Health and Long-Term Care Program Integration

The extent to which geriatric medicine should, and can, be integrated into the delivery of health care and long-term care is not yet resolved. Historically, some HMOs have used geriatricians as part of their primary care practitioner group but have not allowed these physicians to limit their practice exclusively to geriatric patients. Another model for practice is to have geriatricians (or a geriatric team) provide care and management to the most frail and vulnerable elderly within a system. This is implemented through screening programs, such as those noted earlier, that identify and refer new members who are frail (or current members who have become frail) into this specialty practice for ongoing primary care. Such a model requires a large elderly enrollment to generate a cost-effective practice volume. A variant on this model uses geriatricians as specialist consultants for assessment and advice with ongoing treatment. The patient remains under the care of the regular primary care physician. These two models can be used in combination (Friedman and Kane).

A further variation on the above involves the use of multidisciplinary teams (i.e., nurses, social workers, and/or other health professionals) in conjunction with the primary care physician. This model recognizes that geriatric training is generally more common among nurses and social workers, and it allows for case monitoring to occur through means other than office visits and to encompass care plans that go beyond purely medical treatment. In many cases geriatric nurse practitioners (GNPs) or adult nurse practitioners may assume responsibility for basic primary care, freeing the geriatrician's time for more complex cases. These team models can operate as components in ambulatory care clinics or as adjuncts to the home care program. Such teams are perhaps more common in hospital inpatient and nursing home settings. Under these inpatient circumstances the team likely replaces the patient's primary care physician until the patient returns to the community.

One area where GNPs have been used to good advantage is in providing primary care to nursing home patients. A corporation, EverCare, has developed a cost-effective managed care approach to capitating the acute care of nursing home patients, using GNPs as the major source of primary care. The underlying premise of this approach is that closer attention to the nursing home residents' primary care needs will reduce the use of more expensive hospital care (Kane and Huck). EverCare is being demonstrated at six sites across the country. As it has been implemented, some changes have been necessary. The participating physicians are recruited from those in the community who are already active in nursing home care. Because sufficient numbers of GNPs are not always available, adult nurse practitioners are sometimes used instead.

The relative value of any of these approaches is largely untested, but as a practical matter the choices made by a health plan and medical groups more generally are constrained by the size of their Medicare enrollment and by the limited availability of geriatricians.