OUTPATIENT
CARE SYSTEMS
OBJECTIVES
Know and understand:
• Innovative options for specialty outpatient care
• Methodologic differences between Comprehensive Geriatric
Assessment and Geriatric Evaluation and Management
• Key features of GRACE and other models of enhanced
primary care
• Conditions that lend themselves to disease management
programs
• 3 complementary methods of identifying high-risk patients
who could benefit from an innovative outpatient intervention
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TOPICS COVERED
• Geriatric Specialty Care
 Senior Health Clinic
 Program of All-inclusive Care for the Elderly
• Geriatrics in Primary Care
 Outpatient Consultation
 Enhanced Primary Care
 Disease Management
• Patient Selection for Outpatient Interventions
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STANDARDS OF EVIDENCE (SOE)
Rating
Basis of Rating
Studies Justifying Rating
A
Consistent and good quality patientoriented evidence
Large cohort studies for risk
factors/prognosis; RCTs for
diagnosis/treatment
B
Somewhat inconsistent or limited
quality patient-oriented evidence
Smaller or single cohort
studies for risk factors/
prognosis; small or single
RCTs or cohort studies for
diagnosis/treatment;
uncontrolled studies
C
Very inconsistent or very limited
patient-oriented evidence, consensus,
disease-oriented evidence, and/or
case series for studies of diagnosis,
treatment, prevention, or screening
Single small cohort study for
risk factors/prognosis; single
small cohort study or RCT for
diagnosis/treatment; case
series
D
Unstudied common practice or opinion No evidence
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INTRODUCTION
• Traditional outpatient care in the US does not deliver
the recommended standard of care to older adults for
preventive services, chronic disease management,
and geriatric syndromes
• A more proactive, patient-centered, and populationbased approach is needed to improve the overall
quality of geriatric care
• Several innovative outpatient care systems have
been developed over the past 2 decades
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GERIATRIC SPECIALTY CARE:
SENIOR HEALTH CLINIC (1 of 3)
• Specialized ambulatory clinical service center
for older adults
• Provides primary care using interdisciplinary
team approach
• Includes hospital, skilled nursing facility
(SNF), assisted living, and home care
• Links patients with community-based services
and information
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GERIATRIC SPECIALTY CARE:
SENIOR HEALTH CLINIC (2 of 3)
• Core team: geriatrician, NP, social worker
• Extended team: pharmacist, physical therapist,
dietician, home-health nurse, etc.
• Provider teams share a common medical record
and meet at least weekly to review complex care
plans and discuss new or anticipated patient issues
• When SHC patients are admitted to the hospital or
SNF, care is delivered directly and/or coordinated
by SHC providers
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GERIATRIC SPECIALTY CARE:
SENIOR HEALTH CLINIC (3 of 3)
• Patients in SHCs have better mental health and better
health-related quality of life over time than patients in
traditional care (SOE=A)
• SHCs are revenue generators when considered within
an integrated health system because of “downstream”
hospital and professional fees (SOE=B)
• But uptake of the SHC model has been limited because:
 Administrators tend to consider SHCs in isolation, which
makes them seem to be cost centers
 A limited number of specialty trained geriatrics
professionals are available to staff such clinics
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GERIATRIC SPECIALTY CARE:
PACE (1 of 3)
• Program of All-inclusive Care for the Elderly
• Managed care program that provides comprehensive
services to frail community-dwelling elderly persons
by a single organization
• Services are provided in the PACE center, home,
hospital, and SNF by a large interdisciplinary team:
PCP (often a geriatrician), NP, clinic and home
health nurses, social workers, physical therapist,
occupational therapist, recreational therapist,
pharmacist, dietitian, and transportation workers
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GERIATRIC SPECIALTY CARE:
PACE (2 of 3)
• Combined Medicare/Medicaid funding allows PACE
to integrate acute and long-term care
• Most enrollees are eligible for Medicaid because
otherwise the program carries high out-of-pocket
expenses; few insurance plans cover PACE
• Enrollment criteria:
 Age 55 or older
 Eligible for Medicare
 Certified by the state as eligible for care in a nursing home
 Lives in the defined geographical catchment area
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GERIATRIC SPECIALTY CARE:
PACE (3 of 3)
• Data suggest improved quality in process of care
measures and lower hospital utilization among
PACE participants vs. other older and disabled
populations (SOE=B)
• In an analysis comparing capitated payments under
PACE with expected fee-for-service payments,
PACE was overall 10% more costly
• About 3 million older adults in the US might benefit
from PACE, but only a small fraction have enrolled
since PACE was made an Medicare provider
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GERIATRICS IN PRIMARY CARE:
OUTPATIENT CONSULTATION (1 of 2)
• Comprehensive Geriatric Assessment (CGA)
 Aimed at determining a patient’s medical, functional,
and psychosocial capabilities, and developing a plan
for treatment and long-term follow-up
 Typically requires a highly trained interdisciplinary
team, so is expensive and time consuming
 If the team has a purely consultative role, CGA is
unlikely to improve patient outcomes (SOE=A)
 CGA coupled with a strategy to improve PCP and
patient adherence with recommendations has
demonstrated improved outcomes (SOE=A)
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GERIATRICS IN PRIMARY CARE:
OUTPATIENT CONSULTATION (2 of 2)
• Geriatric Evaluation and Management (GEM)
 More intensive than CGA
 A geriatrics interdisciplinary team diagnoses and
treats problems, and provides services such as:
o Adjusting medications
o Providing counseling and health education
o Making referrals to other health professionals and
community services
 The team also provides monitoring and coordination
of care between visits through regular telephone calls
 Trials have shown positive results (SOE=A)
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GERIATRICS IN PRIMARY CARE:
ENHANCED PRIMARY CARE (1 of 2)
• A geriatrics interdisciplinary team provides ongoing care
management (usually including home visitation) in support
of, and integrated with, the PCP
• Other key features are that the care:
 Is personalized to each patient’s goals, values, and resources
 Is provided in accordance with best practices
 Is coordinated among caregivers, including information
linkages such as an electronic health record
 Considers the resources and environment of the patient
 Includes patients as partners in their care when possible
• Studies indicate better quality and outcomes, and reduced
acute care utilization (SOE=A)
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GERIATRICS IN PRIMARY CARE:
ENHANCED PRIMARY CARE (2 of 2)
• Geriatric Resources for Assessment and Care of Elders
(GRACE) model
 An NP and social worker (employed by the PCP) provide
home-based CGA and long-term care management in
collaboration with the PCP, and an interdisciplinary team
led by a geriatrician
 Individualized care planning during weekly team meetings
is guided by 12 protocols for common geriatric conditions
 The NP and social worker continuously implement the
care plan in collaboration with the PCP
 The NP and social worker coordinate care among all
health care professionals and sites of care, aided by an
electronic medical record and Web-based tracking system
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GERIATRICS IN PRIMARY CARE:
DISEASE MANAGEMENT PROGRAMS
• Focus health care delivery around a single
disease with the goal of optimizing patient care
for that disease
• Most effective when integrated with the patient’s
PCP and/or specialist physician
• Potentially cost-saving
• Programs in heart failure, depression, and
Alzheimer’s disease have led to better outcomes
in older adults (SOE=A)
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PATIENT SELECTION FOR
OUTPATIENT INTERVENTIONS (1 of 2)
• Referral by primary care clinicians
 They may lack the time, skills, and incentives
• Screening questionnaires
 The Probability of Repeat Admission (Pra) survey
o Risk score is based on age, sex, perceived health,
availability of informal caregiver, heart disease, diabetes,
physician visits, and hospitalizations
o Validated in many different populations of communitydwelling older adults, including Medicaid, fee-for-service,
and managed-care patients (SOE=B)
o Because of associated expenses and <100% response
rates, an administrative proxy has been developed
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PATIENT SELECTION FOR
OUTPATIENT INTERVENTIONS (2 of 2)
• Screening questionnaires, cont’d
 The Vulnerable Elders Survey-13 (VES-13)
o 13-item questionnaire produces a vulnerability score
from 0 to 10 based on age, self-reported health, function
o Patients with a VES-13 score of ≥3 are at 4 times the risk
of functional decline or death over the next 2 yr (SOE=B)
• Predictive modeling
• Use of administrative data to identify high-risk older adults
• Typically analyzes health insurance enrollment records and
claims data with predictions based on age, gender,
diagnoses, prior use of health services and associated costs,
and pharmacy data
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SUMMARY
• Outpatient interventions for older adults should be
personalized, provided by a team in accord with best
practice, coordinated among all providers and settings
of care, and consider patients’ resources and
environment
• For optimal cost-effectiveness, outpatient programs
need to be targeted to patients at high risk of
hospitalization and likely to be active participants
• Broad dissemination of effective models of outpatient
care for older adults is limited by current payment
mechanisms and the shortage of geriatrics health care
professionals
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CASE 1 (1 of 4)
• A 68-yr-old widower is brought to the office by his son
for follow-up evaluation.
• He has type 2 diabetes mellitus, peripheral vascular
disease, ischemic cardiomyopathy, and macular
degeneration.
• A visiting nurse comes weekly, and his son and
daughter-in-law help him with shopping and chores at
his home.
• He has been hospitalized 3 times over the past 2 mo,
most recently for cellulitis of his right foot.
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CASE 1 (2 of 4)
• The patient drove until 2 mo ago, when his first
hospitalization occurred. He also gave his checkbook
to his son, “just for a little while, until I get better.”
• The son voices concern about the father’s ability to live
independently. The patient becomes visibly upset and
states that he will never leave his home. He suggests
that his son is after his Social Security money.
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CASE 1 (3 of 4)
Which of the following is the most appropriate
next step?
(A) Evaluate for cognitive impairment.
(B) Evaluate for possible financial exploitation and for
mistreatment or abuse.
(C) Initiate discussion regarding advance directives.
(D) Perform comprehensive geriatric assessment.
(E) Arrange for a daily home health aide.
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CASE 1 (4 of 4)
Which of the following is the most appropriate
next step?
(A) Evaluate for cognitive impairment.
(B) Evaluate for possible financial exploitation and for
mistreatment or abuse.
(C) Initiate discussion regarding advance directives.
(D) Perform comprehensive geriatric assessment.
(E) Arrange for a daily home health aide.
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CASE 2 (1 of 3)
• An 86-yr-old woman with dementia and heart
failure has difficulty getting to the bathroom and
is increasingly incontinent. She can no longer
prepare food for herself or take medications
reliably.
• She lives with her son, who is away from home
during the day. He is no longer comfortable
leaving his mother alone, but neither he nor his
mother wants her to move to a nursing home.
• The patient qualifies for Medicare and Medicaid.
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CASE 2 (2 of 3)
If available, which of the following is the most
appropriate recommendation?
(A) Enrollment in a social health maintenance
organization (HMO)
(B) Admission to a nearby nursing home
(C) Referral to Program of All-inclusive Care of the
Elderly (PACE)
(D) Hiring a full-time home care nurse
(E) Referral to state Department of Aging for
assessment
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CASE 2 (3 of 3)
If available, which of the following is the most
appropriate recommendation?
(A) Enrollment in a social health maintenance
organization (HMO)
(B) Admission to a nearby nursing home
(C) Referral to Program of All-inclusive Care of the
Elderly (PACE)
(D) Hiring a full-time home care nurse
(E) Referral to state Department of Aging for
assessment
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ACKNOWLEDGMENTS
GRS Chapter Author: Steven R. Counsell, MD, AGSF
GRS Question Writers: Steve Zweig, MD
Ann R. Datunashvili, MD
Medical Writers:
Beverly A. Caley
Faith Reidenbach
Managing Editor:
Andrea N. Sherman, MS
© Copyright 2010 American Geriatrics Society
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