Coordinating Care for Geriatric Patients


Stephanie Chow, MD, MPH: The final m is: what matters most. For me, as a geriatrician, this is easily the most important. What matters most to a patient is the general question that there is no right answer because it’s specific for that individual. For a geriatrician, centering medical care and social work care on this single or multiple identified thing is very important. It should guide the medical decision and the planning around what we should do to give this older patient the highest, best quality of life possible in the time that we are given. This is a very easy tie into advance care directives in discussions of goals of care.

When an older individual tells you what matters most—perhaps their family, perhaps staying independent and within the community—this will guide how you ask the questions of, “Well, what would happen if you were to unfortunately experience a catastrophic health event? What happens if you were to have a heart attack, your heart were to stop, or you were to stop breathing?” Reflecting on what is most important to them in navigating into the difficult conversation of what you would do if you were not able to have some of these things is a difficult but necessary conversation for a geriatrician or a primary care provider to have.

It’s also important to note that the advance care planning conversation is something that should happen frequently along the trajectory of an individual’s life. There are many different points where you can have this conversation. We understand that there are many factors that often discourage a provider, a physician, from having this conversation in the first place. Sometimes there’s not enough time. Sometimes there’s discomfort on the part of the patient, the family, or even the provider. Sometimes there is just not enough knowledge. Sometimes there is a reimbursement issue. And sometimes, frankly, there are many different, competing things. Maybe there are other comorbidities, or chronic conditions to talk about? Understanding when to insert this into a conversation is a very important skill, and geriatricians do this frequently with patients.

Ideally, the best time to have this advance care planning discussion is during the healthy period of an individual’s life, when you’re ready to talk about a prognosis and what would help—what would be of benefit to having a certain procedure done or undergoing a surgery. So this is kind of prophylactic advance care planning for the healthy individual. And discussing screening measures. Do they need more mammograms, colonoscopies, Papanicolaou tests? Sometimes you can use a generic 75-year-old cutoff. More importantly, or better still, you would talk to the patient about what their functional status is, their prognosis, what their goals are, and what matters to them, and use that to guide decision making in regard to what kind of interventions, screenings you and the patient would like to proceed with. The patient is the primary director of this conversation.

There are other important times when you would insert this conversation. Perhaps if there was a specific chronic condition that had a decline in status—congestive heart failure, asthma exacerbations, or some other exacerbations that might lead the individual to go into the hospital or emergency department, or even into your own clinic for an urgent visit. These might be times when you would want to have this conversation. It doesn’t have to take an hour, but if you periodically address it, this will be a conversation that is dynamic and changes as the patient progresses—as the individual moves through their life.

Many times, this conversation is triggered toward the end of life when the condition becomes very severe. Your hope, as a geriatrician, would be not to have this conversation at the very end but to have it along the life span of the individual, so it becomes easier for the patient, the health care proxy, and the caregivers to really have this in a thoughtful and deliberate way, to carefully account for all the things that matter the most to the patient.

It’s important for an individual to carefully choose their health care proxy. It doesn’t have to be the one they see all the time. It does have to be someone who knows the individual well and is comfortable with receiving information and conveying the information back to the health care provider should they need it. This should be an individual who responds fairly under stress and would be reachable for the physician or the health system should they be trying to find out more about the individual’s wishes. A health care proxy doesn’t always have to be the person who’s sitting right next to you, but it does have to be somebody who really understands your values and knows how to communicate them back to the health care provider should the time come. It’s also important to stress to the patient that naming a health care proxy doesn’t remove their power of autonomy and decision making. The health care proxy is just somebody who comes into place should the individual not be able to express their wishes and their values.

At the Icahn School of Medicine at Mount Sinai in New York, where I work in the Department of Geriatrics and Palliative Medicine, we do have a high-risk clinic that is interdisciplinary. Now, granted, the entire clinic, the outpatient clinic at the Martha Stewart Center for Living, is a very interdisciplinary geriatric clinic. This is a clinic for the care of older adults. We also have a segment where we focus on very close dynamics among social work, care coordination, nursing, and the physician. We also have many learners who come through: fellows, residents, and medical students. It’s very important to keep this open communication via morning huddles, afternoon huddles, lots of staff messaging, telephone calls, secure e-mails. There are multiple ways to convey the information. We have patients who require complex care coordination and with multiple specialists, even outside our clinic. And so for patients who often have difficulty with organizing their care and, perhaps, even remembering their care, it is really important for us to have very tight communication. The communication messages should be very clear.

It’s really difficult for patients, when they’re discharged from the hospital, to remember all that has happened to them while they were there. They were sick. They were maybe delirious. A lot of things happened that they can’t remember. And so if you can only imagine for our older population what it would be like to really understand what happened—they perhaps couldn’t see what was happening, or they couldn’t hear what was happening. They were drowsy. They were poked and prodded, and they also, at baseline, have trouble remembering things.

There are a lot of things. There are a lot of greater challenges that they may have. So to have a good transition of care from the hospital back to the home, or to the nursing home, or wherever it is that they are discharged to, it’s important for somebody—the managing team or medical provider—to contact the patient or their caregiver to make sure there is a good understanding of the medications that have changed, the instructions to the patient, and perhaps the hospital course. It’s important for there to be a very quick follow-up with the primary care team or with a medical provider, within a week or 2, ideally. It’s important to maintain that open communication.

Transitions of care has become a very big proponent of reducing rehospitalizations or readmissions, and it’s something that geriatricians work very hard to avoid. Having the patient in the hospital for unnecessary reasons can often cause more harm than good. We would rather keep our patients in the community, especially if that’s what matters the most to them. This communication in transitional care—examining that and finding a way to reduce the bounce backs, or their readmissions—is very important.

Transcript edited for clarity.

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