Expectations for Basic Care of the Elderly

Expectations for Basic Care of the Elderly

Increase Screening and Preventive Measures

Providers and patients should systematically address preventive services that have demonstrated effectiveness in older persons. Discussions between the care team and the patient regarding preventive services must occur, be documented, and patient education and direct implementation of preventive services should be provided when appropriate in the following areas:

• Influenza immunization

• Pneumococcal vaccination

• Colorectal cancer screening

• Mammography (women only)

• Hearing impairment screening

• Vision impairment screening

• Smoking cessation

• Regular physical activity

• Hormone replacement or other osteoporosis prevention (women only)

Improve Office Visit Efficiency

Because of the multiple chronic conditions and importance of environmental and psychosocial influences, the care of older persons is frequently time consuming, yet rarely comprehensive. Restructuring the clinical encounter can increase comprehensiveness without prolonging office visit times. Specific steps include:

• Delegate data collection to families through pre-visit questionnaires and office staff.

• Disseminate preprinted written instructions for patients and families.

• Use templates for documentation of care.

• Establish networks of health care professionals who can complement and enhance provider advice and recommendations.

Reducing Falls

Despite the common occurrence of falls, those who will fall can be identified before incurring major health consequences. Effective interventions are available. Establishment of identification and management systems for those with high risk of injurious falls can be accomplished by:

• Systematically collecting information on risk factors for falls, particularly those for injurious falls.

• Establishing protocols for basic office evaluation of gait and balance and guidelines for appropriate referral for more detailed evaluation and therapy.

• Establishing formal medication review protocols to reduce medications associated with falls.

• Establishing home safety inspection programs with appropriate changes (e.g., removal of hazards, installation of grab bars and stair rails).

• Creating exercise programs to improve strength (e.g., Thera-bands) and balance (e.g., Tai Chi).

Reducing Depression

Depression in older persons is under-recognized and under-treated. Effective methods for detection and treatment of depression are available by:

• Establishing mechanisms to achieve increased detection of depression.

• Establishing protocols and referral resources for non-pharmacologic therapies for mild to moderate depression.

• Increasing primary care provider expertise in prescribing antidepressants.

• Establishing methods for monitoring response to depression treatment (e.g., side effects of antidepressants).

Controlling Incontinence

Urinary incontinence is under-reported by patients and under-treated, yet effective therapies are available by:

• Establishing mechanisms to achieve increased detection of urinary incontinence.

• Training staff to teach behavioral methods to control stress incontinence (e.g., Kegel exercises, timed toileting).

• Training providers and office staff to conduct initial evaluation of incontinence.

• Increasing primary care provider expertise in prescribing incontinence medications.

• Establishing protocols for referral to specialists (e.g., urology, gynecology).

• Establishing methods for monitoring response to incontinence management.

Elderly Care and the Components of the Chronic Care Model

This grid is to illustrate how the clinical content (for improving elderly outcomes) relates to the areas for “System Improvement.” We have purposefully written it in the form of questions. For many there is no single “right answer.” Rather, these are suggested questions you need to answer for yourself to improve care for the elderly.

Information System /

Practice Redesign

/

Decision Support

/ Self-management support /

Community Resources

Screening and Preventive Services / How can you identify populations for screening?
Is there a way to provide reminders to perform recommended actions?
How do you track results of interventions? / Who completes specific tasks (registry review, questionnaire administration, immunizations, behavior change support) delegated to practice team members?
What options are there for group or individual visits and follow-up designed to facilitate screening and preventive services? / Do you have an evidence based guideline for each screening area?
How do you disseminate guidelines to providers?
How is the guideline embedded in the system? / Do you have documentation of collaborative goal setting process for preventive services?
What options for evidence-based self-management support programming are available for each area?
What is the availability of problem-solving support for patients having difficulty? / Do you have links to effective community programs for exercise, smoking cessation?
Office Efficiency / Are there recording systems for quicker documentation?
Are registries of common problems available? / How is patient information collected before visit and provided to MD at time of visit?
Are non-MD team members trained to do key assessments and education?
Is there an established referral network to meet common management needs? / Do you have guidelines for high priority areas readily available?
Are the guidelines embedded into the system of care? / Are high quality educational materials for patients readily available for common management problems? / Are providers and patients connected to community resources for priority areas?
Reducing Falls / How do you document fall risk factors and interventions? / What options for group or individual visits and follow-up facilitate fall evaluation and management?
Is fall risk factor data collected in standard manner and provided to MD at time of visit? / Do you have guidelines for evidence based gait and balance evaluation and management of fall risk? / Do you have a collaborative goal setting process for exercise?
What options for evidence-based exercise programming is available?
What options for home safety evaluation are available?
Is counseling available for patients with difficulty stopping high risk drugs? / Have organizations formed partnerships to assure exercise programs for strengthening and balance?
Reducing Depression / What methods are used to identify and track populations with depressive symptoms? / What options for group or individual visits and follow-up designed to facilitate depression screening and medication review? / Do you have an evidence based guideline for depression management?
How is it embedded into practice? / Do you have documentation of collaborative goal setting process for depression services? / Are there links to effective community programs for depression?
Controlling Incontinence / What methods are available to identify and track populations with incontinence? / What options for group or individual visits and follow-up are used to facilitate evaluation of incontinence and provision of services?
Who is trained to teach behavioral approaches (timed toileting, Kegel exercises)? / Is there an evidence based guideline for incontinence management?
Are providers trained to assess incontinence?
Are providers trained to manage medications related to incontinence? / Do you have documentation of collaborative goal setting process for incontinence care? / Are there links to effective community programs for incontinent patients?