The Essence of Comprehensive Geriatric Assessment
Introduction
Geriatric care is a matter of intense discussion during the past twenty years due to the growing needs of older adults. As a result of continuous debates, the CareMore model emerged to shift geriatric care towards preventive practices using the money from capitated payments. The implementation of the model, however, requires careful assessment of geriatric patients to identify the needs of patients and select the care management approach. The method of geriatric assessment, however, may differ depending on the facility. The present paper aims at describing comprehensive geriatric assessment (CGA) as a traditional tool for geriatric case management assessment in hospitals and long-term care facilities. The primary purpose of the report is to identify the similarities and differences of the application of CGA in different settings.
CareMore Model
The CareMore model emerged as an attempt to balance the cost of care and meet the needs of high-risk patients. According to Hostetter et al. (2017), the sickest 15% of patients account for 75% of healthcare costs. CareMore acknowledges this fact and spends more funds on preventive care to save money by reducing the average number of in-patient days (Hostetter et al., 2017). The research demonstrates that the CareMore approach is associated with significant benefits, as geriatric patients enrolled in the CareMore program have 20% fewer hospital admissions, 23% fewer bed-days, and 4% shorter hospital stays (Hostetter et al., 2017). Thus, implementation of the model is crucial for improving the health condition of older adults and reducing the cost of care.
CareMore is based upon four basic features that help to manage geriatric cases successfully. First, the model supports partnerships between Care Centers and independent primary care physicians to identify high-risk patients and provide needed care (Hostetter et al., 2017). Second, it relies on low-cost primary care providers (such as medical assistants and nurse practitioners) to save the time of physicians overseeing complicated cases (Hostetter et al., 2017). Third, CareMore encourages prevention and wellness in all patients according to their health condition (Hostetter et al., 2017). Finally, it develops emotional connections to encourage shared decision-making (Hostetter et al., 2017). The application of these four principles has proven to be an effective method for addressing geriatric case management.
CareMore relies on careful geriatric assessment to identify high-risk patients. In general, there are three steps in the CareMore model, including enrollment, medical evaluation, and application o the selected case management approach (Hostetter et al., 2017). Relatively healthy patients receive wellness services and are referred to community health providers (Hostetter et al., 2017). Chronically ill patients with unstable conditions receive care from nurse practitioner-led teams (Hostetter et al., 2017). High-risk patients are encouraged to visit Care centers frequently to receive appropriate care (Hostetter et al., 2017). The classification of patients depends upon the utilization of appropriate evaluation techniques, such as CGA.
CGA in Hospital Settings
CGA is one of the commonly accepted methods for holistic geriatric care management assessment. According to Ellis et al. (2017), CGA is “a multi‐dimensional, multidisciplinary diagnostic and therapeutic process conducted to determine the medical, mental, and functional problems of older people” (para. 1). The purpose of the procedure is to create a coordinated plan of treatment for the senior population. Care for older adults goes beyond standard treatment procedures as it requires the management of multiple conditions and co-morbidities (Ward & Reuben, 2020). The core components of geriatric assessment include functional ability, physical health, cognition, and mental health, and socio-environmental circumstances. These four broad categories include multiple procedures of screening for problems that often occur in old age. The indications for referral are age, medical co-morbidities, such as heart failure or cancer, geriatric conditions, such as dementia or falls, previously predicted high health care utilization, and possible changes in the living situation.
The range of healthcare professionals managing a geriatric assessment may differ depending on the range of offered services. At least three core members of the team care for geriatric patients, including a clinician, a nurse, and a social worker (Ward & Reuben, 2020). However, there may be other members of the multidisciplinary team, including physical and occupational therapists, dieticians, pharmacists, psychiatrists, dentists, audiologists, and opticians. The number of members in a geriatric assessment team should be optimal to increase the efficiency of care provision. At the same time, all team members should utilize the best practices of collaboration to ensure improved patient outcomes.
Functional status assessment is a crucial part of geriatric assessment. Function status is the ability to perform tasks required for living. The functional status evaluation includes ADL and IADL assessments. ADL include self-care activities, such as eating, dressing, bathing, transferring between the bed and a chair, using the toilet, controlling bladder and bowel functions (Ward & Reuben, 2020). IADL is an assessment of activities required for independent living, including doing housework, preparing meals, taking medications properly, and managing finances (Ward & Reuben, 2020). The purpose of a functional status assessment is to maximize autonomy and manage limitations that may lead to problems with daily activities.
Physical health assessment is crucial for older adults due to the high possibility of having multiple chronic conditions. The geriatric assessment incorporates all facets of conventional medical history, including the main problem, current illness, past, and current medical problems, family and social history, demographic data, and a review of systems. The approach to the history and physical examination, however, should be specific to older persons.
Mental health problems and cognitive decline are prevalent among older adults (Bodner et al., 2018). Common mental health and cognition concerns include dementia and geriatric depression. Early diagnosis of dementia can help the families to make necessary arrangements and receive timely access to medications. Depression is also common among older adults due to stigma, lack of social contact, and thoughts of death. Therefore, assessors need to use the most efficient evidence-based tools to screen for these conditions. According to Weissman and Russell (2018), there is a significant correlation between living arrangements and health status. Thus, the assessment team needs to select the most appropriate living arrangement. Even though there may be different options available, there are three basic types of housing options: private homes, assisted living residences and skilled nursing facilities. The living arrangement takes into consideration social interaction networks, available support resources, special needs, and environmental safety.
Comparison with CGA in Long-Term Care
CGA for long-term care (LTC) settings differ, as such facilities are designed to care for older people with complex care needs. A special tool, LTC-CGA, was created and certified in 2007 to optimize the time spent on the assessment of geriatric patients in nursing homes, home health, or adult health services (Marshall et al., 2016). Most LTC patients need care because they are frail, have a cognitive impairment, and nearing the end of their life (Marshall et al., 2016). Thus, CGA was modified to include documentation of behavioral disturbances, foot and dental care requirements, skin integrity, goals of care, and the name of closest relative (Marshall et al., 2016). This tool also uses a shortened frailty due to the health condition of LTC patients (Marshall et al., 2016). While this evaluation tool demonstrated promising results, it has not been adopted universally. According to Panza et al. (2018), CGA can also be applied in LTC without modifications. However, its effectiveness may differ depending on the circumstances and the patients’ conditions.
In both hospital and LTC settings, CGA is associated with improved health outcomes in geriatric patients (Panza et al., 2018; Ward & Reuben, 2020). However, the CGA is currently not standardized in any settings. Thus, it is crucial to adopt a standard CGA in types of settings to ensure integration and coordination among different healthcare facilities. Such an approach to evaluation can become a basis for strong patient-centered care using the CareMore model.
Conclusion
Geriatric care is a matter of increased interest among scholars and practitioners, as it contributes to the cost of the healthcare system. CareMore model can be used to improve the health status of older adults while reducing the cost of care due to the optimal approach to the preventive procedures. Effectiveness of CareMore depends upon accurate assessments of patients, and CGA has proven its efficacy for such purposes. While the application of CGA in hospital and LTC settings is mostly similar, the method can be modified to meet the unique needs of LTC patients.
References
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Hostetter, M., Klein, S., & McCarthy, D. (2017). CareMore: Improving outcomes and controlling health care spending for high-needs patients. Commonwealth Fund. Web.
Marshall, E. G., Clarke, B. S., Varatharasan, N., & Andrew, M. K. (2016). A Long-Term Care—Comprehensive Geriatric Assessment (LTC-CGA) tool: Improving care for frail older adults? Canadian Geriatrics Journal, 18(1), 2.
Panza, F., Solfrizzi, V., Lozupone, M., Barulli, M. R., D’Urso, F., Stallone, R.,… & Logroscino, G. (2018). An old challenge with new promises: a systematic review on comprehensive geriatric assessment in long-term care facilities. Rejuvenation Research, 21(1), 3-14.
Ward, K., & Reuben, D. (2020). Comprehensive geriatric assessment. UpToDate. Web.