New Model of Care Is Needed, Experts Say
December 30, 2008
By JANE E. BRODY
American medicine is already in a crisis mode when it comes to geriatric care, and the problem will only become worse unless new approaches are found, experts say.
"There's been a drastic decline in the number of geriatricians -- and just 300 new ones are being trained each year -- yet the number of people over 65 will double in the next 20 years," Dr. Atul Gawande, a surgeon at Brigham and Women's Hospital in Boston and an associate professor at the Harvard School of Public Health, said in an interview. "Those who work in geriatric care are among the worst paid in the health care system. Is the time I spend as a surgeon excising a patient's cancer worth 10 times more than the time the primary care doctor spent finding the cancer in the first place?"
Dr. Gawande, who examined the problems of medical care for the aged last year in The New Yorker, pointed out that as we grow older, "we don't get one problem at a time."
"People with multiple problems need time, and that is not cheap and is currently not paid for by medical insurance," he said. "It's not possible to address five different problems in a 20-minute visit."
He and others see a pressing need for new
approaches to keep aging patients as healthy as possible and
living independently as long as possible. Dr. Chad Boult, a
geriatrician at Johns Hopkins School of Public Health in
Dr. Boult is involved in testing a team approach, in which nurses trained in geriatrics are helping physicians in the Baltimore-Washington area provide coordinated care for 50 or 60 of their highest-risk older patients. The nurses go to patients' homes, develop comprehensive care plans, help the patients in self-monitoring, help them overcome obstacles to self-care and connect patients and their families to community agencies.
According to geriatrics experts, social workers trained in the problems of the elderly can also participate by performing home assessments, for example, to prevent falls and costly, disabling fractures. They can help overcome barriers to good nutrition, and they can help make the community connections for assistance with the activities of daily living, like shopping.
Given the decline in geriatricians, "we have to rely on primary care doctors who need more training and education on how best to care for older adults,' Dr. Boult said in an interview. "We need to deploy the small cadre of geriatricians and make them real leaders and educators, from teaching first-year medical students to providing continuing education for practicing physicians."
While current insurance systems pay many thousands of dollars for hospital-based care, they cover only a fraction of the far less expensive care delivered by doctors and nurses that can keep patients out of the hospital.
"We're still working within an old model of
care," said Dr. Sean Morrison, a geriatrician at
"The system needs to be restructured to meet the needs of people with chronic illness, and this can't be done without addressing the social needs of older adults. If we fail to do this, we will be facing a bankrupt Medicare system."