Elizabeth L. Cobbs MD
With market forces encouraging the decentralization of health service delivery to the outpatient arena, the office practice serves as the backbone of health care for older adults. The elderly visit outpatient physicians at least 150% more frequently than the general population. This trend is expected to continue in the coming decades, especially in those older than 75, whose visit volume is expected to quadruple. The office practice must be prepared to address multiple aspects affecting the health of older persons, from prevention to end-of-life care (Table 5-1).
A successful outpatient practice must have a sound financial basis, be able to manage costs and produce adequate revenues, and achieve improvements in value over time as market forces continue to shape the external practice environment. Most physicians accept Medicare assignment, which limits revenue reimbursement for “cognitive” practices. Billing evaluation and management codes should reflect the time and effort given by the clinician in the process of evaluation and care of multiple and complex medical problems that are addressed at frequent intervals.
Although current systems for compensating physicians do not directly reward quality and service, practices can achieve financial rewards while maximizing quality and service. Fee-for-service (FFS) reimbursement (as in traditional Medicare) pays for traditional office visits but may not compensate providers for other forms of care (eg, group visits, nonvisit care). The complexity of the visit determines the relative value units (RVUs) and, in turn, determines the level of provider reimbursement for the visit. Financial success is achieved when providers maximize complexity of visit billing in adequate volume. Internal systems for scheduling (eg, open access or same-day scheduling methods) may reduce no-show rates and achieve higher visit volumes. Managing uncomplicated matters without an office visit may pay off in the long term, saving valuable office time to be used for visits that generate a higher level of reimbursement. Providers should seek to do as much as possible for each patient during a visit, thus maximizing the RVU and increasing efficiency of the visit.
Group visits (including several patients, the physician, and other members of the health care team) may be useful even under the FFS model for reimbursement. Group visits, typically lasting 2 h, should always be voluntary and might increase the patient's satisfaction with care as well as quality of care outcomes. Physicians save time by delivering patient education to multiple patients at once. Group visits emphasize self-management of the chronic condition and enhance opportunities for peer support and regular contact with the clinical team. Patients have opportunities to ask questions and gain information in the setting of a supportive peer group. Group visits have been reported to reduce emergency department visits and to improve access to certain aspects of care.
Capitated reimbursement encourages providers to develop innovative and potentially non-visit-based services to meet their patients' needs. Providers are motivated to increase their panel size (or number of capitated patients) while minimizing overhead costs. Capitated systems of reimbursement provide incentives
to providers to manage their panel of patients more effectively, whereas FFS systems provide incentives to increase the number of complex visits in caring for their patients.
Table 5-1. Scope of services in office practice for older adults.
Health Maintenance Organizations
The financial incentives for providers will necessarily have an impact on the kinds of services offered. Health maintenance organizations (HMOs) have provided care for older adults in many regions throughout the United States for the past 2 decades. One managed-care model serving older adults uses nurse practitioners as care managers to integrate social and medical services and provide comprehensive after-hours coverage for urgent-care needs. Providers have a strong incentive to avoid hospitalization if possible and to address geriatric issues (eg, falls, depression, incontinence, exercise, hearing loss, medication use, advance directives).
Most clinicians believe that the quality of care for the elderly is strongly influenced by the communication between patient and clinician.
Communication with old-old patients can be enhanced in the office by using some practical techniques:
Computer use is increasing among older adults and their caregivers and offers a viable tool for enhancing health outcomes. Computer technologies assist providers and patients in the management of chronic diseases by educating providers and patients, identifying nonadherence, and monitoring individual and population outcomes. However, computer use may be deterred by losses in manual dexterity and visual function.
The patient's primary caregiver should be asked to accompany the patient to the office for the first visit so that the main reason for the visit can be identified and quality of care assessed. When the frail patient has difficulty communicating and appears without the family member or friend who scheduled the appointment, the reason for the office visit may remain unclear.
The role of the physician needs to be clarified with the patient and caregiver. Some patients may prefer a brief opinion regarding their health problems in the form of a consultation, whereas others are interested in establishing a primary care relationship.
The patient's living arrangement (nursing home, assisted-living facility, or private residence) and modes of transportation available (and impediments to follow-up office visits) need to be documented. The patient's other family caregivers should be identified and a guardian, power of attorney, or health care advocate should be assigned. Prescription and nonprescription medications as well as alternative treatments should be reviewed; patients should be instructed to bring all their medications with them on the first visit. All of this information can be obtained by asking the patient or caregiver to complete a questionnaire in advance of the patient's initial appointment.
A screening office assessment streamlines the evaluation (Appendix). Trained office staff can complete the
10-min screen before the physical examination. For further initial evaluation, several efficient techniques are available.
Hearing & Visual Impairments
Screening can be done with written and verbal instructions. To check visual acuity, ask the patient to read a few lines from a newspaper or read numbers on a hand-held chart. To check for significant hearing impairment, perform the whisper test by asking the patient to repeat a short list of numbers whispered by an examiner positioned 2 ft behind. The degree of hearing impairment can be quantified with a hand-held audioscope.
The Clock Drawing Test can be used to screen for memory impairment. Patients are asked to draw the face of a clock with hour and minute hands to a specific time.
If cognitive impairment is suspected, document the magnitude and area of impairment using the Mini-Mental State Exam (Appendix).
Balance and gait disorders are common and are associated with an increased risk of falling. The Up and Go Test assesses balance and gait by having the patient stand up from a chair, walk a short distance, turn around, and sit down again. A Timed Up and Go Test, >20 s, may predict the risk of falls in the next year. The Functional Reach Test measures balance. Have the patient stand next to a wall, with feet stationary and 1 arm outstretched, and lean forward as far as possible without stepping. A reach distance of <6 in. is considered abnormal and warrants further evaluation.
Arm & Hand Function
Upper extremity dysfunction can easily interfere with self-care activities. Assess arm and shoulder function by asking the patient to place both hands behind the midback and raise them above the head. Evaluate hand and finger dexterity by having the patient pick up small objects, such as coins, from a flat table surface. Consider referral to physical or occupational therapy if the patient has difficulty with these activities.
Urinary incontinence is an often underreported symptom that can jeopardize older persons' independent living. Ask patients whether they have “lost urine and gotten wet.” If yes, further office evaluation or referral to a specialist is warranted.
Anxiety and depressive disorders affect many older adults. Ask the patients whether they often feel sad (possible depression). If yes, quantify the extent of depressive symptoms with a questionnaire such as the Geriatric Depression Scale.
A targeted physical examination saves time on the initial office visit by deferring certain parts of the customary examination (eg, funduscopic examination) that are not immediately necessary. Check for orthostatic hypotension, pressure ulcers, signs of malnutrition, and signs of physical abuse. Perform brief neurological (gait, muscle strength, balance), cardiovascular (pulses, murmurs, heart rhythm), and abdominal (bruits, masses) examinations.
Brief assessments can identify patients with new or potential medical problems that warrant further evaluation:
GERIATRIC SYNDROMES, CHRONIC DISEASES, & CONDITIONS
Many of the most common chronic conditions (Table 5-2) and their associated disabilities are preventable. Disease management guidelines and targets for diseases (eg, hypertension, diabetes) are increasingly available. Information systems that provide clinical reminders are effective in improving long-term selected outcomes. The office practice should maintain a system of clinician reminders and tracking of select outcomes. Patient educational materials for common diseases and conditions should be on hand.
Specialty care has been shown to improve outcomes in some instances and should always be considered when conditions become progressive and difficult to treat. Other disciplines (eg, physical, occupational, and speech therapy) are helpful adjuncts to care. Selected complementary and alternative medicine should be considered.
Table 5-2. Aging and chronic diseases.
Clinicians must periodically screen for geriatric syndromes and chronic conditions because they often go unreported (eg, urinary incontinence). Such syndromes may also be correlated with others (eg, depression).
The use of practice guidelines and consensus statements for various chronic diseases presents challenges. Guidelines for prevalent conditions (eg, dementia) frequently differ in content, methodology, and recommendations. Clinicians must be continually evaluating new evidence guiding various aspects of screening, diagnosis, and treatment.
The phenomenon of elder mistreatment has become increasingly recognized. Although evidence is lacking for screening effectiveness, clinicians should maintain an awareness of risk factors for elder mistreatment and local resources for referral.
Although most geriatricians acknowledge that physicians are responsible for reporting patients who are potentially dangerous drivers and are willing to take action, many do not know how to do so. Clinicians should be aware of their state laws governing reporting of driving safety concerns.
Many problems that are common in younger adults persist into late life and respond to similar interventions. Older persons benefit from substance abuse screening and intervention to prevent and reverse morbidity. Although alcohol is the substance most frequently abused, prescription sedative abuse and narcotic abuse also occur.
INTERDISCIPLINARY COLLABORATION & CARE COORDINATION
An interdisciplinary, comprehensive approach to patient care is the hallmark of geriatric medicine. It is necessary to collaborate with other health care professionals (eg, therapists, specialists, nutritionists, social workers), other professionals (eg, financial advisors, lawyers, pastors) who may aid comprehensive planning, local (eg, Offices on Aging and the Area Agency on Aging) and national (eg, Alzheimer's Association, adult day health programs, Meals on Wheels, senior nutrition programs) resources, care management services to coordinate interdisciplinary care.
Integrated systems of care promote comprehensive geriatric management and goal-directed service coordination. Collaboration with community service organizations eases the patient's transition from hospital to home or through short-term skilled nursing care. The primary physician serves as the patient's advocate through the system of health services by integrating recommendations and treatments into a coherent plan that serves the patient's best interests. Continuity of care is enhanced by involvement of the primary care clinician (eg, communicating key information to other health professionals about the patient's history, values and preferences for care, and previous functional status). The records of outside providers are incorporated into the patient's office record.
PHYSICAL ENVIRONMENT OF THE OFFICE
The physical environment of the office practice influences accessibility, effectiveness, efficiency, safety, and patient and family satisfaction. Ease of access depends on, among other factors, the availability of transportation, parking, and wheelchair accessibility.
Patients with functional deficits may need assistance in moving to the examination room, undressing, and climbing onto the examination table. An adjustable electric examination tables save time and enhance comfort.
Extra space is needed in examination rooms to accommodate caregivers and wheelchair-bound patients and their families. A handicap accessible bathroom must be available. Good lighting and contrasting colors in signs and interior design are helpful for visually impaired patients.
Preventive care is a major focus of office practice. Substantial variation exists among practice sites in the provision of preventive health services, suggesting that
there are opportunities for many practices to improve preventive care.
Immunizations are widely underused. Immunization recommendation by a health care provider appears to be a key factor in whether an adult will be vaccinated. Adults who are medically underserved are at particular risk for underimmunization.
Decisions about cancer screening for older adults must be individualized to integrate quantitative concerns (risk of cancer death, benefit of outcomes) and qualitative factors (patient preferences). Cancer screening recommendations vary by guideline source and fail to incorporate burdens of other disease states that older persons often have. Various strategies may be used to promote screening practices. The frequency and continuity of office visits are linked to the provision of preventive services such that more, not fewer, office visits are needed to achieve preventive health services targets.
SYMPTOM MANAGEMENT, PALLIATIVE CARE, & END-OF-LIFE CARE
The management of pain and other adverse symptoms associated with chronic disease (eg, dyspnea and chronic obstructive pulmonary disease) is an important aspect of geriatric office practice. Recognition of pain as the fifth vital sign has resulted in the availability of a number of tools for assessing and monitoring relief.
Interdisciplinary care is helpful to develop comprehensive care plans and identify additional resources to help patients and families. Palliative care may accompany treatments aimed at cure or disease modification.
Hospice consultation should be considered when serious conditions progress and when death would not be unexpected.
Patients who wish to be at home through end of life need coordinated services to ensure the delivery of appropriate and timely services, support families and caregivers, and achieve effective end-of-life care (eg, symptom management, death pronouncement, family bereavement).
Goals of Care & Advance Care Planning
The office practice is the natural locus for advance care planning. The process of developing goals of care extends throughout the course of care. For those patients who have the capacity to make health decisions, clinicians provide information about treatment choices with the attendant risks, benefits, and burdens and counsel patients on medical choices. If the patient has an impaired capacity to make health care decisions, a surrogate decision maker should be identified and counseled. Health decision aids may facilitate shared decision making, but the key element is the ongoing dialogue and understanding between the patient and clinician.
Role of Caregivers & Families
Older patients are often accompanied to the office visit by a third person (eg, spouse, adult child, caregiver, or friend), who may be an advocate, a passive participant, or even an antagonist.
Ask the patient in private whether permission is granted for the third person to be present in the examination room. Even with permission granted, it is a good idea for the practitioner to spend some time alone with the patient during each visit.
Accurate assessment of medication use is problematic. Even when patients are asked to bring in all their medications, the list of medications generated is in accord with the lists generated during a visit to the home only about 50% of the time. Vitamins, herbal remedies, and minerals are typically overlooked.
Specific prescribing problems include dosage, duplication, drug-drug interactions, and duration.
Periodic drug regimen review is recommended, especially when benzodiazepines and nonsteroidal anti-inflammatory drugs are prescribed. Communicating with the pharmacist may also be useful, depending on the practice setting. Cognitive function is linked to the ability to take medications independently. Caregivers should be asked to help monitor medication adherence.
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