PERSPECTIVES

Uncovering a "New" Clinical Niche for the Geriatrician: Page 2 of 2

June 17, 2013

While PCMHs and ACOs may train care managers (eg, nurses and social workers) to help coordinate care, the anchor of interdisciplinary care for frail older adults needs to be a physician with geriatric expertise. Geriatricians already have 3 years of postgraduate clinical training that focuses on both inpatient and outpatient care. In addition, they have at least an additional year of training in the assessment and management of geriatric syndromes and in the delivery of home-based care and LTC services. Geriatricians acquire expertise working in interdisciplinary teams and developing patient-centered plans of care. Furthermore, geriatricians have expertise in end-of-life care and in the assessment and prevention of hospitalization-associated disability.

Geriatricians, as well as many general medicine physicians, already have the unique skill sets to assume the clinical niche of providing true continuity of care for medically complex elderly patients across outpatient, inpatient, and LTC settings. A recent study by Sorbero and colleagues9 using data from 2002 found that elderly patients whose care was managed in the hospital by geriatricians compared with nongeriatricians had a shorter length of stay and lower costs of care, yet had similar clinical outcomes. Whether physician longitudinal care would involve an inpatient role as the primary attending or as a consultant to a hospitalist service remains unclear. The ability of geriatricians to follow patients across the continuum of care is feasible as many specialists continue to provide care across inpatient and outpatient settings. Similarly, concierge physicians follow their patients when they are hospitalized. Defining the ideal patient profile size and level of interdisciplinary support also needs to be determined.

By providing longitudinal outpatient care and following patients through care transitions, geriatricians could “lead” interdisciplinary teams to deliver concierge-like service to those patients most in need of coordinated care. To provide this level of service will require substantial changes to the relative value units (a measure of value used by Medicare reimbursement formulas for physician services), payments for care coordination (MD and non-MD services), and cost-sharing incentives. Defining a clinical niche for the geriatrician may help to stem the declining interest in the subspecialty of geriatric medicine.10 Such a model would also provide the level of customer satisfaction and personal accountability that elderly patients fondly remember and continue to expect.

References

1.     Stefanacci RG. Care coordination today: what, why, who, where, and how? Annals of Long-Term Care. 2013;21(3):38-42.

2.     Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155(8):520-528.

3.     Prvu Bettger J, Alexander KP, Dolor RJ, et al. Transitional care after hospitalization for acute stroke or myocardial infarction. Ann Intern Med. 2012;157(6):407-416.

4.     Hesselink G, Shoonhoven L, Barach P, et al. Improving patient handovers from hospital to primary care: a systematic review. Ann Intern Med. 2012;157(6):417-428.

5.     Golden AG, Tewary S, Dang S, Roos BA. Care management’s challenges and opportunities to reduce the rapid rehospitalization of frail community-dwelling older adults. Gerontologist. 2010;50(4):451-458.

6.     Jackson GL, Powers BJ, Chatterjee R, et al. The patient-centered medical home: a systematic review. Ann Intern Med. 2013;158(3):169-178.

7.     Correia EW. Accountable care organizations: the proposed regulations and the prospects for success. Am J Manag Care. 2011;17(8):560-568.

8.     Peikes D, Zutshi A, Genevro JL, Parchman ML, Meyers DS. Early evaluations of the medical home: Building on apromising start. Am J Manag Care. 2012;18(2):105-116.

9.     Sorbero ME, Saul MI, Liu H, Resnick NM. Are geriatricians more efficient than other physicians at managing inpatient care for elderly patients? J Am Geriatr Soc. 2012;60(5):869-876.

10.   Golden AG, Silverman MA, Mintzer MJ. Is geriatric medicine terminally ill? Ann Intern Med. 2012;156(9):654-656.

 


Disclosures: The authors report no relevant financial relationships. 

Address correspondence to: Adam Golden, MD, MBA, ACOS, Geriatrics & Extended Care, Orlando VA Medical Center, UCF College of Medicine, 5201 Raymond Street, CLC-136, Orlando, FL 32803; adam.golden@ucf.edu