Guiding elderly care

Healthcare professionals caring for elderly Americans with three or more chronic health conditions should minimize the number of medications they prescribe to those patients, as well as talk at length with them and their families to determine their treatment preferences and outcome goals, according to the American Geriatrics Society's new guiding principles on caring for older adults with multiple morbidities.

“There really is a striking prevalence of people who have multiple chronic conditions … yet much of the way we practice healthcare is really sort of one disease at time. There is increasing recognition that we need to think about how to integrate the treatments for all these conditions,” said Dr. Cynthia Boyd, co-chair of the panel that developed the guiding principles, and an associate professor of medicine at Johns Hopkins Medicine.

The question, however, is how medical practices and hospitals will be able to put these guiding principles into practice on tight budgets and with busy clinicians.

“It sounds great on paper,” said Lorraine Ryan, senior vice president for legal, regulatory, and professional affairs for the Greater New York Hospital Association. “It is a matter of prioritizing with limited resources.”

In fact, the document notes, the way that clinicians and hospitals are reimbursed does not take into account the time clinicians need to have lengthy discussions with patients and their families about treatment preferences. Another challenge noted in the guiding principles is that performance-based payment systems usually measure patient outcomes for a single disease, which may encourage healthcare providers to overprescribe tests and procedures for elderly patients.

Yet still another obstacle to implementing the guidelines is that caring for older adults with many health conditions requires the coordination of services in various inpatient and outpatient settings, and all of these providers should follow the guiding principles, said Dr. Michael Malone, medical director for senior services at Aurora Health Care, a 14-hospital system based in Milwaukee. For example, he said, Aurora already has a program in place for hospitalized elderly patients in which multidisciplinary teams assess the patients' condition daily and identify the patient's most important concern. The challenge is applying that intensive, multidisciplinary approach in other settings where elderly patients are treated, he said.

“There are a lot of moving parts in the care of seniors with complex conditions—their medical needs, their medication needs, how they are functioning, how they are able to take care of themselves and their links to community services,” Malone said.

Despite these complexities in carrying out the American Geriatric Society's principles, Malone welcomes their “refreshing focus on patient preferences and on the kind of holistic approach to patients with multiple illnesses.”

This approach may pay off in lower costs in caring for elderly patients. According to a study published in the April 22 online issue of JAMA Internal Medicine, a multidisciplinary approach to caring for hospitalized elderly patients resulted in lower average hospitalization costs and fewer 30-day readmissions than standard care for elderly patients. Another study in the same issue concluded that specialized, multidisciplinary care for hospitalized elderly patients reduced the incidence of adverse events and shortened hospital stays.

In addition to calling for less use of medications and more emphasis on determining the preferences of patients and their families, the guiding principles also call for better coordination of care for elderly adults with multiple morbidities, more research on best practices in caring for older adults with several chronic health problems and changes to reimbursement policies to accurately reflect the amount of time that clinicians spend with these elderly patients.

The AGS published “Guiding principles for the care of older adults with multimorbidity:

A guide for clinicians” in the Sept. 19, 2012 online version of the Journal of the American Geriatrics Society.

The principles are based on a literature review and recommendations of a 12-member expert panel, which included physicians from academic medical centers, a nurse practitioner, a pharmacist and a physician from HHS. They are grouped in five domains: patient preferences, interpreting the evidence, prognosis, clinical feasibility and optimizing therapies and care plans. Within each domain are several suggestions regarding the care of geriatric patients, including that clinicians should:

• Inform elderly patients about the expected benefits and risk of treatment options using numeric data and then determine the treatment preferences of the patient and his or her family.
• Assess if evidence on treatment outcomes applies to elderly patients with multiple health problems.
• Consider the timeline of treatment benefits in light of the treatment's side effects, impact on quality of life and the patient's expected lifespan.

Julie Jacob is a freelance writer in Racine, Wis.

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