The geriatrics approach to care

My focus on the importance of the medical director in improving nursing home quality occasionally gets pushback from family members who have had negative experiences with doctors in nursing homes. Those stories provide an even greater impetus for having more competent and engaged medical directors. 

My first column in this space identified the importance of “embracing the role of geriatricians and certified medical directors in the day-to-day operations of nursing homes.” Geriatric medicine is very different from other disciplines. I have pointed out how “saving a dollar or two on food costs can lead to poor clinical outcomes and symptoms that require greater assistance from nursing staff.” 

The 12 elements of the Geriatrics Approach to Care highlight the importance of their full integration into the operations and workflow of a nursing home. This is one of the critical roles of the medical director. It’s also one of the reasons that having a competent medical director, certified by the American Board of Post-Acute and Long-Term Care Medicine (ABPLM), is essential. 

Unfortunately, only a minority of nursing homes have certified medical directors who are actively engaged with their facility. This, despite the regulatory requirement that the medical director is responsible for the coordination of medical care.

Function is the sine qua non of the geriatrics approach to care. To have any idea of what’s important to the person, we must know their functional capacity and abilities.  

Purpose is critical to the health and wellbeing of older adults. There is growing evidence that purpose protects against cognitive decline in older adults.

Managing chronic disease cannot be viewed from a single disease perspective. Taking a person-centered approach, which includes engaging the person themselves and their families, is a central focus for many chronic disease management approaches.

Identifying psychological and social aspects of care is profoundly important in determining effective approaches to caring for the person. It is critical that these factors be contextualized and considered when approaching the individual older adult.

Respecting a person’s dignity and autonomy is at the heart of medical ethics and has profound implications in the care of all persons. A deep understanding of how a person’s goals and preferences relate to their dignity and autonomy are unequivocally necessary if we are committed to an ethical approach to care.

Respecting cultural and spiritual beliefs is a critical and often ignored area of care.  Many individuals have goals and preferences that are informed by their cultural background, and this is often intermixed with their spiritual and religious backgrounds.  Connecting with a person in terms of their cultural and spiritual beliefs is critical to the ongoing relationship between the person and the professional caring for them.

Being sensitive to a person’s financial condition is an often overlooked aspect of an individual’s situation that can impact their health and wellbeing.  

The importance of promoting wellness has often been lost in the care of older adults. While it is traditional for medical specialties to focus on disease, health prevention and wellness are very important elements in the geriatrics approach to care.  

Listening and communicating effectively are skills at the heart of being able to deliver a person-centered approach to care.  Recognizing that someone with Parkinson’s disease might take longer to respond to a question is a great example of the importance of this skill set. Not doing so can lead to the inaccurate diagnosis of cognitive impairment or dementia. Listening and asking the right questions are essential in obtaining the context necessary to deliver person centered care.

Realistically promoting optimism and hope is a clinical skill that is often forgotten in the setting of advanced illness or limited function.  Recognizing that the individual person will always have priorities and goals, and that their preferences will be informed by their present condition, is critical to identifying mechanisms to allow for optimism and hope.

The Geriatrics Approach to Care spans a broad range of disciplines.  This very fact creates opportunities to utilize a team approach to care for older adults.  The concept of QAPI (Quality Assurance and Performance Improvement) has underscored the values and opportunities that exist in utilizing a team to deliver care to older adults. Understanding the importance of teamwork and the effective functioning of a team is critical to caring for older adults. 

A competent and engaged medical director is essential to the integration of the Geriatrics Approach to Care in nursing homes. It’s time to make this a priority. 

Michael Wasserman, MD, CMD, is a geriatrician and member of the Board of Directors for AMDA–The Society for Post-Acute and Long-Term Care Medicine. The views expressed here are his and his alone.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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