Because older adults 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, people ≥ 65 account for
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, particularly when patients are transferred between settings, is critical to ensuring that patients receive appropriate care in all settings. Electronic health records may help facilitate communication.
Health care settings:
Care may be delivered in the following settings:
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 formal 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. If interdisciplinary care is not available, an alternative is management by a geriatrician or a primary care physician with experience and interest in geriatric medicine.
Interdisciplinary teams aim to ensure the following:
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 practitioners must communicate honestly to prevent patients from suppressing an opinion and agreeing to every suggestion. Cognitively impaired patients should be included in decision making provided that practitioners adjust their communication to a level that patients can understand. Capacity to make health care decisions (see Capacity (Competence) and Incapacity) is specific to each particular decision; patients who are not capable of making complex decisions may still be able to decide less complicated issues.
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 October 2013 by Barbara Resnick, PhD, CRNP
Content last modified November 2013