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AGS Health Care Systems Committee
*Last Updated January 1, 2000*
Background
With the growth of the older adult population,
community based elder health services are becoming attractive entrepreneurial
opportunities as well as critical components of the continuum of
care for many health systems. Specialized ambulatory clinical service
centers for older adults (hereafter referred to as "Senior
Clinics") are being developed and marketed to the public. They
vary widely in mission, scope of available services, background
and skills of providers and overall capacity. The American Geriatrics
Society believes that high-quality ambulatory care services for
older adults must contain seven critical components: primary as
well as consultative care; personnel with training and experience
in geriatrics; an interdisciplinary team able to coordinate care
and services; access to care that is considerate of the special
needs of many elders; an information system and quality improvement
program that is geriatric-focused; and financial viability to ensure
continuity of care. While most Senior Clinics are affiliated with
hospitals or part of a large group practice, some of the points
made may also be relevant to a private office with general internists
or family practitioners who see many geriatric patients. For example,
access to social work, lines of referral to community agencies and
care managers, access to geriatricians and knowledgeable nursing
home physicians, educational materials for older adults and their
families, and transportation services are always important. However,
the intent of this position paper is to describe the necessary components
of specialized ambulatory care clinics dedicated to older patients.
This position paper does not apply to dedicated geriatric consultation
services, such as Geriatric Assessment Clinics, which typically
do not provide primary care, or ongoing coordination of health services
for older adults.
Positions
1. A primary care
geriatric medical delivery model should be seen as the gold standard
in delivering high quality care to the senior population.
Rationale: Patients should be given the opportunity
to utilize the Senior Clinic for primary care services. Continuity
with a group of experienced providers, who are available to manage
care across the continuum, is essential for older persons. The patient
should be provided information and materials to enable him or her
to participate in self-management of chronic disease, whenever possible.
Senior clinics may also offer consultation, such as Comprehensive
Geriatric Assessment and specialty consultations, to other primary
care physicians, but must assure adequate follow-up of patients.
Opportunities for the consulting team to play a role in implementing
suggestions should be afforded as evidence suggests that clinical
outcomes are improved when there is integration between the recommendations
that are generated by geriatric assessment and the implementation
of those care processes.
2. All providers
must have an appropriate level of competency in geriatrics.
Rationale: Senior clinics often manage complicated
elders with multiple medical co-morbidities, functional deficits,
complex medical regimen, and a high rate of mental health problems.
Physicians should have fellowship training in geriatrics, a Certificate
of Added Qualifications in geriatrics, or have extensive experience
and continuing education in geriatrics. Geriatric Nurse Practitioners,
Registered Nurses and other disciplines should have either advanced
training or sufficient continuing education in geriatrics. Staff
throughout the program must have senior sensitivity training.
3. An interdisciplinary
team approach to care must be available.
Rationale: In addition to traditional medical
care, comprehensive geriatric care involves attention to the patient’s
psychological, social and functional needs. The team is responsible
for developing and carrying out a plan of care. Regular meetings
and/or documentation of team interactions should occur. A close
working relationship with a social worker skilled in geriatric care
is imperative. A Senior Clinic must provide a mechanism for the
interdisciplinary team to function effectively, including necessary
information systems, scheduled time for meetings, and documentation
of decision-making.
Primary geriatric care encompasses the entire
continuum of care, including hospital, skilled nursing facility,
assisted living and home care. A care coordinator or case manager
(usually a nurse or a social worker) should be available to facilitate
the care. The team members involved in the Senior Clinic must be
able to work with patients, families and caregivers. There must
be adequate interface with community-based services to ensure safety
and assistance when needed.
4. Access that is sensitive to the needs of geriatric patients must
be assured.
Rationale: Many elders have limitations in sensory
functions or mobility, and special transportation needs. A Senior
Clinic must be accessible by public transportation, and have readily
available parking or parking services. Privacy and confidentiality
must be ensured, especially when discussing billing and insurance
issues. The clinic must be physically accessible, i.e., disabled
parking, adequate lighting, wheel chair and walker accessibility,
rest rooms and appropriate examination tables. There should be telephone
access for the hearing impaired. A resource library with community
resource information should be available. All attempts must be made
to fulfill the transportation needs of the patients served by the
program.
5. The program must
have an appropriate information system to allow for tracking of
key clinical items, e.g., preventive services, diagnoses, medications,
and advance directive status.
Rationale: An adequate information system is needed
to manage the vast amount of clinical data on complex geriatric
patients. Ideally, programs should be able to transfer information
to different care sites, including the hospital, nursing homes,
other community-based care facilities, and social services agencies.
Data should be maintained on important clinical activities and outcomes
so as to allow patients and others to judge quality of care.
6. Quality improvement
programs must demonstrate, at a minimum, compliance with key geriatric
indicators.
Rationale: The program must have a defined set
of health promotion and disease prevention activities based on sound
geriatric principles and recognizing patient preference and individuality.
Specialized programs for the detection, evaluation and management
of incontinence, falls, degenerative joint disease, depression and
dementia are advised. A mechanism for screening and treating functional
disabilities should be established. New patients should be screened
for high risk for hospitalization and functional disability. Ongoing
clinical quality monitoring should include attention to immunizations,
prevention of advancement of chronic disease or disability, pain
control, end-of-life care, and satisfaction with care.
7. A program focusing
on the senior population will by its very nature require more financial
resources than the traditional approach to care.
Rationale: In the fee-for-service environment
interventions common in geriatrics, such as case management, may
not be reimbursable. Senior Clinics must be innovative in financial
approaches to expand services into those areas most needed but often
not covered by traditional Medicare or supplemental insurance. Medicare
should expand the billable activities that are critical to management
of complex older patient’s care, such as case management, palliative
care, and family conferences.
In the managed care environment, Senior citizens
often need more time to interact with their providers. Traditional
productivity measurements for providers must be reevaluated. It
is critical that overall heath care costs be taken into account
in assessing the financial viability of such a program. Certain
target areas such as reduced use of hospital resources, the appropriate
use of skilled nursing care as an alternative to hospitalization,
enhanced home care, improved pharmaceutical management, and more
appropriate specialty utilization need to be considered in the financial
model. Alternative methods for risk adjustment or capitated payments
for frail or complex elders offers special opportunities in the
managed care environment. Programs must provide information to clients
and their families regarding current coverage and benefits and limits
of reimbursement.
Developed by the AGS Health Care Systems Committee
and approved May 2000 by the AGS Board of Directors. Journal of
the American Geriatrics Society, 48:845-846, 2000. AGS, The Empire
State Building, 350 Fifth Avenue, Suite 801, New York, NY 10118.
The AGS thanks Michael Wasserman, MD, Kenneth Brummel-Smith, MD,
Cheryl Phillips, MD, and Steven Phillips, MD for their work on this
statement.
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