Is It Time to Redefine the Geriatric Care Model?
Geriatric care in a provider setting has traditionally focused on addressing whatever acute condition required the patient’s hospitalization. This could range from an older patient presenting at the Emergency Department with stroke, heart attack or a broken bone resulting from a fall to a scheduled surgery, physician-ordered observation or medical procedure that requires a clinical setting. Once the in-patient care is no longer medically indicated, the patient is either sent to rehabilitation, a skilled nursing facility or home to continue their recuperation.
While this model has adequately served both providers and their older patients, this does not mean it currently meets, or will meet, the changing needs of a rapidly expanding elder population. Seniors today, more than ever, understand the difference between “life span” and “healthy life span” and are looking to the medical profession to help them have a good quality of life for as long as possible.
Given that the U.S. Census Bureau predicts that by 2030 older people will outnumber children for the first time in the nation’s history, providers should be actively rethinking geriatric care in general, and their role in particular, to better meet the increasingly varied health demands and needs of this population.
What will (or should) this reimagined geriatric care look like and how will it benefit both providers and the communities they serve? The first thing to know is that it will not be limited to how geriatric care is currently understood and practised. Routine medical care and acute interventions will, of course, be a key element given the number of age-related diseases and conditions that seniors face, often at the same time, as they get older. But what will be different is the scope and range of physical, emotional and even spiritual support that this 360-approach to geriatric care will need to encompass.
It also will require a significant change in perspective from “we are here to cure you” to “we are here to support you in having a full and healthy life.” Advances in geriatric care have done wonders in helping people have a longer healthspan, which basically means being free of disease and disability, having good cognitive function and being socially engaged. However, it does not fully consider that social factors account for most poor health outcomes. For this, the new geriatric model needs to help foster and promote an ecosystem that supports maximizing the number of healthy years in a lifespan versus just adding more years to it.
Why a Change is Needed
Most people, both within and outside of the healthcare profession, know that eating a well-balanced diet, getting enough sleep and exercise, seeing a doctor regularly for preventative care and staying connected to family and friends are important for healthy aging. What is not as well-known is the influence that various elements of daily life – such as the community where someone lives, the type of housing they have, their lifestyle, access to convenient healthcare and other more subjective elements of life, such as perceived security, have on the possibility of achieving healthier longevity.
What also may not be as well understood or appreciated, is how these factors are usually interrelated in a synergistic way – both positive and negative. For example, a person may have a wonderful home. But if this home, because of location, family situation or design, fosters isolation and loneliness, then it poses a significant health risk to its residents. In fact, some experts theorize that loneliness can cause as much damage as smoking almost a pack of cigarettes a day.
At some point, most elders will begin to have limited mobility. This could be the outcome of an age-related condition such as advanced arthritis, osteoporosis, loss of muscle strength or obesity. No matter the cause, this lack of mobility can turn any house into a major risk factor for falls, which are the leading cause of fatal injury and the most common cause of nonfatal, trauma-related hospital admissions among older adults.
Limited mobility, especially when the person is no longer able to drive or easily walk to public transportation, creates an additional health risk by making it more difficult to access services and places that are important for healthy aging. These include doctors and other healthcare providers, places of worship, senior social centers, stores and recreational facilities. This lack of access can result in more loneliness and reduced quality of life, which may contribute to an increased risk of developing new or worsening existing, age-related diseases.
Another element of this healthy longevity ecosystem that can, at times, be difficult to address is elder security. This includes not just having a safe place to live, but also feeling secure and being secure in other life areas, such as finances, housing, healthcare, food and transportation. Worry and concern for these insecurities can contribute to chronic stress, which has been shown to increase the risk of developing chronic inflammation, mental health problems, obesity, cardiovascular disease and gastrointestinal problems. It is clear that the reimagined model of geriatric care needs to address these insecurities to promote senior health.
It also includes being safe from elder abuse in all its forms. This is critical since an estimated 10 percent of older adults over the age of 60 suffer some form of elder abuse. The actual number is probably much higher since many experts believe many cases of abuse are not even reported. And this abuse is probably far wider ranging than many people think (or want to believe), covering the gamut from physical abuse and sexual abuse to financial abuse and emotional abuse. It also, sadly, includes abuse that elders inflict on themselves either because of depression or cognitive decline as well as healthcare abuse.
A New Vision for Geriatric Care
In an ideal world, providers and organizations – both public and private – would be able to join forces to readily design, create and manage a healthy longevity ecosystem that addresses the diverse needs of an aging population. This ecosystem would need to be integrated and synergistic in a way that would be both operationally and financially feasible.
But while this vision is not yet fully a reality, there are, however, programs and services – most notably in healthcare and in community design – that give a glimpse of how it would work. In the area of healthcare, for example, more and more providers are seeing the economic and community health benefits of developing and offering “Hospital at Home” programs.
Originally developed by the Johns Hopkins School of Medicine and Public Health, these programs allow patients to either recuperate or be treated for a variety of conditions in their homes rather than in the hospital. They routinely include daily visits by nurses or other healthcare professionals with both doctors and nurses on-call 24/7 for any emergency situations. In addition to being popular with both patients and their caregivers, these programs have been shown to lower costs by nearly one-third while reducing medical complications that could develop with in-patient care.
Another program developed at John Hopkins to promote healthy longevity is what is known as “Community Aging in Place – Advancing Better Living for Elders (CAPABLE),” which provides home-based nursing, occupational therapy and repair services for low-income older adults to increase mobility, functionality and capacity to age in place.
And, for older patients requiring in-patient care, various providers are taking steps to increase the likelihood that patients can transition directly to their homes versus to a nursing facility. This is important since around one-third of patients over age 70, and over half of patients over 85, leave the hospital more disabled than when they arrived, according to a recent study in JAMA.
One example of such a program is San Francisco General’s Acute Care for Elders (ACE) ward. This is a specialized unit whose focus is on helping patients foster their independence so they can return to their homes. Patients are encouraged to be mobile, eat in a communal dining hall and practice taking care of themselves as much as possible. Such units have been shown to reduce hospital-inflicted disabilities, lengths of stay and the number of patients discharged to nursing homes.
Just as important as adapting healthcare to the changing needs of older patients, the healthy longevity ecosystem also needs to address how and where they live to increase social interaction, reduce the risk of isolation and related emotional challenges, enhance mobility and help seniors feel more secure (in all senses of the word).
One model, and one that is becoming increasingly popular in various areas of the country, is what are known as either Continuing Care Retirement Communities (CCRC) or Life Plan Communities. Today, there are some 2,000 of these communities around the country and annual spending by residents on CCCRC is estimated to continue to rise through 2026.
These communities offer a “one stop shop”, as it were, of everything an older person could need for healthy aging, from independent living to assisted living to skilled nursing care, and from memory to end-of-life care. They also usually offer a range of social activities to keep residents engaged.
There also are programs designed to increase elder independence, mobility, social interaction and ready access to healthcare. One example is Vermont’s “Support and Services at Home” (SASH), which takes a multi-disciplinary approach to help that state’s residents live independently at home.
Achieving this new vision for geriatric care will require the commitment of government, private and public payers, community leaders and others. And providers – given their unique understanding of gerontology and experience in treating the elder population – are in a unique position to not only play a key role in redefining the future of geriatric care but to also be the catalyst for its realization. Doing so would help them fulfill their commitment to protecting the health of the communities they serve while creating new revenue opportunities that could positively impact their bottom line.