Patients over the age of 75 are often the sickest and most disenfranchised population in a hospital, and their unique needs mean the role of a geriatrician differs from other specialties.
“A lot of our job is to make sure that our patients are well cared for and safe no matter what their environment,” said Rebecca Boxer, MD, MS, associate professor of geriatric medicine.
The clinic’s multidisciplinary team offers patient-centered, wraparound care for all patients over the age of 75, regardless of whether they are living independently or in a long-term care facility. The key to the team’s success is collaboration across multiple aspects of patient care, particularly patient wellbeing, social care and prescription medication.
Monthly case conferences
Positive change started when a patient with dementia wandered away from the waiting room. Once the urgency of the situation had been resolved, the team was left with a single question: Who is responsible for patients while they sit in the waiting room?
It wasn’t an easy answer. So the Division of Geriatric Medicine pulled the entire team into one room to better understand the roles and responsibilities of each team member. And thus began a monthly multidisciplinary case conference, where everyone has an opportunity to speak about issues that impact the safety and wellbeing of their patients.
“Anyone can bring a case to the whole team,” said Dr. Boxer. “We come together to share stories so we can solve the problems that come up when caring for this vulnerable patient population.”
Often the discussion segues into improving systemic issues, such as how mental health as a whole is addressed within the clinic.
“Sometimes we invite guests, particularly when we’re seeing issues arise as a result of working with community partners,” said Dr. Boxer. “Sometimes it’s about a single patient, such as a 98-year-old patient with dementia who was acting out within the community. How do we keep her safe and in her housing? Other times it’s about how we deal with families and the best way to troubleshoot when a family member disagrees with her mother’s care.”
Social worker interactions
Kirbie Hartley, LSW, is a social worker in the Senior’s Clinic at University of Colorado Hospital. Her primary responsibility is to discuss social supports for patients and their families outside of the clinic. She links patients to community resources, transportation, housing and Meals on Wheels, and provides assistance around care transitions and advance planning.
As she is embedded within the clinic, Hartley is able to meet directly with patients and families after their appointment with their primary care provider. “Our conversation might start because the patient has made the provider aware of a need for transportation,” she said. “But then I’ll meet with the patient and learn that they are also having difficulties getting meals or groceries, so I’ll work with them within the clinic to make phone calls to different services and set them up with different resources.”
One of the most difficult aspects of Hartley’s job is managing the patient and family dynamic. “It’s common to have complicated family dynamics, but the patient always comes first. I’m a big advocate for dignity as we age, and if a patient is making a poor decision, their rights come first. We can encourage but we can’t stop them.”
A big benefit of an integrated, collaborative approach is eliminating the “he said, she said” aspect of coordinated care.
“There are a lot of times when we meet with patients and their families as a team, and we talk about issues together in an open forum,” Hartley said. “We look at our patients as a whole person and individually, and think about the factors that play a part in that person’s health.”
Embedded pharmacy consults
A third factor that makes the Senior’s Clinic different is its history of having pharmacy staff embedded within the clinic. Although the clinic does not dispense any medications, it’s not uncommon for geriatric patients to have multiple prescriptions so the potential for drug-drug interactions and serious side effects is high.
Danielle Fixen, PharmD, BCGP, BCPS, is one of three pharmacists who provide consulting services within the clinic. “I get a lot of questions from providers who want me to review their patient’s medications for drug interactions,” she said.
But while it is convenient for providers to have this level of access to a pharmacist, patients also benefit directly, through the gift of time—something that’s not always possible in today’s health care system.
“We’re able to talk to patients in a way that’s not available in a traditional pharmacy setting,” Fixen said. “We see patients in the clinic, but we’re also available for phone consults where I can spend up to 45 minutes on the phone. I go over what they can expect from new medications and give them as much information as I can.”
The team has recently started a cognitive assessment clinic, where pharmacy plays a big role in reviewing medications with the patient prior to the appointment and providing recommendations based on those conversations to the provider. Similarly, the pharmacy team is involved in the transitions of care program, providing the same service to patients who were recently discharged from a facility.
“I’m on the phone a large portion of my day, which requires patience,” Fixen said. “But I do feel like I’m really making a difference.”
A comprehensive team approach
As the Senior’s Clinic prepares for the future, it is taking a look at how the expertise of the School of Medicine’s geriatricians can be further disseminated to reach more aging patients.
“Since geriatrics expertise is not widely available, we’re looking at ways we can use telemedicine to provide consults to rural physicians and patients throughout Colorado,” said Bennett Parnes, MD, associate professor and practice director of the Senior’s Clinic. “Our team provides a very high-quality service to frail elderly patients, and we want to continue to improve on the care we deliver and expand it to be even more comprehensive.”
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