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Geriatric Care Creating a Continuity of Care: The Right Care in the Right Place at the Right time.


1. Geriatric Care. Creating a Continuity of Care: ... Levine, S. A., B. Brett, et al. (2007) ... Saag KG, Doebbeling BN Rohrer JE, Kolluri S, Mitchell TA Wallace RB. ... – PowerPoint PPT presentation

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Title: Geriatric Care Creating a Continuity of Care: The Right Care in the Right Place at the Right time.

Geriatric CareCreating a Continuity of CareThe
Right Care in the Right Place at the Right time.
  • Thomas C. Rosenthal MD
  • Professor and Chair
  • University at Buffalo Dept of Family Medicine
  • Director NYS AHEC System

  • Proposal for the future of geriatric care.
  • Integration of care Primary/Specialty
  • Describe primary care
  • Describe specialty care
  • Explain efficiencies of both.
  • Unique rural issues.
  • Models
  • Conclusions

We Have a ProblemThe Cost of Dying depends on
where you do it.
Medicare expenditures, Dartmouth Atlas Project,
ProposalAnd Basis for My Presentation
  • Whereas most older patients can identify a
    regular source of primary care already, and
  • Whereas it seems unlikely that there will ever be
    enough specialized Geriatric providers available,
  • Whereas most of the care needed by older patients
    is well provided by already by their primary care
  • Therefore Geriatric healthcare be organized
    around the existing primary care base with
    support, research and training to create a broad
    base of access to highest quality care.
  • Rosenthal, 2000

International Quality Rankings1Best
Commonwealth Fund 2006
Why Primary Care?
  • Essential Characteristics of Primary Care
  • Access
  • Seen within a reasonable period of time and with
    a manageable hassle factor.
  • Affordable.
  • Continuity
  • Care imbedded in a relationship between provider
    and patient.
  • Comprehensive
  • Taking care all common problems and many uncommon
  • Coordination
  • Organized testing and consultations with results
  • (Starfield, 1998)

Kerrs Box 2001 (Greens Box)
Monthly Distribution of All Age Population at
Risk in Health Care Settings (Green, 2001)
1,000 Persons
800 Report Symptoms
327 Consider Seeking Care
217 Visit Physicians Office (113
primary care)
65 Visit Alternative Med
21 Visit Hospital OP
14 Receive Home Care
13 Visit Emergency Room
8 are Hospitalized
lt1 is Hospitalized in Academic Medical Center
1. Health is better in regions with more PCPs.
75th Percentile Quality 3.9 PCPs/ 10,000
High Quality
25th Percentile Quality 2.5 PCPs/ 10,000
Low Quality
States with more generalists use more effective
care and have lower spending, while those with
more specialists have higher costs and lower
Primary CareHealthier People
  • People who report having a relationship with a
    PCP rather than using only a specialist as
    regular source of care have a higher 5 year
    survival rate. (Franks, 1998)
  • Death rates fall when patients are required to
    see a PCP prior to referral. (Villalbi, 1999)
  • Surgical outcomes improve when a referral from a
    PCP is required. (Roos, 1979)
  • Greater use of preventive services. (OMalley,
  • Less Depression, greater self reported wellness.
    (Shi, 2002 Starfield, 2005)
  • Generalist care with specialty back up exceeds
    either alone. (Starfield, 2003)

PCPs Explain Relativity
  • Relative Risk Statement
  • The treatment of hypertension in the elderly is
    associated with a 30 reduction in stroke over 10
  • Absolute risk statement
  • The reduction in strokes in elderly who
    adequately control their hypertension over the
    next 10 years decreases from 10 likelihood to

Two Paths to Quality
  • Repetition Common practice.
  • Doing the same procedure over and over again.
  • Essential for rare procedures and procedures
    requiring very specialized skill set.
  • Protocols Follow guidelines.
  • Following Care Maps to assure each step of the
    work-up, procedure itself, and post procedure
    care are followed.
  • Equally effective for treatments and procedures
    that are uncommon but not rare.
  • (Bertram, Rosenthal, 1996)

Geriatric Specialists are Essential!For an
effective Health System
  • They improve care by
  • Generating new knowledge and new techniques.
  • Performing special skill procedures.
  • Clarifying confusing/unusual presentations of
  • Sharing experience and teach others (including
    generalists Rosenthal,1996).
  • Support primary care.
  • Accumulating experience in uncommon problems.

The Special Case of Rural
  • 24 of Americans live in non-metro communities
  • but more of them are gt 65 years of age.
  • Rural elderly tend to age-in-place.
  • Younger citizens migrate to urban areas
  • Except for retirement communities,.
  • Only 7 of rural elderly are minority.
  • 1 of African Americas live in non-metro areas
  • Many of them (43) live in the rural Southeast.2
  • Poverty is a major characteristic of rural
  • Coward, 1998

The Special Case of Rural
  • Non-metro elderly Compared to Metro Elderly
  • Equally likely to live alone (50)
  • Or be married (66)
  • Rural more likely to rate their health as poor.
  • Only 4 live on farms
  • But they are more likely to be healthy.
  • Rural elderly with osteoarthritis report their
    fear of medical care expense to be greater than
    fear of their disease itself. (Saags, 1998)
  • Transportation is a major determinant of access.
  • Residents with financial resources report the
    major determinant of access is the ability to
    drive. (Ricketts, 1999)

The Special Case of Rural
  • 57 of all physicians practicing in small rural
    counties are generalists
  • 60 of whom are family physicians.
  • Regard for personal relationships, sense of duty,
    and enjoyment of wholistic care.
  • These are values that correlate with rural
    practice. (AmCollPhys, 1995)
  • Rural residents are likely to receive care
    exclusively from a generalist physician. (Rost,
  • Rural physicians know that problems not taken
    care of by them are likely not going to be taken
    care of.

The Special Case of Rural
  • Financial viability of rural health systems is a
    complex mix of factors.
  • A hospital that abandons care of any condition
    (ie. MI care), may find that a marginal decrease
    in admissions results in bankruptcy.
  • Closing to one class of diagnoses results in the
    community losing access to emergency and maternal
    services, and increased neonatal morbidity.
    (Nesbitt, 1997)
  • Low volume teams can match high volume teams when
    protocols are instituted. (Bertram, 1996)
  • A full range of services does require urban

What Models Exist?

Systems Save MoneyIt now costs 6,000/yr less to
care for an elderly Veteran than a Non-Vet.
  • In 1980 the VA system instituted primary care
    based management.
  • EMR
  • Expenditures have been curtailed as a result.
  • Systems cost less.
  • Moran, 2005

Cost in 1980 1.0
UK Geriatric Model
  • In the UK the specialty of Geriatrics objective
    is to spread geriatric skills as widely as
    possible so that the standards of quality care
    become normal practice. (Evans, 1997)
  • Like so many other specialties in America, U. S.
    geriatricians have become direct providers.
  • Pre-occupation with direct patient care distracts
  • Diffusing skills into the general community.
  • Incorporating protocols and standards.
  • Decreasing opportunities for PCPs to partner with
    a geriatric specialist.

Home Care Models
  • Leeds Health Authority (UK)
  • Rehabilitation in home or short stay centers.
  • Multi-disciplinary team approach includes
    geriatric physicians.
  • Outcomes Comparing Hospital Rehab to Home Rehab
  • Death rate of 33 same in both groups at 12 mths.
  • Functional outcomes were equal.
  • Readmissions were the same for both groups.
  • Young, 2005

Improved Care for Poor Elderly
  • A randomized trial of primary care physicians and
    their patients over 65 in the community. (500
    each group)
  • Intervention 2 years with regular consultations
    by geriatrician, NP, SW.
  • Results (Compared to usual care group.)
  • Lower ER use.
  • Hospital admissions lower.
  • Improved social functioning, mental health.
  • Death rate equal. (Counsell, 2007)

Relative Contributions of Specialty vs Generalist
  • Generalist
  • Knowledge of the patient in context of family and
  • Relationship with family and caregivers.
  • Medical history.
  • Availability.
  • Specialists
  • Knowledge of geriatric issues.
  • In depth experience with more cases.
  • Use of special assessment tools.
  • Special services

Collaborative Services
  • Care mapping and guideline selection.
  • Geriatric assessment.
  • Risk screening and assessment.
  • Poly-pharmacy evaluation.
  • Prognostication.
  • Academic Detailing.
  • Mini-fellowships for generalists.
  • Caregiver services.
  • Telecommunication monitoring strategies.
  • (Fromm Faria, 2007 Levine, 2007)

Goal of all Health Systems
  • Right Care, in the Right Place,
    at the Right Time.
  • Improvement of the care to all of Americas
    elderly will require a universal system of health
  • Based on primary access to everyone.
  • Support of high quality primary care.
  • Integration of specialty care at the right time,
    in the right place.

  • Trying to create enough geriatricians for all
    elderly Americans is like trying to recreate a
    parallel health system for the elderly.
  • It is unattainable.
  • It is not ideal.
  • Strengthening the existing primary care system is
    attainable, affordable and will achieve better
    outcomes for all New Yorkers.

  • American College of Physicians. Rural Primary
    Care. Ann Intern Med. 1995122380-390.
  • Bertram DA, Rosenthal TC. Implementation of an
    in-patient case management program in rural
    hospitals. J Rural Health. 1996 Winter
  • Counsell, S. R., C. M. Callahan, et al. (2007).
    "Geriatric care management for low-income
    seniors a randomized controlled trial." Jama
    298(22) 2623-33.
  • Coward RT, Krout JA. Aging in Rural Settings,
    Life Circumstances and Distinctive
    Features.Springer Publishing Company. New York,
    NY. 1998.
  • Evans JG. Geriatric medicine a brief history.
    BMJ 19973151075-7.
  • Franks, P. and K. Fiscella (1998). "Primary care
    physicians and specialists as personal
    physicians. Health care expenditures and
    mortality experience." J Fam Pract 47(2) 105-9.
  • Fromm Faria, D., V. V. David, et al. (2007).
    "Using collaboration to maximize outcomes for a
    John A. Hartford Foundation geriatric enrichment
    project." J Gerontol Soc Work 48(3-4) 367-86.
  • Gladwell M. The Moral Hazard Myth. The bad idea
    behind our failed health-care system New Yorker.
    8/29/05. (Gladwell wrote The Tipping Point.
  • Green LA, Fryer GE, Yawn BP, Lanier D, Dovey SM.
    The ecology of medical care revisited. NEJM

  • Levine, S. A., B. Brett, et al. (2007).
    "Practicing physician education in geriatrics
    lessons learned from a train-the-trainer model."
    J Am Geriatr Soc 55(8) 1281-6.
  • Moran DW. Whence and whither health insurance? A
    revisionist history. Health Affairs
  • Nesbitt TS, Larson EH, Rosenblatt RA, Hart LG.
    Access to maternity care in rural Washington Its
    effect on neonatal outcomes and resource use.
    American Journal of Public Health. 19978785-90.
  • O'Malley, A. S., C. B. Forrest, et al. (2005).
    "Disparities despite coverage gaps in colorectal
    cancer screening among Medicare beneficiaries."
    Arch Intern Med 165(18) 2129-35.
  • Ricketts III TC. Rural Health in the United
    States. Oxford University Press. New York. 1999.
  • Roos, NP. Who should do the surgery?
    Tonsillectomy-Adenoidectomy in one Canadian
    Province. Inquiry 19791673-83.
  • Rost K, Owen R, Smith J, Smith GR. Rural-Urban
    differences in service use and course of illness
    in bipolar disorder. Journal of Rural Health

  • Rosenthal TC, Horwitz ME, Snyder G, OConnor J.
    Medicaid Primary Care Services in New York State
    Partial Capitation vs Full Capitation. J Fam
    Pract. 199642(4)362-368.
  • Rosenthal TC, Fox C. Access to health care for
    the rural elderly. JAMA 20002842034-6.
  • Rosenthal T, Naughton B, WilliamsM Editors.
    Office Based Geriatrics A Practical Approach.
    Lippencott, Williams, Wilkins. NY. 2006.
  • Saag KG, Doebbeling BN Rohrer JE, Kolluri S,
    Mitchell TA Wallace RB. Arthritis health service
    utilization among the elderly the role of
    urban-rural residence and other utilization
    factors. Arthritis Care Res. 199811177-85.

  • Starfield B, Powe NR, Weiner JR, Stuart M,
    Steinwachs D, Scholle SH, Gerstenberger A. Costs
    vs quality in different stypes of primary care
    settings. JAMA. 19942721903-8.
  • Starfield B, Shi L, Macinko J. Contribution of
    primary care to health systems and health.
    Milbank Quarterly. 200583457-502.
  • Starfield, B., K. W. Lemke, et al. (2005).
    "Comorbidity and the use of primary care and
    specialist care in the elderly." Ann Fam Med
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  • Young JB, Robinson M, Schell S, Sanderson D,
    Chaplin S, Burns, E, Fear J. A whole system of
    intermediate care services for older people. Age
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Government is Capable!
  • Americans with Medicare are happier with every
    aspect of their insurance coverage than people
    with private insurance.
  • Medicare recipients are insulated against the
    financial shock of serious illness.
  • The rest of the industrialized world assumes that
    when the burdens of illness are shared
  • The population as a whole is better off.
  • Only the US believes insurance is the problem and
    not the solution. (Gladwell, 2005)