Fitting the growing geriatric population's complex and chronic healthcare needs into today's fragmented health system is like putting a round peg into a square hole, many suggest.
Among those looking for better geriatric care solutions -- University of Pennsylvania nurses Mary Naylor, PhD, RN, FAAN, and Nancy A. Hodgson, PhD, RN, FAAN, who chaired a think tank called Assuring High Value Care for Vulnerable Older Adults and their Caregivers: Maximizing the Contributions of Nurses. An invitation-only list of health system leaders, policymakers, innovators, consumer advocates and scholars gathered at the meeting to recommend ways to improve the U.S. health system for older adults with complex chronic conditions. The May 2018 meeting spawned actionable recommendations for transforming care delivery for the more than 40% of older Americans living with four or more chronic illnesses. The Gerontologist journal is expected to publish the meeting's full report this fall. Hodgson, the Anthony Buividas term chairwoman in gerontology at the University of Pennsylvania School of Nursing (Penn Nursing), shared important points for nurses -- not only about the initiative, but also how its recommendations might impact the profession. "We know that there are models of nursing care that would do well in terms of value to address chronically ill older adults," Hodgson said. But many are not yet scaled into routine practice. This isn't a nurse-only initiative. In fact, nurses represented only about a handful of those at the meeting, according to Hodgson.
"We were trying to see where nurses could be leveraged in this crisis," she said. "We recognize that nurses are key members of interdisciplinary teams. But we felt there was a strong role that nurses could provide and, in the future, nurses could be leveraged as leaders because we have the skills to address this crisis. That's really what we wanted to convene this group to think about."
Why geriatric care is a key healthcare issue
Aging patients' increasing healthcare complexity is an important issue, Hodgson said. "We know that the majority of older adults have at least one chronic condition," she said. "Up to 40% have four or more chronic conditions, which adds to the complexity of care in the way they present complaints and symptoms. It also indicates that they're probably on multiple medications and multiple treatment regimens that add to complexity. They're being cared for increasingly by family members, who do not feel prepared to take on that complex care. And they encounter a very fragmented health system, so there is not communication across care providers. I think nurses are there to pick up the pieces. We're there at every point of care for older adults." Among the geriatric care solutions to emerge from the meeting:
- Creating seamless electronic health record systems that could talk to multiple points of care. Although some health systems are beginning to move in this direction, the experts honed in on more extensive use of EHRs, with hospitals easily communicating to nursing homes and home care.
- Leveraging technologies and innovations that are happening in other industries, with nurses being among the innovators. Technologies that innovators might leverage include wearable technologies that interface with clinicians and using mobile phone apps for easier patient-provider communication. Experts at the meeting suggested that technologies clinicians use to provide care for older adults must be user-friendly.
"Currently, some of these things exist but older adults have a harder time navigating [these technologies]," Hodgson said. "Nurses could be well positioned to help facilitate their interacting with technology and also in working to create new technology that's more user-friendly." The full report will include all the think tank's recommendations. The report's themes will address:
- Overcoming barriers for using evidence-based care models in practice.
- How nurses can partner with consumer advocacy movements to advance agendas aimed at helping older adults living with chronic conditions.
- How to position nurses to advance innovations to better geriatric care.
What nurses can do today
Hodgson said it's important for nurses to be aware of policy changes focused on advancing care for people living with chronic conditions. One is the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act, which will go into effect in 2020 and was part of the Budget Act of 2018. The CHRONIC Care Act is specific for Medicare and Medicare Advantage plans and puts more emphasis on telehealth and other creative options for providing coverage for people living with chronic diseases, Hodgson said. The other is the Caregiver Advise, Record and Enable (CARE) Act, which AARP supports. It recognizes and backs family caregivers' increasing roles in caring for adults with chronic health conditions. Another, the Recognize, Assist, Include, Support and Engage (RAISE) Family Caregivers Act, requires the Secretary of Health and Human Services to develop, maintain and update a strategy to recognize and support family caregivers, according to AARP.com. "These are some examples of policy shifts that will influence nursing care, as we try to recognize the role of family caregivers, for one, and come up with more creative strategies that Medicare will reimburse to help these older adults with chronic conditions," Hodgson said.
The aging clock is ticking
The ever-increasing geriatric care population and ill-equipped healthcare system to care for them is a problem that isn't going away. The U.S. population's median age climbed from 35.3 years in 2000 to 37.9 years in 2016. Americans ages 65 and older grew from 35 million in 2000 to 49.2 million in 2016, which is more than 15% of the total population, according to U.S. Census Bureau statistics released in June 2017.
"There is little question that the increase in the number of elderly Americans will continue to pose a steadily growing demand for healthcare and supportive services," researchers wrote in the study Implementation of the Geriatric Patient-Aligned Care Team Model in the Veterans Health Administration, published in the May-June 2018 issue of the Journal of the American Board of Family Medicine. "Much of the existing United States healthcare system is tightly wedded to a complex infrastructure and the medical expertise trained to leverage those resources to diagnose and treat disease. An uncertain but unquestionably growing proportion of the health needs of the aging population is better addressed through services that do not fit this traditional healthcare model."
Novice nurses also see the challenges of caring for older patients in the current healthcare system. "I definitely believe there are a lot of problems in the adult geriatric setting," said Isabel Mendoza, RN, a DNP student in adult geriatrics at the University of Buffalo School of Nursing. Mendoza, a med-surg nurse, said traditional hospital settings are among the healthcare environments that need to transform to cater to geriatric patients. The fast-paced acute care setting isn't suited to patients with so many comorbidities, issues and, potentially, confusion. But there are possible solutions, including the Acute Care for Elders (ACE) unit, which was the topic of one of Mendoza's research papers. ACE units, in hospitals nationwide, is based on an interdisciplinary team model, which collaboratively works to achieve patient-centered care and features a more home-like atmosphere. Mimicking a home-like environment is important in the acute care of older adults, according to Mendoza, because older patients often get confused in traditional hospital settings.
"The care of older adults, especially those living with multiple health and social problems, is one of the most complex and costly priorities confronting societies across the globe," Naylor, gerontology professor at Penn Nursing, said in a press release about the meeting. "It is our hope that immediate action on these recommendations will substantially enhance the value of care delivered by health and community-based systems."
Strategies to disseminate and implement findings from the report have already begun, according to Hodgson. For example, Penn Nursing and NYU are among the universities that have nursing curriculums that include training nurses how to create and further innovation, she said.
Take these courses on 'geriatric care'
60254: The Geriatric Health CE Anthology, 2018 Edition(20 contact hrs) This continuing education module provides a broad range of topics on geriatric-related health issues for nurses who work or who are considering working with this population. CE519: Mental Health & Older Adults, Part 2 (1 contact hr) An estimated 20% of Americans older than 65 have some form of mental or neurocognitive disorder. The most prevalent conditions are anxiety disorders, mood disorders and severe cognitive impairment. In nursing homes, two-thirds of residents suffer from some form of diagnosable mental health illness. As the population of older adults grows, so will the need for healthcare providers knowledgeable in geriatric mental health and illness. This second part of a two-part series on aging examines psychiatric conditions most common in older adults. CE507: Keeping the Beat(1 contact hr) Pacemakers can be life-changing devices that assist the electrical activity of a patient's heart rhythm. They may provide relief of symptoms associated with many heart rhythm disturbances and improve functional status. Some devices may improve a patient's quality of life. Pacemakers -- temporary or permanent -- can sense a patient's heart activity and produce an electrical stimulus (pace) when the heart fails to beat on its own. This electrical impulse may create a myocardial contraction as directed by timing of the heart and the programmable pacemaker. The geriatric population continues to be the fastest-growing age group in the U.S., with patients older than age 65 accounting for more than 85% of pacemakers implanted. The risk that the heart's electrical conduction system will become degenerative increases with age, which results in electrical alterations that may be best managed with pacemaker therapy.
