Merck Manual

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Overview of Geriatric Care


Debra Bakerjian

, PhD, APRN, University of California Davis

Reviewed/Revised Oct 2022

Every 4 years, the US Department of Health and Human Services (HHS) updates its strategic plan and defines its mission and goals. The HHS strategic plan for 2022 to 2026 includes the following 5 goals (1 General references Every 4 years, the US Department of Health and Human Services (HHS) updates its strategic plan and defines its mission and goals. The HHS strategic plan for 2022 to 2026 includes the following... read more ):

  • Strategic goal 1: Protect and strengthen equitable access to high-quality and affordable health care

  • Strategic goal 2: Safeguard and improve national and global health conditions and outcomes

  • Strategic goal 3: Strengthen social well-being, equity, and economic resilience

  • Strategic goal 4: Restore trust and accelerate advancements in science and research for all

  • Strategic goal 5: Advance strategic management to build trust, transparency, and accountability

The Center for Medicare and Medicaid Services (CMS) then updates its strategic plan building upon the HHS strategic plan and sets its quality agenda for the next 5 to 10 years. The 2022 CMS strategic plan consists of the following pillars (2 General references Every 4 years, the US Department of Health and Human Services (HHS) updates its strategic plan and defines its mission and goals. The HHS strategic plan for 2022 to 2026 includes the following... read more ):

  • Advance equity

  • Expand access

  • Engage partners

  • Drive innovation

  • Protect programs

  • Foster excellence

Practitioners who provide care to older adults should be aware of all of these goals and pillars and incorporate them into their approach to geriatric care. The overarching goal is to improve the patient experience and provide high-quality and safe care that is cost-effective. It is essential to address health disparities and advance health equity.

Engaging with patients and families to become partners in care leads to more meaningful person-centered care and more effective prevention and treatment plans with better outcomes. Practitioners need to coordinate care among patients' various health care settings and communicate effectively with other practitioners, as well as patients and their families. Additionally, geriatric practitioners need to work with communities to create and implement best practices that incorporate prevention strategies with a goal of keeping patients and populations healthier. Lastly, health care professionals and staff, academics, and researchers must work with policymakers to make health care more equitable and affordable.

Because older adults tend to have multiple chronic disorders and may also have cognitive, social, or functional problems, they have higher health care needs and use a disproportionately large amount of health care resources:

Because of their multiple chronic illnesses, older adults 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 older 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.

General references

  • 1. U.S. Department of Health & Human Services (HHS): Strategic Plan FY 2022–2026.

  • 2. Center for Medicare and Medicaid Services (CMS): CMS Strategic Plan 2022.

  • 3. Sun R, Karaca Z, Wong HS: Trends in hospital inpatient stays by age and payer, 2000–2015. HCUP Statistical Brief #235. Agency for Healthcare Research and Quality, 2018.

  • 4. Moore BJ, Stocks C, Owens PL: Trends in emergency department visits, 2006–2014. HCUP Statistical Brief #227. Agency for Healthcare Research and Quality, 2017.

  • 5. Cubanski J, Neuman T, Damico A, et al: Medicare beneficiaries’ out-of-pocket health care spending as a share of income now and projections for the future. Kaiser Family Foundation, 2018.

  • 6. Qato DM, Wilder J, Schumm LP, et al: Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011. JAMA Intern Med 176(4):473–482, 2016. doi: 10.1001/jamainternmed.2015.8581

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 older 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 geriatric nurse practitioner or a primary care physician or nurse practitioner or physician assistant with experience and interest in geriatric medicine.

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

  • That care is comprehensive

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. However, with the increased use of technology (ie, cell phones, computers, internet, telehealth), it is not unusual for team members to work at different sites and use various technologies to enhance communication.

A team typically includes physicians, nurses, nurse practitioners, physician assistants, pharmacists, social workers, psychologists, and sometimes a dentist, dietitian, physical and occupational therapists, an ethicist, or a palliative care or 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 develop a shared vision of care, identify patient-centered objectives and 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, nurse practitioner, or physician assistant leads the meeting and introduces the team to the patient and family members. The physician, nurse practitioner, and physician assistant often work together and determine what medical conditions a patient has, inform the team (including differential diagnoses), and explain how these conditions affect care. If the patient and family members need help in coordinating care, the social worker might be most knowledgeable and therefore assume team leadership. Similarly, if there are medication issues, the pharmacist might be the best person to lead the team. Alternatively, if the main concern is related to nursing care, such as wound care, then the nurse should take the lead.

The team’s input is incorporated into medical orders. The physician or one of the provider team members 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 or physician assistant, 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, family member, and caregiver participation

Recent evidence has pointed to the importance of providing person-centered care, which means that providers are highly focused on patient preferences, needs, and values. The key principles of patient-centered care include respecting patient preferences; coordinating care; providing information and education to the patient and family members; involving family and friends; and providing both physical comfort and emotional support.

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 about their preferences and goals of care and to take a lead in helping the team set goals (eg, advance directives, end-of-life care, level of pain).

  • Patients and caregivers should be included in discussions of drug treatment, rehabilitation, dietary plans, and other therapies, and these treatments and plans should align with patient preferences.

  • Practitioner teams should respect the patients' and caregivers' ideas and preferences (eg, 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. 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 Capacity (Competence) and Incapacity Historically, “incapacity” was considered primarily a clinical finding, and “incompetency” was considered a legal finding. That distinction, at least in terminology, is no longer firmly recognized... read more is specific to each particular decision; patients who are not capable of making decisions about complex issues may still be able to make decisions about 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.

More Information

The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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