geriatrics
Overview of Geriatric Care
Geriatric Interdisciplinary Teams
Geriatric interdisciplinary teams consist of practitioners from different disciplines who provide coordinated, integrated care with collectively set goals and shared resources and responsibilities. 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 practitioners 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 the following: That patients move safely and easily from one care setting to another and from one practitioner to another That the most qualified practitioner provides care for each problem That care is not duplicated That 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. Recent evidence has pointed to the importance of providing 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. Practitioner team members must treat patients and caregivers as active members of the team—eg, 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 drug treatment, rehabilitation, dietary plans, and other therapies, and these treatments and plans should align with patient preferences. Practitioner teams should respect the patients' and caregivers' ideas and preferences (eg, if patients will not take a particular drug or change certain dietary habits, care can be modified accordingly). Patients and practitioners 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 practitioners adjust their communication to a level that patients can understand. Capacity (Competence) and Incapacity 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. 