EXECUTIVE SUMMARY

With a rapidly growing elderly population, healthcare professionals need to learn how to handle geriatric patients. Their care is different from the care of middle-aged or younger patients.

  • The key is to create a sustainable model for geriatric care in primary care offices.
  • The Geriatric Workforce Enhancement Program (GWEP) seeks to train clinicians to handle older patients.
  • Falling is one of the most serious issues geriatric patients face. Training teaches all healthcare professionals and workforce about the physiological changes that happen as people grow older and covers fall risk.

The nation’s elderly population is growing at a rate of 10,000 people per day, and the healthcare industry will have difficulty handling their medical needs optimally without more clinicians trained in geriatric care. This was part of the reason for the Geriatric Workforce Enhancement Program (GWEP), which seeks to train clinicians to handle the oldest and most frail of patients.

“The volume of patients who are turning 65 is 10,000 per day, and what that means for our health systems across the nation — as well as locally — is that it’s a looming issue for our nation,” says Laura J. Benner, RN, BSN, ACM, CCTM, population health manager–GWEP at Lehigh Valley Health Network in Allentown, PA.

The big questions for the healthcare industry and for Lehigh Valley Health Network, in particular, is how to address the needs of the geriatric population, how to manage them — especially those with dementia — and how to create a sustainable model in primary care provider offices, Benner says.

“We’re focused on developing primary care services for geriatric patients, specifically to improve the education and delivery system of care at the primary care level for geriatrics,” says Julie Dostal, MD, vice chair of education in the department of family medicine at Lehigh Valley Health Network.

Lehigh Valley Health Network, which is involved with GWEP, has a family medicine residency program and is based in an internal medicine residency.

“We have the opportunity to both improve the delivery of care to elderly patients, and to improve their education and what they need to do to meet primary care needs of geriatric patients,” Dostal says.

“Across the country, they say there are not enough geriatricians to take care of all of those elderly patients,” she adds. “But not all elderly patients need a geriatrician if they have a primary care clinician who knows how to take care of geriatric patients.”

The purpose of the GWEP grant at the 40 or so sites nationwide is to figure out different approaches and find what works best, Dostal says.

Training teaches all healthcare professionals and workforce about the physiological changes that happen as people grow older. It covers performing functional assessments for fall risk, activities of daily living (ADLs), and social isolation.

“Their understanding of how to treat a 50-year-old with diabetes is different than how to treat an 80-year-old,” Dostal explains. “The risks of low blood sugar are much worse for the older person than with the younger patient, where the goal is to prevent long-term complications. With an 85-year-old, you are trying to prevent them from falling.”

Before GWEP, Lehigh Valley Health Network had broadened its care management services for high-risk populations through its community care teams (CCTs) that work with high-utilizing patients in primary care offices, says Cathryn Kelly, RN, LDN, CCCTM, manager with the population health department at the network.

“Beginning in 2012, our organization implemented a new, multi-tiered care management approach, piloting the specialized community care team model,” Kelly says. “This team includes nurse case managers, social workers, behavioral health specialists, and a pharmacist.”

The CCT program was the first layer, and GWEP was added to it, Benner says.

CCTs work with the top 5% highest-risk, highest-utilization populations, determined by an algorithm that uses risk data from clinical indicators, including chronic conditions, polypharmacy and utilization, inpatient and ED visits, and social determinants of health.

“These were the indicators we looked at to prompt a physician to refer a patient to this community care team resource,” Kelly says.

The health network’s program is showing success. It saw a reduction in inpatient admissions by 27.4% in 2015, within six months post-intervention with the community care team. There was a 15% reduction in ED utilization, Benner says.

The following are some of the ways they achieved the positive outcomes:

  • Address behavioral health issues. “If a care manager was referred a patient who had underlying behavioral health needs that were preventing this person from engaging in their care, the team would first connect the patient to the behavioral health specialist to address these needs,” Kelly says.
  • Work collaboratively with primary care offices. “We are working collaboratively within a primary care office to help patients better self-manage,” Kelly says. “We started in six physician offices and now are in almost 40, and we also branched out to specialty practices.”

As the program evolves, there will be efforts to better connect patients in the outpatient arena, she adds.

Case managers work side-by-side with primary care doctors and nursing staff, communicating directly with clinicians, Dostal says.

“They share the same medical record and develop care plans together, so they’re learning as they go, and we provide the practice with education about advance directives and dementia,” Dostal says. “A social worker or pharmacist who is family medicine, board-certified in geriatrics does the education.”

  • Engage with and educate elderly patients and caregivers. “We chose to focus on patients ages 60 and older as part of a geriatric health resource grant,” Benner says.

“We’ve focused on patients with Alzheimer’s, providing a way for them to age in place and be maintained at home,” Benner says. “They receive services at the appropriate home and provide a support system for caregivers.”

One of the program’s goals is to reduce caregiver stress, she adds.

CCTs also can educate caregivers about geriatric medicine. For instance, Dostal recalls the case of an 85-year-old patient who had three medications for her blood pressure, a high dose of medicine for diabetes, and when she was moved to a new area, she and her children wanted all of the medication prescriptions renewed.

“I thought there was a lot of medication for someone her age, and her blood pressure was on the low side of normal and her blood sugar was in the normal range, on the low side,” Dostal says. “So I wanted to start reducing some of her medications and talked with her sons, who said they wanted to keep her blood sugar in the range of 70 to 110.”

Dostal successfully taught the patient’s family the risks of maintenance under too strict of control. For a person of her age, the blood pressure and glucose levels should be higher to prevent her from becoming dizzy and falling.

“If she falls, she breaks a hip. Falls are the number one preventable thing that happens to our elderly patients, and that starts a whole cascade of hospitalization, broken hips, and a downhill slide,” Dostal says.

“Her life expectancy isn’t 15 years, so we don’t have to worry about what will happen in 15 years, but if we manage it really well right now, we can prevent that fall and then maybe she might make it another 15 years.”

  • Follow Guided Care model. “We’re trying to work as an interdisciplinary team and utilize a model, called Guided Care, from Johns Hopkins,” Benner says. “It’s a model that has shown to make some true impact on patients and their caregivers, relieving some of their stress, and it promotes interdisciplinary team collaboration.”

Using a tool, care teams can monitor caregivers’ stress index, getting an understanding of where they’re at, Benner says.

“We developed a plan that considers what the patient needs, as well as the caregiver, and we developed care plans,” Benner says. “It might be the caregiver is having trouble getting the patient to doctors’ appointments and is physically unable to do it, so we set them up with transportation.”

Likewise, if caregivers need help with bathing or dressing patients, the program helps them find community partners and programs that can help, she adds.

“Caregivers are not trained health professionals, so we’re coaching them through it,” Benner says. “As an industry, we’re asking them to do more and more at home.”

  • Use community health workers. Nonmedical professionals, called community health workers, link people to community resources, Benner says.

“They’re from the community and are aware of what’s out there for their clients, and they provide a lot of service support and connection to those community resources,” she says.

Community health workers often are multilingual and can work with non-English-speaking populations, Kelly says.

For example, one community health worker who speaks the same language and has the same cultural background as patients is received with fewer barriers than case managers, Benner notes.

“She gets invited into the kitchen, while I get the living room,” she says. “They’re under the supervision and guidance of our social workers on the team, and if there is a high-level question or concern or issue, then it does go to the social worker.”