How to Communicate What's Important Among the Many Geriatrics Care Models

Abstract

The chief medical officer of a large health system recently interrupted a presentation by the geriatric medicine leader, saying, “You have too many models for us to discuss today. Just tell me your highest priority and why.” This feedback came during a meeting focused on shaping the future direction of the health system after four decades of efforts to enhance care for older adults. We are reminded of the importance of clearly describing geriatric models and how those models fit in our health system when reading the scoping review of Ann Dandich et al. in this issue of the Journal of the American Geriatrics Society [1].

The challenge described above arose because, over the years, many successful care models for older adults had been developed. However, leadership turnover and heavy reliance on generous donations had left the organization in need of clear priorities. The not-for-profit organization needed to determine which of the many effective models should be prioritized to allocate resources and provide appropriate salary support.

Dadich and colleagues' paper contributes to the geriatric medicine literature by examining numerous geriatric care models and identifying important gaps. According to the authors this analysis yields a call to action for current and future model development to follow consistent definitions and reporting standards, and to incorporate family caregivers and social determinants of health with greater attention to under-represented minorities and rural environments.

Additionally, in the context of other recent evaluations of existing geriatric care models, this report speaks to the current opportunities for shaping healthcare to meet the needs of older adults. Dadich's approach complements McNabney and colleagues who summarized predominant themes in geriatric practice models [3]. In their evaluation the themes of person-centeredness, interdisciplinary assessment and complex care management predominate among geriatrics care models. Likewise, an essay by Terry Fulmer and her colleagues highlighted six vital steps to improve care across health care settings [4]. Fulmer et al. described the importance of remediating disparities and inequities in care of older Americans. They described the public support that is needed (i.e., an adequately prepared workforce, financial structures, and public health resources) as we develop, evaluate and implement new health care models. Service line leadership, they argue, should prioritize programs for older adults. Dr. Chad Boult and his colleagues performed a meta-analysis of comprehensive care models for older adults in 2009 concluding that while there was evidence to support multiple models of care, few models were widely adopted across health systems and across the country [5]. Similarly, an essay by Dr. Mary Tinnetti advocated for broad implementation of core geriatric medicine principles and elements across all care settings [6]. These impactful assessments of our current state of care model development have culminated in a set of four evidence-based practices e, known as the “4Ms,”: What Matters, Medication, Mentation, and Mobility, that are used in age-friendly health systems to provide high-quality care. In the United States the Age-Friendly Health Systems is an initiative of The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI), in partnership with the American Hospital Association and the Catholic Health Association of the United States (https://www.ihi.org/networks/initiatives/age-friendly-health-systems). The recent CMS FY2025 Inpatient Prospective Payment Systems final rule includes a required Age-Friendly Health System measure for hospitals that participate in Medicare's Hospital Inpatient Quality Reporting (IQR) Program to publicly report their organized efforts to provide age-friendly care across multiple domains [7]. This policy will be an inflection point to promote the broad dissemination of geriatric principles in American hospitals.

Dadich et al. describe the primary literature on care models as lacking in consistent organization or focus on the process of implementation and dissemination. A recently published book has organized this information for 42 geriatric care models spanning inpatient and outpatient care settings [8]. Our task is to identify which model, among those evaluated by Dadich and colleagues, should be prioritized while recognizing and ameliorating their weaknesses when possible by involving family care partners, considering geographic density of patients and resources and attending to overlooked populations. Hospitals can meet the recent CMS publicly reported measure on Age-Friendly care by implementing specific models. We must clearly articulate why a model is chosen and what is needed for its dissemination. By focusing on what is most important for older adults and how we will scale this work, we can effectively advocate for the core geriatrics principles and elements. Importantly, older adults are becoming more culturally diverse, this creates a novel opportunity for geriatric leaders to evaluate and deploy strategies to improve care transitions in unique patient populations.

Finally, in 2024, Drs. Colenda and Applegate described remedies needed to advance geriatric care within large healthcare systems [9]. They posit that systems too often impede geriatrics care because they are focused on reimbursement, and thus are dominated by disease-specific episodes and fee-for-service structure that yields high reimbursement. They advocate coopting the disease-specific “service-line” vocabulary predominant in strategy discussions to the management of medically complex older patients embraced by existing geriatric care models. Furthermore, they recommend using the 2010 Patient Protection and Affordable Care Act mandate for community needs assessments to identify service gaps and form local community-based coalitions to advocate, partner, and incentivize hospitals/health systems to build their capacity and thus fulfill the hospitals' and health systems' mission to their communities.

Geriatric leaders and health system administrators must clearly communicate both “the why” and “the how” to move forward with real world adoption of models in clinical practice.

Drs. Michael L. Malone, Heidi White, Jonny Macias Tejada, Marie Boltz contributed to writing and revising this manuscript.

Drs. Heidi White, Jonny Macias Tejada, Marie Boltz: declare no conflicts of interest. Michael L. Malone, M.D. discloses this potential conflict of interest: Owns stock in Abbott Labs and AbbVie.