However, we believe that investing in this type of holistic approach to elder care today will pay off in the future with improved outcomes and decreased costs and with the future of Medicare at stake, that’s important," she says. "And the quality improvement information it provides is invaluable as we plan our future in this burgeoning field."
The pilot program that began in September of last year at St. Mary targets Medicare patients ages 65 and older who are having difficulty functioning at home or who are unable to maintain their normal day-to-day activities because of physical, mental, or emotional changes.
A multidisciplinary team made up of a board-certified geriatric physician, nurse practitioner, neuropsychologist, and social worker first administers a comprehensive physical, psychological, social, and cognitive assessment. The team then reviews the findings and recommendations with the patient and family members and develops a customized strategy for maximizing the patient's independence and maintaining his or her functioning.
Because elders have complex health care needs, they often are shuffled from one specialist to another. "Even as cost of care rises, there’s no one provider that is captain of the ship’ no one who is looking at the big picture," she explains.
For example, elderly patients may need a change in medication, nutrition, or living situation to truly thrive not to mention to avoid hospitalization.
And they may need to hear this advice from someone other than a family member. "That’s the beauty of the program," Crandall says. "Each member of the team plus the patient and family members is present for the entire evaluation process."
Not only does the assessment allow for each discipline to contribute its skills and experience, but it also uncovers family dynamics and triggers issues that otherwise would have gone unnoticed or unaddressed.
Here’s how the program works over a series of three outpatient visits:
• At time of referral.
An intake form provides a general idea of the patient’s needs and challenges. "Referrals may come from a physician, family members, or the patients themselves."
• Before the visit.
The client receives a welcome letter containing instructions and information, a medical release form, and a self-assessment form that was designed with the elderly patient in mind, says Carol Benderson, MSW, director of social work and senior services.
"It is a three-page grid sheet so they can quickly rate themselves in 14 areas that seniors and their families are typically concerned about," she says.
For example, under the area of self-care, elders can rate themselves as "independent; able to walk; use a cane, walker, crutches, or cart; spend most of day in chair; need assistance to get out of bed; or bedbound." (For a listing of areas rated, see chart, p. 12.)
The actual appointment is scheduled for several weeks after the initial call in order to give the team time to obtain and review both the assessment form and medical records.
A note also is sent to the primary physician explaining that his or her patient has an interest in the program. "We are very careful to stress that we are a consultative service and are intended to add to, not replace, their care," Crandall says.
• The first visit.
Lab work and EKG are scheduled for 7:30 a.m., after which a breakfast is served in a conference room of the medical office building.
"For about an hour, while the patient and family members eat, the team talks one-on-one with them and gets a sense of the family dynamics and patient concerns," Crandall says. "We’ve all previously reviewed the records from the family physician, so we may have an idea of the ultimate strategy, but this intense consultation allows us to validate it and see from all sides simultaneously."
From 8:45 to 9:45 a.m., Crandall completes a history and "head-to-toe" physical exam with the patient. The patient spends the next hour with the neuro-psychologist, who administers a battery of cognitive tests to determine cognitive and psychological functioning, which includes a depression rating. During this time the family is meeting with the social worker and other team members.
By 11 a.m., the physician meets with the patient. "We each do an exam because we approach it from two different views," explains Crandall. "As a nurse, I am looking at preventative health concerns, and a physician looks for medical outcomes and diagnoses."
The team then schedules the patient and family for a follow-up visit to present the final, formal report.
"After they leave, we discuss the case. We may order evaluations based on this first visit, or we may go ahead and write up our six- to seven-page report of our recommendations," Crandall says.
• The second visit.
Based on the assessment information from the first visit, the patient comes in for evaluations as needed for incontinence or diagnostic tests from various disciplines including speech, occupational or physical therapy, pharmacy, neurology, or nutrition. A team member also may make a home visit.
• Interim activity.
After the data are in, team members meet to coordinate and formulate the plan.
• The third visit.
The team meets again for about an hour with the patient and family this time to present recommendations and establish a plan. The family physician is then sent the entire report, which contains the patient’s social and health history, physical exam, allergies, medications, results of diagnostic tests, cognitive and psychological screening, and the team’s recommendations.
• After the evaluation.
The team is designing a quality assessment form to track the program’s effectiveness. Included on the form will be a section in which to report results of a follow-up call to the patient, family, and primary care physicians.
Is the program working?
"We were booked for three months almost immediately, and the only publicity we’ve done was one article that ran in the local paper," Crandall says. "The phone is ringing off the hook. People want to come from other states."
Not only is the Geriatric Assessment Center meeting an unfulfilled need in the community, but it also provides the hospital a focus group to help them identify the needs of this population on a firsthand basis. Such a program can serve as the foundation for a range of geriatric services, Crandall says.
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