Focus on special needs improves geriatric care

As the U.S. population ages, medical groups face the dilemma of providing cost-effective geriatric care that allows patients the best possible quality of life. Successful solutions have emerged that target high-risk elderly with an interdisciplinary, team-based approach to diagnosis and treatment.

In a study of a geriatric evaluation and management (GEM) program at the University of Minnesota Medical School in Minneapolis, functional ability declined less rapidly than that of a control group. The GEM patients also reported greater patient satisfaction,1 and their informal caregivers were less likely to experience increasing burden over time. Health care costs were similar in the GEM and control groups.

However, researcher Chad Boult, MD, MPH, notes that Minnesota is a state with heavy managed care penetration in which overall health care costs are already minimized. In other areas, GEM may produce substantial savings, he says.

"You’re preserving function at no cost with GEM," says Boult, who is an associate professor at the University of Minnesota Medical School. He presented the GEM results at the May meeting of the American Geriatrics Society. "Ten percent of the people cost 70% of the money. If you can find those 10% and work closely with them, you have a potential to make a big difference."

Geriatric outcomes are becoming increasingly important to payers. The Health Care Financing Administration is monitoring the health status of elderly Medicare managed care patients through the Medicare Health Outcomes Survey. The National Committee for Quality Assurance in Washington, DC, has several health plan performance measures that relate to health of older people, including pneumonia and flu vaccination.

"One way to [comply with standards and produce better outcomes] is to monitor the population with some sort of screening tool and to implement comprehensive action plans for those who are high-risk," says Boult.

Participation in the GEM program began with a screening questionnaire, the Pra, an eight-item questionnaire that identifies high-risk elderly patients.1

"When we tested the Pra, we found out when you follow people identified as high-risk over the following year, they go on to use about twice as many health services and spend about twice as much on health resources as those below the [cut-off]," he says. "It’s simple and inexpensive to administer." Boult is one of the developers of the screening tool.

The tool has a scoring algorithm to determine whether patients are high- or low-risk. An expanded version, the Pra Plus, contains questions that can lead directly to interventions.2 For example, the Pra Plus asks patients how many medications they are currently taking. That became one focus of the GEM program at the University of Minnesota. (For a copy of the questionnaire, see p. 82.)

"One of the most frequent things we did was to reduce the number and dose of medications people were taking," says Boult. "Older people with chronic diseases tend to accumulate medica

Teams consisting of a geriatrician, nurse, social worker, and gerontological nurse practitioner managed the care of GEM patients, beginning with a home visit to assess their psychosocial and environmental needs. Each patient had treatment goals and a plan of care, and in addition to comprehensive medical treatment, they received counseling, education, and necessary referrals.

GEM was designed as a short-term program in which patients would return to their primary care physicians for routine care, says Boult. "GEM is intended to be self-limited. You bring people in and get them on the path to where they need to go." However, some very high-risk patients may need periodic GEM care to maintain improvements, he says.

In a similar program, Group Health Cooperative of Puget Sound in Seattle is creating links between primary care physicians and geriatricians. But this "action plan" ultimately involves every older patient, with a special focus on those at high risk. Group Health has provided a special comprehensive assessment program for elderly patients for 10 years. Primary care physicians referred patients with complex care needs to the program.

But that assessment program didn’t impact ongoing care and helped only a small percentage of seniors, says Chris Himes, MD, director of geriatrics and long-term care at Group Health Cooperative. Instead, Group Health is beginning a program that links geriatric physicians and nurses with primary care doctors.

This new model includes a "care road map" with key indicators based on geriatric health needs. Eventually, all patients 65 and older will receive assessments. It is patterned after a similar program designed to improve care for diabetics. "If a diabetic comes in for an office visit, the medical receptionist presses a button that prints out that person’s registry," says Himes. "Anything that’s out of date comes up."

The geriatric program will strive for a similar system, although the care goals are more difficult to define. "No one can agree on what the appropriate measures for geriatrics are," she says, "not the federal government, not even the U.S. Preventive Services Task Force."

Group Health has developed assessment tools and interventions based on the issues that research shows most affect geriatric health. "There are three things that overall have been shown to make a difference [in care]," says Himes. "The first one is exercise. Second is social activation. Third is overall good geriatric care with focus on the geriatric syndromes." The geriatric syndromes include urinary incontinence, depression, and memory/cognitive changes. The geriatric program also deals with prevention of falls, advance directives, and other preventive health.

Seniors generally enter this program when they schedule a "health maintenance visit." Before their visit, they receive a screening tool that incorporates those major areas of concern. For example, the tool asks patients if they have lost interest in daily activities or if they have been feeling sad or blue. If they answer yes, they receive another questionnaire that is a screening tool for major depression.

Group Health has developed an array of interventions. For example, patients with urinary incontinence can be referred to the physical therapy department’s new Kegel exercise classes. Urolo-gists agreed on guidelines determining which patients should be referred. And primary care doctors received a refresher course on medications and other interventions to address the problem.

Group Health also has determined that it can obtain a score similar to the Pra Plus by reviewing medical records. "We’re being proactive with high-risk folks and trying to put them into the system," she says. Lifestyle issues present the greatest challenge to Group Health’s program. But Himes is convinced that exercise is a key to improving the quality of life for older patients.

Group Health worked with the University of Washington and local senior centers to develop a strengthening, fitness, and aerobic program for seniors called Lifetime Fitness. The MCO also offers seniors an independent program called Silver Sneakers.

"We’ve started to write prescriptions for exercise at all the health monitoring visits," says Himes. "[Lack of exercise] really is the one thing that keeps people from being able to be happy and be able to do what they want to do."

References

1. Morishita L, Boult C, Boult L, Smith S, et al. Satisfaction with outpatient Geriatric Evaluation and Management (GEM). The Gerontologist 1998; 38:303-308.

2. Boult C, Pualwan TF, Fox PD, Pacala JT. Identification and assessment of high-risk seniors. Am J Man Care 1998; 4:1,137-1,146. n

The Dartmouth-Hitchcock Clinic, Lebanon, NH. Eugene C. Nelson, Director of Quality Education Measurement and Research. Telephone: (603) 650-4882.

Memorial Sloan-Kettering Cancer Center, New York City. Colin Begg, Head, Department of Epidemiology and Biostatistics. Telephone: (212) 639-7573.

Santa Clara County Individual Practice Association, San Mateo, CA. Calvin Chao, Associate Medical Director. Telephone: (650) 358-5807.

University of Minnesota Center on Aging, Minneapolis. Chad Boult, Associate Professor. Telephone: (612) 627-4686.

University of Missouri Hospitals and Clinics, Columbia. Leslie R. Jebson, Manager of Specialty Clinics Operations. Telephone: (573) 882-2017.

Virtua Health, Marlton, NJ. Tracy Carlino, Director of Community Education. Telephone: (609) 246-3364.