I have often wondered why medical doctors are not required to complete certifications each year by taking continuing education courses. This is required of registered dietitians (RD). Having a continuing education requirement for physicians to update their certifications in geriatric medicine or other specialties would be one way to bridge this gap. Nutrition and physical fitness education is needed that is tailored specifically for older adults. There are multiple barriers faced in both healthy eating and exercise. On the other hand the increased need to socialize (since the work place is no longer an option) becomes an enabler for social eating and exercise. The short answer is the geriatric specialist.

Dear Arthur,

Thank you for a most pertinent question. In the current climate of "efficiency" and fast knowledge where numbers means more than results, the short answer is the health care workers in the community. This vein of thought is founded along the same line as "old people don't really need admission or to be seen by any specialist, Geriatrician or otherwise".

However, those of us at the front line knows that the converse is usually true, as most "old people" will do their utmost to avoid contact with "healthcare professionals" and hospitals, for the dangers of iatrogenicity is all too real and they know it well.

Hence, when an elderly patient actually presents to the healthcare system, they do need specialist attention, geriatrician or othrwise. This is simply because they are either very ell and can be reassured and discharge safely back into the community, or they are very ill and can deteriorate very rapidly and disastrously when not recognised as such.

The question then arises as what to do with those who survives the admission and the acute episode?

From my years in the National Health Service in the UK, my humble opinion is that there is a great need for a primary physician to be responsible and coordinate their care. This care can then have additional input of specialists, geriatrician or otherwise, as appropriate. This has to be a dynamic multi-way discourse, with honest discussions with between physicians, physicians and patients, physicians and relatives and also patients with their own relatives , as regards the risks and benefits of care and primary or secondary prevention.

For example, we know that in the trials of the use of beta-blockers in significant heart failure, up to 1/3 of elderly patients in the already pre-screened and pre-selected trial population cannot tolerate the treatment due to postural hypotension and bradycardia. Without blood pressure to the brain, risks of falls and decontioning is high. Without the ability to walk and as a result or multiple falls, many will suffer injury. both physical and from great fear of falling and become institutionalised.

Being bed bound in itself carries a significant morbidity and mortality, and this must be weighed against the expected benefits from any treatment.

The short answer is that there is a need for more collaboration between primary care and specialists in the care of elderly patients, particularly for those with multi-morbidity and complex health needs. Geriatricians, by virtue of their chosen specialty, will eventually find themselves having to lead this need for increased engagement.

Thank you.

General Practice needs access to robust specialist primary healthcare. This should be delivered through collaborative teams that sit in Primary sector services. Teams should be made up of Nursing and Allied Health speciailsts and have access to Medical specialists as and when required.

Health pathways are essential to identify at risk groups and then implement some early intervention (community Pharmacy, OT, falls assessment etc) that then can lead on to medical specialist input when needed.

A multifaceted multidisciplinary intervention would probably result in the best outcome.

For example, incorporation of teams would be expected to be helpful in the management of certain geriatric issues (e.g. annual medication review to rationalise polypharmacy), as would be the implementation of predefined (and reimbursed) care pathways (e.g. heart failure syndrome, regardless of etiology). A care pathway not focusing on a specific disease (state), but rather on a patient profile (e.g. frail older person), that would incorporate multidisciplinary cooperation, would be interesting, to say the least. This is something however, that to this date does not exist in my country (Belgium). Nonetheless, even if it would exist, GPs would still have to trained more intensly to tackle all the problems that would be missed by whatever intervention.

In the end, it will be the GP and not the geriatrician who has to follow-up on certain interventions, take blood samples, titrate a drug to its target dose, etc. They are called first-line for a reason.

Just the humble opinion of pharmacist.

Dear Lorenz

Your opinion is most valuable since it is cosidered that about one third of the medical

problems of the elderly population are related to the rational use of the drugs. This, of course depends on the elderly patients themselves ( their estimated addherence is only 50 %) but more than this it depends to the fact I will formulate as " not

enough knowledge of the primary care physicins with the principles of the pharmacokinetics in the elderly". Both the geriatricians and the clinical pharmacologysts should advice and train wherever and whenever available but

it should not come instead of a better knowledge level of the family doctors of the elderly in the basics of geriatrics, At least those that qulify in family medicine and

other primary care in community disciplines. ( over 95 % of the elderly live in the community )

With relation to polypharmacy I think that drug control by the staff should be carried out once in 3 months . Once a year seems a too long interval mainly for those over 75.

Thank you again for your contribution .

Specialist in geriatrics

I believe that as the mean age of people is growing up and as there are not enough specialists in geriatric field, it is good to publish new up to date articles for improving our knowledge in this field and even any field that we need during our professional work.

Less than 1% of US medical graduates take the minimumof 1 year of accredited geriatric fellowship training (beyond 3 years in family medicine or internal medicine) to qualify as geriatricians through the ABIM or ABFM, and all geriatricians are hence primary care physicians. Hence meeting the educational needs (much less the other academic expectations of university-based faculty) requires each of the certified (and re-certified Q. 10 years) geriatricians in the US to achieve maximum leverage on their professional activities to disseminate geriatrics into all of the specialties and subspecialties in medical and non-medical (surgical, neurology, psychiatry, emergency medicine) fields. But, yes, all primary care physicians are the base of the medical expertise appropriate to meeting the needs of our ever-escalating number and age of our elderly patient in the USA. However, perversely, the compensation of geriatricians is a the bottom of the scale among all physicians in this country. And this disparity is receiving virtually no attention in the health care reform struggle in the USA at this juncture. So an all-hands approach will be necessary to provide optimal care for aging and elderly patients in this country.

The gap needs to bridged, until then anyone that is qualified should render as much care as possible. This would include phyiscians, nurses and family. We are very shorthanded in the area of geriatrics.

Dear Prof Hazzard - The author of Hazzard's Geriatric Medicine and Gerontology

- we are honoured by your valuable contribution to this discution.

Arthur Leibovitz

Dear Ezequel

Indeed nowadays ' either Family Medicine and Geriatric Medicine are well defined

medical professions in many countries. The question is if geriatric teaching is significantly represented in the syllabus of Family Medicine. In my oppinion , significantly , means at least a residency of 3 months in a Geriatric Ward and 3 months in a Community geriatric clinic - and obligatory. Today some similar formula is hardly offered as elective ....

Dear Arthur,

I am involved in the process evaluation of a multidisciplinary integrated goal oriented intervention (Prevention and Reactivation Care Program (PReCaP)) to reduce hospital related functional decline in elderly patients. As part of the intervention, a case manager with geriatric expertise acts as the patient's casemanager throughout the entire chain of care, i.e. hospital care, hospital replacement care, and primary care until six months after hospital admission. In consultation with the PReCaP team and (in the home situation) primary health care providers, the casemanager coordinates the multidisciplinary care process, supports and motivates the patient in treatment adherence, and monitors the patient's risk factors for functional decline throughout the reactivation period. In other words, the casemanager is the patient's broker to ensure the most appropriate form of health care, as well as a provider of the treatment.

We have published articles discussing the protocol and evaluation design. As the data analysis is currently underway, I cannot provide evidence yet regarding the effectiveness of the case manager's contribution to the elderly patient's health and wellbeing.

Kind regards,

Annemarie de Vos

Dear Colleagues

The question is how many gertiatric specialists can serve in community? When populations are ageing, they like it or not - general practitioners/family physicians are becoming "more specialized" in age-dependet conditions as they HAVE TO answer their own patients' needs. The idea of primary care based on general practitioners/family physisicans is that they adopt to the very specific community they work/live in.

The othere issue is what proportion of their training is geriatrics and how is the cooperation between primary care organized and faiclitated?

Regards

Marek Oleszczyk, MD

family physician

Dear Anemarie

Thank you for your contribution ! I am covinced that the integration of casemanagers is

a must of any modern and complex healthcare system , And not only elderly patients will benefit from it but also those with chronic condition of all kinds. We are now making first steps in exploring this issue with respect to elderly in community. I will appreciate if you send me those aricles you mention. What interests me specially is

the way these casemanagers are prepared for their task. Who they are and what kind

of training ( syllabus ) they get ?

Arthur

Dear Marek

All you said is right , But what I think is that the basic knowledge in geriatrics should be offered to the primary care physicians that are already working for years as an obligatory section in the frame of the existing continuing medical education programes. There is a Core Curricullum I suggest, of no more than 5 items : Geriatric Pharmacology , Comprehesive Geriatric Evaluation ,

Physiology of Aging , Psychogeriatrics and Riks Old Age and their Prevention.

Each one can be prepared as one lecture and all this training pakage could be integrated as an obligatory module ,

Arthur

Hi Arthur

In my experieince of over 40 years the treatment of patients in the community has evolved tremondously as is working towards Person centred Care, albeit som way off as yet but getting there. We support people to stay at home with long term conditions whether they be co-morbid or not and find the collaborative approach works very well. The staff team are trained in relation to the person's needs and their condition and will refer to the GP' District Nurse or other health professionals to coordinate input as and when necessary. It will be the GPs decision to refer to a specialist if the need is identified but this may mean a trip to a meidcal centre which is not always possible and Hospital Consultants in my experience, don't do house calls unless it is on a private fee paying basis.

I believe the Alzheimer's Scotland 8 pillars of Support model is the way forward as it can be modelled across other long tern conditions. The coordinator must be the front line staff that she the patient daily basis as they will see the changes or distress the patient experiences and can report these to the GP etc for further advice and treatment. This has worked time and time for us and our clients right through to end of life but it does take acceptance and trust from the medical staff for this to work.

Bob

Dear Arthur,

In response to Annemaries comment and your question: we developed a proactive primairy care strategy for frail older people in primary care. In this study we selected patients at risk using a frailty index score based on routine patient data, polypharmacy and or patients with a consultation gap. Next, an frailty questionnaire was sent to the patient and frail patients received a CGA at home conducted by special trained registered practice nurses who were embedded in the general practice. These nurses provide and coordinate the care, and if needed other disciplines were involved. The training of the nurses consisted of 48 hours (6 week) training and included the topics: 'how can I identify patients at risk", which instruments can be used, a comprehensive geriatric assessment, collaboration with GP and other health care professionals in primary care, coordination, and focus on eleven common geriatric conditions such as falls, cognition, urinary incontinence, disability etc. More detailed information is described in Bleijenberg et al, 2013 Journal of Nursing Scholarship, Bleijenberg et al (2012) BMC Geriatrics.

Based on the experiences of our study we think that a good collaboration between nurses and GPs is crucial in order to provide care that meet the complex needs of older people.

Good luck, Nienke

I suspect that how our respective systems are organised may influence the answer. In Australia we have a fee for service system that does not really support the management of complex care such as in frail and vulnerable elderly patients. In general, local doctors are not well integrated into the hospital system and therefore the challenge is accessing specialist input or navigating through the complex referral pathways to link patients to. Often they just do not have the levers necessary to rapidly access diagnostics, assessment by specialist interdisciplinary assessments. As a result of this it is suggested that up to 50% of older people presenting to emergency departments are there really to access to comprehensive assessment and access to services because the local doctors are frustrated or do not have the time and/or knowledge to do it. We have Aged Care Assessment teams which include geriatricians and trained multidisciplinary staff which have the skills but they are often present at the end point when the crisis occurs.

To this end we are supporting health services to replicate what they might provide in ward based setting but in the community. This has the advantage of older people getting access to a comprehensive geriatric assessment and management in a familair environment and avoid a possible unnecessary admission to hospital with all the risks that entails for vulnerable older people. Expectation is that such a service can rapidly respond as such patients are likely to be at the point of crisis; a geriatric flying squad! At this stage it will tend to operate much like a hospital in the home program, but in time I can see such a service having close ties with local health providers who can identify older people at risk and refer. In this way it can become more collabortive. Either way, there will always need to be close links to the local health providers.

The holy grail is to develop an integrated health care system; a real challenge in our current multi-tiered funding structure of federal, state and local governments and with little vision around to unite them.

Intersting discussion, Andre

Dear Andre,

Health care across the world are now approximating the same model (fees based, means tested, partially insurance/government subsidised) across the world (bar Cuba). This is particularly so after the NHS Reform Bill was passed into law in 2012,

putting an end to all intent and purposes, the underlying caritas ethos of care for in the NHS.

The same challenges you so clearly described in your post is also faced by many elsewhere, and by us here in Singapore. The

issues are so similar that it may as well been me writing them.

Having worked in the NHS model, I have to say that it is indeed an great challenge to provide continuity of care and ensue the seamless transfer of care for frail elderly patient, particularly those with multi-morbidity, as they move from one system or area or care into another. There are many services available in theory, but most are fee based.

How these services are then best integrated to best serve the patient is even less clear. The experience is unfortunately often one of "chaos" for many patient and relatives, as they get "lost" and "overwhelmed" in the multitude of processes and different individuals engaging them.

What is clear however, is that this is an international problem, and it is here to stay.

At the Tripartite Medical Congress of the Malaysian-Singapore and Hong Kong Academy of Medicine held recently in Singapore, Professor Black from RCP London talked about the possible use of a "Sub-acute Assessment and Admission" role for Geriatric Day Hospitals, where patients with frailty and complex multi-morbidity can be seen on request on an "early-basis" (days) when they destabilised.

In the Day Hospital, these patient can then have a full targeted Comprehensive Geriatric Assessment. A decision on whether to carry on ambulatory management with modification to their therapeutic regiments, contacting and liaising with the community services to escalate the level of support (including community palliative services if the decision is for comfort care) or even for admission and acute intervention for acute reversible causes can then be made immediately. This will lead to planned admissions with specific targets, reduce iatrogenicity and less chaos, as well as preventing unnecessary admissions in the first instance.

At present, we do not have a formal service as described. However, through patient and clinical need, a similar model of care has evolved in some of our day to day practice. What has become clear is that for such a service to become formally operational, there will need to be:

1. Geriatricians with broad-based training and clinical experience, willing to engage and with a flexible enough schedule, to assess patients with complex needs at short notice and have access to community and Day Hospital facilities, and basic investigations

2. A good summary and knowledge of the patients complexities (ideally, a patient on long term follow-up by the same Geriatrician). A good electronic healthcare records system will be key for rapid access of information.

3. Departmental and Senior Hospital Management Support

4. Support and willingness to engagement by the patients relatives, committed to provide best care for the patient

After that, there will be the question of how to measure the qualitative benefits of such a service, as this would be of importance in terms of business plans and clinical research.

In my own practice, these sub-acute reviews are led by me and can be triggered by the primary carer in the community (i.e. Transitional Care Services, etc) or even by the patient's family themselves whom are the primary care-giver at home. Patient selection is strict and individualised based on clinical needs.

Usually, it is the patients under my care, post-acute admission, who have access to this due to limited resources. They are not taken into account in terms of clinical performance or financial remunerations.

Perhaps in the future, it is not so much reducing the admissions of the elderly into hospital that will be most important, but rather to provide most of their care in the community, and yet have rapid access to specialist assessment as and when required, in order to avoid unnecessary admissions and all the associated iatrogenicity. This will allow timely planned targeted admissions during periods of true exacerbations.

Perhaps in the future, Geriatricians may be able to work in a dynamic way and in close collaboration, with GPs and Family Medicine Physicians in the community, along with the other community Geriatric services, in a virtual ward fashion. In this way, complex frail patients will always be in a close loop, with planned coordinated care and continuity built-in.

Funding, however will remain an issue, as those who needs help the most will often be unable to afford them. This, I have no answer to, although Aneurin Bevan once did (http://opennhs.org/openNHS_state_funding_nhs.html).

I list some papers, which may be relevant, below:

1. Patient-Centered Care for Older Adults with Multiple Chronic

Conditions: A Stepwise Approach from the American Geriatrics

Society. J Am Geriatr Soc 2012

2. Ordering the chaos for patients with multimorbidity. Building continuity of care takes work but earns trust. Haggerty J L. BMJ 2012;345:e5915

3. What do we know about patients’ perceptions of continuity of care?

A meta-synthesis of qualitative studies. Waibel S et al. International Journal for Quality in Health Care 2012; Volume 24, Number 1: pp. 39–48

4. Beyond diagnosis: rising to the multimorbidity challenge. Urgently needs radical shifts in research, evidence based guidance, and healthcare. Mangin D, Jamoulle M. BMJ 2012;344:e3526

5. Preventing admission of older people to hospital. D'Souza S, Guptha S. BMJ 2013;346:f3186.

6. Inappropriate admissions to hospital: myth versus reality. Royal College of Physicians Edinburgh, 2012.

7. Chronic Care In The English National Health Service: Progress And Challenges. Ham C. Health Affairs, 28, No.1 (2009):190-201

Hi Samuel

Very detailed point of view. How does the healthy system in Singapur function ?

Alike the NHS in the UK ?

Thanks Samuel for the comprehensive summary. There seems to be some consensus that complex care older peope would benefit from specialist early intervention in the community rather than awaiting a crisis theat leads them into hospital.

I would support the notion that an integrated care history is essential but so often lacking. I would add the need for a multidisciplinary team approach to care planning and that these are coordinated and are flexible to work across programs. You may be interested in our Health Independence Programs guidelines, find it at http://health.vic.gov.au/subacute/. These are for our ambulatory and community based services whih include ambulatory rehabilitation programs and specialist clini services, HARP, post acute care and now include residential aged care in reach services. All aim to support early discharge from hospital or avoid unnecessary hospitalisation. We have recently consolidated funding across these various programs that come under HIP so as to reinforce need to have an integrated and coordinated response that isn't fragmentedby funding streams.

Cheers Andre

Dear friends thank you for contributing to this discution. The models of services for the elderky that will prevail in the future will be those that will prove their efficiency and obviuosly their cost / effective benefit. This could probably take at least 10 yeras .

I would now go back to the original question : Whom should an elderly person in community first address for a medical problem ? His family doctor or , in case he is

for instance over 70 , to a geriatrician ?

I think age is often a poor indicator of need, but if you had to pick an age to refer to a geriatrician I would look at an older group where fraility becomes more significant an issue - perhaps around the mid 80s.

I believe that the majority of medical isses in older people can be quite successfully managed by their GPs. Problems arise in the face of the geriatric syndromes and multimorbidity which risk not being well managed unless GPs are skilled and resourced to manage such complexities.

Fee for service practices tends to lead to unidimensional assessments and not to more comprehensive assessments that may be needed. One that frames a discussion of treatment options based on a truly holistic and person centred approach; one that is framed around remaining healthy life expectancy, functional status and quality of life. Such discussions take time and skills. The question is do we want our GPs to have the time and these skills or should they be better at identifying those patients best managed by specialist services in ageing to gain such a comprehensive approach.

GPs generally know their limitations and refer to specialists what would be best is for them to identify the holistic needs in complex older people and refer accordingly and avoid te merry-go-round of single organ specialists.

Andre

The most competent and informed doctor available that understands that all of dementia is not AD, and who also understands mixed versus vascular dementia. Must have a good sense of probable dementia versus dementia diagnosed upon brain autopsy. These may be few and far between in small communities.

Merrill Elias, PhD MPH

Many psychologists in communities have this information and can share it with practitioners if they can cut through the usual politics of persons less competent feeling threatened. Geriatricians, are of course the best resource, and the most likely to recognize the need to avoid poly-pharmacy side effects and depression that may mimic dementia.

Merrill Elias, PhD MPH

Dear Arthur,

A quick answer to your query.

Initially, the model in Singapore would approximate that of the NHS, funded by tax-payers money, being an ex-colony and a member of the Commonwealth.

Then in the 1980s, a decision was made to open the health care services to market forces. Soaring costs and unexpected consequences then led to the current hybrid system of compulsory medical savings accounts (something Obama is trying to do in the US) and state subsidy for those whom could least afford care.

The lessons remain the same, but the Cobb's paradox prevails:

“We know why projects fail; we know how to prevent their failure – so why do they still fail?”

If you are interested in knowing more, the following is a good concise yet detailed account of lessons learnt from the Singapore experience:

Hsiao WC. Medical Savings Account: Lessons From Singapore. Health Affairs, 14, no.2(1995):260-266. doi: 10.1377/hlthaff.14.2.260

Regards,

Samuel

Dear Andre,

Thank you for sharing.

I like the following quote very much:

"The Health Independence Program is a model of care not a discharge destination"

It is a helpful site, but it appears to me that the funding for care for HIP may be a little different from the local context, which is more akin to the US system, where more funding is available for acute care, so as to avoid the creation and fostering of moral hazards in consumption of community/ambulatory services, which by definition, is without a foreseeable end, particularly in the context of the frail elderly patients with multi-morbidity.

It has been an interesting learning experience, sharing on models of care, but we should probably stop here so that others can return to Arthur's original question.

Regards,

Samuel

Dear Samuel

Thank you for the contribution. I liked the Cobbs paradox,

Arthur

There is growing evidence that primary nurse practitioners (NPs) can safely and effectively manage the care of elders in the community. In Canada, NPs are educated to practice from a holistic needs perspective, and have the skills to manage the complex needs of an community-dwelling elder, an do so in a cost-effective manner.

Hi Arhur

Interesting to hear all the models involved.

As Andre may have mentioned, in Australia, GPs/primary care practicioners are the first call for patients, and geriatriicans only see patients on referral (secondary care) from GPs unless the patient is considerd high risk, or linked to a hospital in the home or chronic care program. Also, GPs call me frequently to discusses cases, and many patients do not need a face to face review.

It would important to map services to know at what phase a particular practitioner should get involved; and to ensure minimal duplication and maximal collobration/integration. However I find this is lacking in most health planning; which tend to occur in "silos". This is partly because heatlh care in the community is made up of various organisations and private practitioners.

Perhaps this is less of the problem in the UK with the NHS but I understand the waiting times to see specialist clinics can be long.

Dear Arthur:

My answer is : The primary care physicians, but they must receive a Geriatrics training program.

I have read about; The Einstein - Montefiore GeriEd Program, is a geriatrics training program that improves physician's skills and knowledge of geriatric medicine, with a special focus on older adults with complex medical and neurologic disease such as dementia, falls and delirium.

The GeriEd program develops and enhances the medical school curriculum in geriatrics and provides activities to stimulate medical students interested in geriatrics.

The learners include internists, family physicians, hospitalists and emergency medicine physicians, as well as residents and medical students.

Einstein

Albert Einstein College of Medicine of Yeshiva University.

sincerely.

Diana from Perú.

Dear Diana

Your answer is indeed the " ideal solution " . Community physicians should receive

a training in basic geriatrics, . GerEd is one such program , We at MEUHEDET HMO in Israel developed something similar but with higher modularity and potential of addaptation and others may also develop theirs. This should be delivered to all community physicians in a systematic way that includes obligatory participation .

It is just a mater of coordination and organization . It is one of the Imperatives of

nowadays medicine !

Dear Arthur:

You are right. ¡¡

Best wishes.

Diana from Perú.

Dear Arthur,

In Hong Kong, hospitals are publicly funded, while publicly funded primary care for the older people is limited. Geriatricians are primarily based in pubicly funded hospitals, though we do support outreach services to nursing homes and community nurses. The bulk of primary care of older people in the community relies on private general practitioners.

The Hong Kong Geriatrics Society in collaboration with University of Hong Kong has been running a postgraduate diploma course for GP's for nearly ten years. Each year, we have 10-20 students. The Royal College of Physicians at Glasgow also holds their diploma of community geriatrics examination in Hong Kong once a year.

As I see it, the basic problem is not the lack of trainers, but a lack of willing GP's. This is because the private market from older people is not big enough. In order to encourage or assist older people to consult private GP's, the HK government has introduced a voucher scheme in which all older people get a fixed sum for private medical care. The amount is about US$140 per year, which is woefully inadequate. But this is at least a start.

Timothy Kwok

Dear Timoty

Thank you for this valuable information. What about primary care in general ( for all ages ) ? Is it also private ? Are there Health Insurance Companies ( HMOs)?

And what is the extent of the Geriatric Training course ? How many teaching hours?

Indeed as long as there are specialists in geriatrics there will be trainers but GPs

should probably be obligated to take such a course - in the frame of continuous medical education. Such a step is probably difficult to take when the physicans are

self employed,

Primary care in general is private in Hong Kong. Employees of big companies or the government have health insurance. I guess at least half of working population do not have health insurance.

All GP's have to have about 30 hours of postgraduate education e.g. lectures, self study, research per year.

I agree that a team approach is best, and the use of advanced practice nurses educated in geriatrics serve as a good first line for assessing and managing frail elders, consulting with geriatrics physicians and other specialists as the case so needs. A study published in the Journal of the American Geriatrics Society last year showed that NPs working with MDs was the way that guidelines were better met and the approach significantly improved the outcome of patients. The NPs can follow patients into the homes and coordinate their care at a much lower cost as well.

Great discussion.

In Ontario Canada the 'teamed' primary care approach that includes family physicians working in a co-located environment with health professionals from multiple backgrounds (Nurse practitioners, Social Workers, System Navigators, Pharmacists and Registered Dieticians) has been operative since 2006 and serves over 3 million Ontarians. Natural grass-roots models have evolved from the opportunities afforded by the multidisciplinary, front-line collaboration of these family health team professionals who are mutually faced with the challenges of their aging patients. Larger Health teams that serve over 40,000 patients bring in a visiting geriatrician monthly to meet with a dedicated interprofessional primary care geriatric team to review more complex care challenges that the team identifies as requiring the expertise of the geriatrician. The health professionals receive both tacit and implicit learning from each other, as well as the visiting geriatrician. Other models rely on a family physician champion of sorts to lead the interprofessional primary care team, This model involves formal training (workshops, on-site mentoring from a care of the elderly focused family physician) both are consistent with adult learning strategies that involve peer-to peer training within the trainees environment. These approaches are promising and have undergone some evaluation and validation making use of independent geriatrician reviews of the primary care team management of seniors with complex health problems, as well as patient/caregiver, health professional satisfaction of involvement with team. Impact on health system outcomes remains elusive (ED attendance, time to long-term care admission, etc) as well as a broad understanding of the collective impact of the various models. Similar primary care reform process are occurring in other provinces (Quebec, British Columbia, etc) a planned systematic evaluation is underway to consider patient, caregiver, family and health professional care experiences, system impact and quality of care outcomes across models in all three provinces. Hopefully shedding some light on the problem.

Bye for now, Ainsley

Hi Ainsley, I am interested to what degree the model you descibe coud be considered an integrated care model? To what extent does the team provide an interface between the hospital and the community support services. You mention that these are primary care teams. I am inteested in the mechanics of these teams. Who/how are people referred? How are they funded? Can you provide link to mre information.

Regards Andre

VA recently transitioned their primary/ambulatory care department to a Patient-Centered Medical Home Model (called Patient Aligned Care Teams or PACT). This involves team based, pt centered, pro-active care utilizing data to guide programs (e.g., targeted self-mgmt program, group clinics, etc) - all of which are hallmarks of quality geriatric care. What is lacking however are the knowledge/skills/tools to use that are specfic to the geriatric population and how specific team members can be used efficienty & effectively to target geriatric syndromes (i.e., everything seems to fall on the medical provider including items that could easity be done by other team members - like medication review, functional assessment w/ ADLs/IADLs, etc). Thus, we are currently trying to" infuse geriatrics into PACT" in my facility by working with teams in identifying clinic processes for specific syndromes (e.g., clinic process on what to do if patients with dementia warning signs are identified by the clerk or nurse during clinic check-in) and teaching interested staff on use of specific geriatric tools (e.g., LVNs doing the MoCA as part of a cognitive evaluation)..... The question on who should treat community-dwelling older adults - primary care versus geriatric specialists - I think is a moot point because there isn't enough geriatric specialists (in any discipline) to care for all older adults. So in my opinion I think we need to try to work more with primary care clinicians (again - any discipline, not just medicine) and try to 'geriatricize' (for lack of better term) their practice... Just my two cents. :)

The Health Authority in Stoke-on-Trent (North Staffordshire, England, UK) recently set up a pilot community geriatrics service and employed me (Consultant Physician/Geriatrician) to work exclusively within Primary Care for a few months. Until then, I had worked as Community Geriatrician in that area for the last 12 years, based in small cottage hospitals where I developed various services (Rehabilitation; Intermediate Care; Geriatric Clinics; Direct admission and assessment of sub-acute patients; Educational courses for senior nurses). The new service mostly entailed seeing older patients at the General Practice premises, performing thorough assessment, making recommendations on management of current problems, and advising on preventative measures. I also assessed some patients at their own homes or in Residential and Nursing homes. All these patients were purposely selected by their General Practitioners on the basis of frailty, multiple pathology, disability, and polypharmacy. For each patient we allocated one hour. I followed this up with a detailed typed report. Crucially, at the end of each working day, I held a meeting with the relevant GP, we went through in detail every patient I saw, and I outlined my recommendations and their rationale. This exercise was very well received by all the GPs. They felt that they were receiving specialist input for their most complex patients, and at the same time they gained more insight and expertise in Geriatric Medicine. As regards the patients themselves, their informal feedback was enormously positive. There is planning in progress to implement this service on a more regular basis. There are many different models of 'community geriatrics', and I feel the one I described above can play an effective role. As regards cost-effectiveness, this is currently being analysed by our local Research & Development Department. I hope my above contribution is of some interest to colleagues in other regions and countries.

Dear Barnabas

Thank you for your contribution with this most interesting experience, I will appreciate

to have a look at the results. But before the analysis is completed . What is your general impression about the way the patients were referred to the Geriatric Consulant by their GPs? Have they formulated / defined a Question to you or they were sent with general describtions " for geriatric evaluation"... " please your advice ' etc

Do you think that all referrals by the GPs were justified ? About how many were not ?

Did the GPs have reasonable basic knowledge in Geraitrics in order to maintain a professional communication with them ? It seems to me that you are now rich in

valuable experience regarding the interface GP / Community Geriatrician and hope you can share it with us.

Arthur

Thank you Arthur for your helpful feedback and for seeking more information. In answer to your specific questions that shed more light on this project:

1. PATIENT SELECTION/REFERRAL: At the outset, the broad objective was for GPs to refer to me 'high-risk frail patients to see what more can be done for them medically and proactively'. More precisely, we aimed to optimise management of long-term conditions (e.g. rectify under-treatment of COPD, heart failure etc), reduce unnecessary medications and polypharmacy in order to reduce harmful side-effects and improve general well-being, and proactive management wherever possible (e.g. to reduce falls and hospital admissions).

As most General Practices have 2000 to 6000 patients, the method of selection was firstly by accessing the computerised 'frail elderly register' at each Practice. To pick out the patients most likely to be in greatest need, additional selection criteria were then added sequentially e.g. multiple long-term conditions, multiple consultations, polypharmacy. This approach continued until it yielded the number of patients I could manage in my available time. All the referrals were selected by the GPs themselves in this way. In other words, the referrals were made for the purpose of comprehensive evaluation and to provide advice. In only a minority of cases the GPs referred from the outset some patients for a very specific clinical reason.

2. SUITABILITY OF THE REFERRALS: As it happens, almost all referrals were suitable in the sense that problems/issues were identified for which significant beneficial intervention was possible. Only in very few patients (3 or 4 as I recall) no or minimal intervention was possible.

3. GPs LEVEL OF KNOWLEDGE IN GERIATRICS: Most of them did have a good understanding of the basic principles of geriatric medicine, but not to the extent that they can manage autonomously the most complex/challenging cases. This was particularly evident in relation to clinical pharmacology. In the majority of patients I found unnecessary medications, excessive dosing, and/or undesirable combinations of drugs. We cannot expect GPs to know everything as they are dealing with conditions from a large number of disciplines/sub-specialties. Hence, there is need for on-going support of GPs and development of their skills.

4. OTHER COMMENTS: I did this work for a total of six weeks. Two of my Specialist Registrars nearing the end of their training also did the same as me for four weeks. We saw in total 200 or patients. I will let you know the results of the formal evaluation when it becomes available. Thank you again for your interest and helpful cooments.

Thank you for sharing with us this valuable information.

Kind regards

Arthur

Dear all - not at least the nurses,

I am a geriatrician and crucial aware of my lack of knowledge in many areas - so I need my geriatric team. With nurses, physiotherapists, occupationel therapists, pharmacists, socail care mangers, dietricians and sometimes even more professionals. How can a nurse practitioner be a geriatric team and perform the evidence-based superior Comprehensive Geriatric Assessments (CGA) to frail old people?

Not every old aged person addressing  with a medical problem needs a complete CGA.  He should  go first to his  community  GP and  only when he is not able to resolve his problem  he may ask for geriatric  advice. Even at this stage many cases can be satisfactorily  evaluated by the core team ( geriatrician, nurse and SW.)

I agree. In Sweden we have mostly "care on demand" - not always need. Unfortunately many of the frail old people suffers from cognitive decline - and are not able to seek care. The challenge is to identify and actively take care of patients that needs the full team and let other patients be taken care of by the core team and very well lead by a nurse as coordinator. In this way we will get both the best and cheapest solution.

I think the Alzhiemer's Scotland Model using the "eight pillars of support" (2012) works very well, where a collaborative approach is used. The various organisations need a coordinator to involve the various contributors to the overall support. I strongly believe that this should come from those that provide the support (who have a nursing background) and work  "at the coal face". They will see the person on a day by day basis at home and can bring in the various medical expertise/equipment, telecare etc. on an as and when , to avoid unnecessary hospital admissions and the symptoms of delirium. This should be  deemed as a speciality service but many treat it as peacemeal in the old paradignm of care and it appears to be very fragmented and expensive to run. It really needs the buy in from all to agree who will coordinate and agree to be called in as and when necessary. Unfortunately the medical model prevents this from happening which is a real shame.

Hello  Bob

This is one important aspect of the work that is done in the UK  I have just attended  " "The Alzheimer Show 2014"  ( London ' May 16-17) and was very impressed by the contribution of Stirling University .

Arthur

To Jenice in particular (but all who may read this): Thanks for your efforts within the hard-working, futuristic (but currently much maligned) VA, where I worked as director of Geriatrics & Extended Care ar VA Puget Sound from 2000-2010): I could not agree more. I would only suggest substitution of  "gerontologize" for "geriatricize". Gerontologize rolls off the tongue more easliy, plus it encompasses all we do and know as a scientific discipline that studies and values life from conception through death as well as caring for those nearing the end of their lives. Good luck! Bill

I think we need to distinguish first between elderly people who might be normal in their general health  and elderly who who special health problems which might need special care. The first can be cared for by health care staff working in primary health centres. Specialist in family medicine working in primary care  are expected be competent in handling most of the problems of the catchment population including the elderly group. Elderly with special health problems need staff with special knowledge and skills to handle these cases. A few specialized geriatric teams may deal with referred cases from the primary care centres.

I think geriatric physician (who specializes in the care of elderly people) should treat elderly patients. 

Very simply, there are only a few specialist geriatricians in any one area, but a very large number of elderly patients almost everywhere. Hence, it's impossible for us geriatricians to deal with all these patients and many of them have to be managed by primary care professionals e.g. General Practitioners, Community nurses, rehabilitation therapists etc. This means ensuring that non-geriatrician personnel such as these receive extra education and training in Geriatric Medicine.  Where I am (North Staffordshire, England UK) we have set up a postgraduate Diploma and Masters course in Geriatrics for primary care staff.  If anyone is interested you can contact me on [email protected] for more details of the course.  

Lastly, following on from my previous contributions to this debate in June 2014, the project I referred to at that time  regarding specialist geriatricians working within primary care has at last been written up and will hopefully be published soon in the BMJ Open journal.

Good Morning:

I agree with Barnabas.

I think this article is important too.

Chad Boult, Steven R. Counsell, Rosanne M. Leipzig and Robert A. Berenson.

The Urgency of preparing Primary Care Physicians to care for Older People with Chronic Illnesses.

Health Affairs   May  2010 vol 29 nº 5  811-818.

Sincerely.

Diana from Perú.

I now have an update on a couple of themes we discussed previously:

1. The results of the project of Geriatricians performing community-based holistic assessments in General Practice has now been published in the BMJ Open journal - please link: http://bmjopen.bmj.com/content/7/9/e015278

The predominant outcome was in relation to medicines optimization, hence we made this the main theme in the paper.

2. I am happy to attach a leaflet explaining our new postgraduate Certificate / Diploma / Masters course in Frailty & Integrated Care at Keele University, Staffordshire, England. The first two years have been very successful. The majority of students are General Practitioners and community nurses. The aim is to improve the care of older people by training non-geriatrician professionals who manage older patients.

Care of elderly people by the general practitioner and the geriatrician in Belgium: a qualitative study of their relationship

The care of elderly people is a large part of a general practitioner’s work. The growing elderly population means that the medical community must give thought to the management of their care. Within this large field, we focused on the relationship between general practitioners and hospital geriatricians.

Article Care of elderly people by the general practitioner and the g...