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):
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 Centers 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 current CMS strategic plan consists of the following pillars (2):
Advance equity
Expand access
Engage partners
Drive innovation
Protect programs
Foster excellence
Clinicians 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, safe, person-centered 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. Clinicians need to coordinate care among patients' various health care settings and communicate effectively with other clinicians, as well as patients and their families. Additionally, geriatric clinicians 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:
The United States spent $22,356 on average per older adult for health care in 2020, which is 5 times more than for children and 2.5 times more than for younger adults (3).
Medicare spending increased 5.9% to $944.3 billion in 2022, which is 21% of all national health expenditures (3).
People 65 years and older have the greatest per capita use of emergency departments (538.3 visits per 1,000 population) (4).
In 2013, 50% of traditional Medicare beneficiaries 65 years or older spent 14% or more of their total income on out-of-pocket health care costs, with an even greater burden for those over 85 years; by 2030, 42% of traditional Medicare beneficiaries are projected to spend at least 20% of their total income on health-related out-of-pocket costs (5).
Of older adults, 88% take at least one prescription drug and 36% take 5 or more prescription drugs, the cost of which creates financial hardships for many older adults (6, 7).
Because of their multiple chronic illnesses, older adults are likely to see several health care professionals 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 professionals, 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:
Physician's office: The most common reasons for visits are routine diagnosis and management of acute and chronic problems, health promotion and disease prevention, and presurgical or postsurgical evaluation. Medicare pays for a yearly wellness visit for older adults enrolled in Medicare Part B for longer than 12 months (see Medicare Coverage for limits and exceptions). The annual visit focuses on identifying areas of risk, prevention of disease and disability, screening for cognitive impairment, and creating a prevention plan.
Patient’s home: Home health care is most commonly used after hospital discharge, but hospitalization is not a prerequisite. Also, a small but growing number of health care professionals deliver care for acute and chronic problems and sometimes end-of-life care in a patient's home.
Long-term care facilities: These facilities include assisted-living facilities, board-and-care facilities, skilled nursing facilities, and 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. Because of the trend toward shorter hospital stays, some long-term care facilities are now also providing post-acute care (eg, rehabilitation and high-level skilled nursing services) previously done during hospitalization.
Day care facilities: These facilities provide medical, rehabilitative, cognitive, and social services several hours a day for several days a week.
Hospitals: Older patients should be hospitalized only if they are seriously ill. Hospitalization itself poses risks to older patients because of confinement, immobility, diagnostic testing, and exposure to infectious organisms. Some hospitals have developed programs that provide hospital-level services in the home environment. These programs are particularly useful for patients who require long-term therapies that need to be administered by licensed nurses and may reduce risk of hospital-acquired conditions, such as delirium and some infections.
Long-term acute care hospitals: These facilities provide extended hospital-level recovery and rehabilitative care to patients with severe injuries and clinically complex conditions (eg, severe stroke, severe trauma, multiple acute and chronic problems (8). These facilities are for patients who are expected to improve and return home but who need a longer period of time. Long-term survival is possible after prolonged mechanical ventilation (9).
Hospice: Hospices provide care for the dying. 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 an 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 health care professionals from different disciplines who provide coordinated, integrated care with collectively set goals and shared resources and responsibilities. Among other models, the Geriatric Interprofessional Team Transformation for Primary Care model was developed to deliver optimal care to older adults in primary care and has been shown to improve outcomes for older adult patients through systematic team training in primary care practices (10).
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 clinicians 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 that
Patients move safely and easily from one care setting to another and from one clinician to another
The most qualified clinician provides care for each problem
Care is not duplicated
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
Health care teams should seek to provide 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 (11).
Health care professional team members should treat patients and caregivers as active members of the team 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 pharmacotherapy, rehabilitation, dietary plans, and other therapies, and these treatments and plans should align with patient preferences.
Health care professional team members should respect the patients' and caregivers' ideas and preferences (eg, if patients will not take a particular medication or change certain dietary habits, care can be modified accordingly).
Patients and health care professionals 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 clinicians adjust their communication to a level that patients can understand (12). Capacity to make health care decisions 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.
References
1. U.S. Department of Health & Human Services (HHS): Strategic Plan FY 2022–2026. Accessed May 2024.
2. Center for Medicare and Medicaid Services (CMS): CMS Strategic Plan. Accessed May 2024.
3. Centers for Medicare & Medicaid Services (CMS): National Health Expenditures by Age Group (2022). Accessed May 2024.
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
7. Olson AW, Schommer JC, Mott DA, Adekunle O, Brown LM: Financial hardship from purchasing prescription drugs among older adults in the United States before, during, and after the Medicare Part D "Donut Hole": Findings from 1998, 2001, 2015, and 2021. J Manag Care Spec Pharm. 2022;28(5):508-517. doi:10.18553/jmcp.2022.28.5.508
8. Le Danseur M: Stroke Rehabilitation. Crit Care Nurs Clin North Am. 2020;32(1):97-108. doi:10.1016/j.cnc.2019.11.004
9. Jubran A, Grant BJB, Duffner LA, et al: Long-Term Outcome after Prolonged Mechanical Ventilation. A Long-Term Acute-Care Hospital Study. Am J Respir Crit Care Med. 2019;199(12):1508-1516. doi:10.1164/rccm.201806-1131OC
10. Flaherty E, O'Connor S, Steltenpohl CN, Preiss M, et al: Geriatric Interprofessional Team Transformation for Primary Care overview. J Am Geriatr Soc 2024;72 Suppl 2:S4-S12. doi:10.1111/jgs.18637
11. Cutler S, Morecroft C, Carey P, Kennedy T: Are interprofessional healthcare teams meeting patient expectations? An exploration of the perceptions of patients and informal caregivers. J Interprof Care 2019;33(1):66-75. doi:10.1080/13561820.2018.1514373
12. Dörfler E, Kulnik ST: Despite communication and cognitive impairment - person-centred goal-setting after stroke: a qualitative study. Disabil Rehabil. 2020;42(25):3628-3637. doi:10.1080/09638288.2019.1604821
