Enhancing Primary Care of Elderly People

F. Ellen Netting, Frank G. Williams

• Publisher: Routledge
• Year: 2014
• Print ISBN: 9780815325314
• eBook ISBN: 9781317777168
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This important work offers the first detailed analysis of recent changes in health care for the elderly. The contributors examine primary care in urban, suburban, and rural settings and show what makes each of these successful care-providers.

CHAPTER 1

An Overview of Primary Care and the Generalist Physician Initiative

Mark A. Sager, Frank G. Williams, and F. Ellen Netting

Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients and practicing in the context of family and community.

—Institute of Medicine, 1996

The growth and expense of the United States health care system have renewed interest in the potential of primary care practice to improve patient outcomes and control health care costs. This renewed interest in primary care represents a historic shift in emphasis away from sub-specialty-dominated high-level technical care toward a more integrated system of care capable of addressing a wide spectrum of personal health care needs. This reorientation toward primary care is supported by federal efforts to encourage the training of more generalist physicians and by the growth of health maintenance organizations, which rely on generalist physicians to provide first-contact care.

The re-emergence of primary care has also highlighted the limitations of our current primary care system. The structure and function of primary care reflect fiscal incentives which have rewarded episodic, urgent care and discouraged more broadly based efforts to maintain health. As a result, current primary care practice tends to be disease-oriented, office-based, and restricted to reimbursable services. This narrow scope of primary care has unfortunate consequences for an elderly population, which requires a more comprehensive system of care in which prevention and health promotion are integral components. These limitations threaten to exacerbate the economic and social consequences of an aging society in which the most rapidly growing segment is age 85 and over. Without improvement in the health of older persons, health care costs for this segment of the population alone are projected to increase sixfold in constant 1987 dollars by the year 2040 (Schneider & Guralnik, 1990, p. 2335). Cost-containment strategies alone will be insufficient to contain the health care costs of an aging population. The implication is that unless our society is willing to devote additional resources to health care in the future, medical care—especially primary care—must shift toward a proactive system of care in which the maintenance of health and function are primary goals.

The potential economic burden of an aging society and the urgent need to reform current medical practice are reflected in statistics from the Medicare program, which now accounts for 20% of all personal health care expenditures. Davis and O’Brien (1996) report that 29% of Medicare enrollees now have at least one disability in activities of daily living (p. 184), 26% rate their health as fair or poor (p. 185), and 44% are age 75 and older (p. 187). The poorer health status of the elderly is associated with a hospitalization rate four times that of the rest of the population (Levit et al., 1996). In 1994, 37% of all admissions to non-federal short-stay community hospitals were for care of elderly persons, and Medicare now accounts for 30% of this country’s spending for hospital services (Heffler, Donham, Won & Sensenig, 1996, p. 223). In constant 1987 dollars, Medicare costs are expected to double by 2020 (Schneider & Guralnik, 1990, p. 2337).

Physicians, like the hospital industry, have become progressively more dependent on Medicare funding. In 1994, 37% of the Medicare budget or $39 billion was paid to physicians (Health Care Financing Administration [HCFA], 1996, p.66). Medicare now pays for 19% of all personal health care expenditures to physicians, one-third of which are for office visits (HCFA, 1996, p.97). In 1994, Medicare enrollees made 537 million office visits, accounting for 48% of the 1.1 billion physician and supplier services provided in the program. Twenty-seven percent of these physician services were provided by general practice, family practice, and internal medicine physicians who received $6.5 billion or 17% of Medicare payments (HCFA, 1996, p. 190). Physicians listing geriatrics as a specialty received the lowest total Medicare reimbursement of any specialty, exceeding only the payments received by the specialties of pediatrics, nuclear medicine, oral surgery provided by dentists, and manipulative osteopathy (HCFA, 1996, pp. 324–325).

The low proportion of Medicare payments to physicians listing geriatrics as a specialty reflects the small number of physicians with formal training in geriatric medicine. A call to the Association of American Medical Colleges revealed that in 1995–1996 only 235 internal medicine and 32 family practice physicians were receiving training in geriatrics. The implications of this are clear. The majority of care for older patients will be provided by generalist physicians, most of whom will become increasingly dependent on Medicare patients to support their practices. In the Medicare program, the number of physician and non-physician services increases dramatically with age. This suggests that in the future, physician practices, and health care in general, will be increasingly dominated by the older patient and the special challenges of geriatric care.

The Challenges of Geriatric Care

Most elderly persons live healthy and active lives without significant functional disability or health-care resource consumption. However, within the geriatric population is a unique group of frail elders characterized by lowered physiological reserves and an increased risk of functional loss and long-term institutionalization. Age-related changes in physiology, pharmacology, and illness presentation make the health care of frail elders a challenge to the average clinician. The presence of multiple illnesses complicates diagnosis and treatment and significantly increases both the risks associated with having multiple providers and the likelihood of polypharmacological and iatrogenic complications. Frail elders are particularly vulnerable to the adverse effects of medications, not only because of age-related changes in drug pharmacokinetics and pharmacodynamics, but also because of the large number of drugs taken, many prescribed inappropriately. In one study, 24% of people age 65 and over received at least one of 20 drugs contraindicated in older persons (Wilcox, Himmelstein & Woolhandler, 1994, p. 292). The combination of adverse drug events, inappropriate prescribing, and poor compliance with treatment regimens make drug-related complications expensive and a potentially avoidable cause of 10 to 19% of nonsurgical hospitalizations in persons age 65 and older (Chrischilles, Segar & Wallace, 1992, p. 634; Grymonpre, Mitenko, Sitar, Aoki & Montgomery, 1988, p. 1092).

The health care of frail elderly persons is also characterized by many medical conditions not commonly seen in younger populations. These geriatric syndromes—falls and immobility, osteoporosis, dementia, delirium, urinary incontinence, visual and hearing impairments, and polypharmacy—represent a significant challenge to practitioners and a substantial cost to society. Twenty-five million Americans suffer from osteoporosis, of which hip fracture is the most serious consequence. Approximately 90% of hip fractures occur in persons age 70 years and older and 90% of hip fractures occur as the result of a fall (Grisso et al., 1991, p. 1326). The economic costs of falls, hip fractures, and osteoporosis alone are between $10 and $18 billion annually (Schua-Haim & Gross, 1997, p. 54). The personal costs of these geriatric syndromes in impaired quality of life and loss of independence are incalculable.

Previously uncommon conditions are now major public health problems in an aging society. Diseases like dementia that were once considered rare now affect 5% of the population over age 65 and up to 50% of those over age 85 (Evans, et al., 1989, p. 2551). The clinical landscape is therefore changing. Clinicians, many without formal training in geriatric medicine, are now being asked to care for increasing numbers of elders with chronic conditions that have medical as well as psychosocial consequences.

Approximately 13% of elders living in the community (as opposed to institutions) report visual impairment and 30% report hearing impairment. The prevalence of visual and hearing impairments increases to 28 and 48% respectively for those persons age 85 and older (Reuben, 1991, p. 160). Sensory impairments represent barriers to communication that would be expected to increase the length of an office visit by prolonging history taking and increasing the time required for explanations of treatment regimens. Nevertheless, information from the National Ambulatory Medical Care Survey (Sloane, 1991) and other studies (Radecki, Kane, Solomon, Mendenhall & Beck, 1988a, 1988b) consistently show that individual office visits for the elderly are shorter and less comprehensive than for younger patients. For women age 55 to 64, 61% received a breast exam and 56% a pelvic examination during a general medical examination, while the percentages of women age 65 to 74 receiving those same services were only 36% and 34%, respectively (Sloane 1991, p. 42).

Optimal geriatric care is distinguished by the need to identify and skillfully manage psychosocial, economic, and environmental problems that may be difficult to identify during a typical office visit. Social isolation, untreated depression, and inadequate support services are frequent explanations for noncompliance with treatment regimens, potentially avoidable hospitalizations, and premature long-term institutionalization. Comprehensive and potentially time-consuming psychosocial and environmental evaluations are not part of routine primary care practice and usually require a home visit. In one study, the home visit resulted in the identification of an average of four new problems, 23% of which could have resulted in death or significant morbidity. The most common problems identified related to psychobehavioral-, safety-, and caregiver-related difficulties (Ramsdell, Swart, Jackson & Renvall, 1989, p. 17). Importantly, clinical information obtained during an office visit could not predict the kinds of problems identified by the home visit, illustrating the potential benefits of extending primary care beyond the office visit for this population.

The complex and multifaceted psychosocial, as well as the biomedical, aspects of geriatric care require a broader focus by the geriatric practitioner. One way to achieve this broader focus is to employ interdisciplinary teams capable of assessing and managing illness and promoting well-being in older patients. Geriatric teams are most frequently composed of a physician, nurse, and social worker who work with pharmacists, rehabilitation specialists, and other professionals to provide and coordinate geriatric care. Interdisciplinary teams in outpatient geriatric programs have been shown to lower mortality and to improve patient satisfaction and functioning as well as the quality of health and social care (Engelhardt et al., 1996; Hendrickson, Lund & Strømgård, 1984; Melin, Wieland, Harker & Bygren, 1995; Rubenstein, Stuck, Siu & Wieland, 1991; Stuck et al., 1995; Toseland et al., 1996). However, because Medicare does not pay for many non-physician services, interdisciplinary teams in non-academic primary care settings are rare. When non-physician practitioners are employed in primary care practices, they are often limited to providing reimbursable office-based services.

The Potential of Primary Care

Integrated primary health care services that address a large majority of medical problems would seem to have the potential for providing high quality and efficient geriatric care. Long-term physician-patient relationships should allow for more comprehensive management of multiple problems, the substitution of less expensive outpatient care for hospital care, earlier communication about changes in condition, and more comprehensive health promotion and education. Available data suggest that elderly persons benefit from long-term doctor-patient relationships and are remarkably loyal to their physicians. In a representative sample of enrollees participating in the Medicare Current Beneficiaries Survey, 55% reported a tie to a physician of five or more years and 36% reported a tie to a physician lasting ten or more years. The benefits of these sustained physician-patient relationships were lower inpatient and outpatient Medicare costs (Weiss & Blustein, 1996, p. 1742). Having a usual source of primary care has been shown in other studies to improve patient satisfaction and reduce health care use without compromising quality of care (Institute of Medicine, 1996, pp. 62–63; Mark, Gottlieb, Zellner, Chetty & Midtling, 1996).

In spite of the potential benefits of primary care, the U.S. health care system has no clearly defined method for primary care delivery. In contrast to most industrialized countries, primary care in the United States is provided by diverse practitioners in a variety of settings and has been criticized for its narrow disease orientation. Poorly reimbursed aspects of primary care, such as patient education and health promotion, are often neglected by a system designed to respond to acute needs and characterized by an emphasis on diagnosis and treatment. For patients with chronic diseases, there is no integrated system of care that effectively combines disease management with the ability to provide a full range of coordinated personal health care services, including preventive and rehabilitative care (Franks, Nutting & Clancy, 1993; Wagner, Austin & Von Korff, 1996).

The potential benefits of reorganizing the primary care system and the weaknesses of the current system are illustrated in two randomized controlled trials, the Hypertension Detection and Follow-Up Program (HDFP) and the Diabetes Complications and Control Trial (DCCT). These clinical trials evaluated therapeutic interventions for both diabetes and hypertension and incorporated comprehensive efforts into their design to develop and reorganize the medical care delivery system for patients with these diseases. In both the HDFP and the DCCT trials, models of care were designed to improve follow-up, the frequency and quality of systematic assessments, and patients’ involvement in the management of their illnesses. Importantly, each trial delegated major aspects of care to non-physicians to improve the continuity and comprehensiveness of care management. The findings were impressive. The HDFP trial reduced mortality by 17% (Hypertension Detection and Follow-Up Cooperative Group, 1979, p. 2562) and the DCCT Research Group trial significantly reduced the complications of diabetes (Diabetes Complications and Control Trial Research Group, 1993). Although both of these clinical trials were designed to test disease-oriented therapies, their outcomes emphasize the importance of reorganizing primary care into collaborative teams for better chronic care management. Primary care of elderly people should be no less likely to benefit from an organized effort to enhance and broaden primary care services.

The organization and economics of primary care in the United States have worked to restrict non-hospital practice to physicians’ offices and to discourage a team approach to patient care. The narrow focus of current primary care, centered around an office visit, limits opportunities for intervention and prevention. In one study, an in-home preventive assessment program conducted by trained volunteers identified an average of four new or sub-optimally treated conditions in a community dwelling population age 70 and over. Home visits at 4-month intervals achieved a 31% reduction in smoking, a 94% compliance rate with recommendations for vaccinations, and improved functioning among participants (Fabacher et al., 1994, p. 630). In another study, the therapeutic benefits of in-home assessment and monitoring were evaluated in a 3-year randomized and controlled trial in which persons age 75 years or older were visited every three months at home by a nurse practitioner working in collaboration with a geriatrician. The nurse practitioner made recommendations for self-care (e.g., exercise, medication management), identified new or suboptimally managed conditions, assisted with community services, and monitored for compliance with recommendations and changes in condition. The intervention significantly reduced disability and long-term nursing home placement in the experiment...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Foreword
• Abbreviations and Acronyms
• Acknowledgements
• Introduction: Medicare Managed Care and Primary Care for Frail Elders
• Chapter 1 An Overview of Primary Care and the Generalist Physician Initiative
• Chapter 2 Complementary Geriatric Practice Model
• Chapter 3 Collaborative Care Teams
• Chapter 4 Advanced Practice Nurses as System-Wide Case Managers for Internists
• Chapter 5 A Collaborative Model with Nurse Practitioners and Social Workers
• Chapter 6 Physician Assistants in Urban Neighborhood Health Centers
• Chapter 7 Primary Care Physician, Nurse, and Social Work Collaboration in the Care of Community-Dwelling, Chronically Ill Elders
• Chapter 8 An Effective Managed Care Strategy: Case Managers in Partnership with Primary Care Physicians
• Chapter 9 Cost Effective Care Coordination in the Rural Physician's Office
• Chapter 10 How Understanding the “Patient's World” Can Improve Geriatric Care in Physicians' Busy Practice Settings
• Chapter 11 The Physician and Care Coordinator: A Chronic Care Partnership
• Chapter 12 Lessons Learned Across Sites
• Contributors
• Index