Because the elderly tend to have multiple disorders and may have social or functional problems, they use a disproportionately large amount of health care resources. In the US, they account for

• > 40% of acute hospital bed days
• > 30% of prescription and 40% of OTC drug purchases
• $329 billion or almost 44% of the national health budget
• > 75% of the federal health budget

The elderly are likely to see several health care practitioners and to move from one health care setting to another. Providing consistent, integrated care across specific care settings, sometimes called continuity of care, is thus particularly important for elderly patients. Communication among primary care physicians, specialists, other health care practitioners, and patients and their family members is critical to ensuring that patients receive appropriate care in all settings.

Health care settings: Care may be delivered in the following settings:

• Physician's office: The most common reasons for visits are routine chronic problems, acute problems, flare-ups of a chronic problem, preventive care, and presurgical or postsurgical evaluation.
• Patient's home: Home care (see Provision of Care to the Elderly: Home Health Care) is most commonly used after hospital discharge, but hospitalization is not a prerequisite.
• Long-term care facilities: These facilities include assisted-living facilities (see Provision of Care to the Elderly: Assisted-Living Programs), board-and-care facilities (see Provision of Care to the Elderly: Board-and-Care Facilities), nursing homes (see Provision of Care to the Elderly: Nursing Homes), and life-care communities (see Provision of Care to the Elderly: Life-Care Communities). Whether patients require care in a long-term care facility depends partly on the patient's wishes and needs and on the family's ability to meet the patient's needs.
• Day care facilities: These facilities provide medical, rehabilitative, cognitive, and social services several hours a day for several days a week.
• Hospitals: Only seriously ill elderly patients should be hospitalized (see Provision of Care to the Elderly: Hospitalization). Hospitalization itself poses risks to elderly patients because of confinement, immobility, diagnostic testing, and treatments.
• Hospice: Hospices provide care for the dying (see The Dying Patient: Hospice Care). The goal is to alleviate symptoms and keep people comfortable rather than to cure a disorder. Hospice care can be provided in the home, a nursing home, or a separate inpatient facility.

In general, the lowest, least restrictive level of care suitable to a patient's needs should be used. This approach conserves financial resources and helps preserve the patient's independence and functioning.

Geriatric Interdisciplinary Teams

Geriatric interdisciplinary teams consist of practitioners from different disciplines who provide coordinated, integrated care with collectively set goals and shared resources and responsibilities.

Not all elderly patients need a geriatric interdisciplinary team. However, if patients have complex medical, psychologic, and social needs, such teams are more effective in assessing patient needs and creating an effective care plan than are practitioners working alone. For these patients, care is often best managed by a geriatrician. Interdisciplinary care is not available everywhere.

Interdisciplinary teams aim to ensure the following:

• That patients move safely and easily from one care setting to another and from one practitioner to another
• That the most qualified practitioner provides care for each problem
• That care is not duplicated

To create, monitor, or revise the care plan, interdisciplinary teams must communicate openly, freely, and regularly. Core team members must collaborate, with trust and respect for the contributions of others, and coordinate the care plan (eg, by delegating, sharing accountability, jointly implementing it). Team members may work together at the same site, making communication informal and expeditious.

A team typically includes physicians, nurses, pharmacists, social workers, and sometimes a dietitian, physical and occupational therapists, an ethicist, or a hospice physician. Team members should have knowledge of geriatric medicine, familiarity with the patient, dedication to the team process, and good communication skills.

To function effectively, teams need a formal structure. Teams should set deadlines for reaching their goals, have regular meetings (to discuss team structure, process, and communication), and continuously monitor their progress (using quality improvement measures). In general, team leadership should rotate, depending on the needs of the patient; the key provider of care reports on the patient's progress. For example, if the main concern is the patient's medical condition, a physician leads the meeting and introduces the team to the patient and family members. The physician determines what medical conditions a patient has, informs the team (including differential diagnoses), and explains how these conditions affect care. The team's input is incorporated into medical orders. The physician must write medical orders agreed on through the team process and discusses team decisions with the patient, family members, and caregivers.

If a formally structured interdisciplinary team is not available or practical, a virtual team can be used. Such teams are usually led by the primary care physician but can be organized and managed by an advanced practice nurse, a care coordinator, or a case manager. The virtual team uses information technologies (eg, handheld devices, email, video conferencing, teleconferencing) to communicate and collaborate with team members in the community or within a health care system.

Patient and caregiver participation: Practitioner team members must treat patients and caregivers as active members of the team—eg, in the following ways:

• Patients and caregivers should be included in team meetings when appropriate.
• Patients should be asked to help the team set goals (eg, advance directives, end-of-life care).
• Patients and caregivers should be included in discussions of drug treatment, rehabilitation, dietary plans, and other therapies.
• Patients should be asked what their ideas and preferences are; thus, if patients will not take a particular drug or change certain dietary habits, care can be modified accordingly.

Patients and practitioners must communicate honestly to prevent patients from suppressing an opinion and agreeing to every suggestion.

Caregivers, including family members, can help by identifying realistic and unrealistic expectations based on the patient's habits and lifestyle. Caregivers should also indicate what kind of support they can provide.

Last full review/revision June 2009 by Mary Ann Anderson, PhD, RN

Content last modified February 2012