MODELS AND GOALS OF CARE FOR THE OLDER ADULT

The U.S. population is aging rapidly, and this growth, along with a slow adaptive policy framework, is creating an urgent need to reengineer and improve the quality, safety, and cost-effectiveness of health systems to meet the needs of older adults. The nation’s decision makers are confronting an enormous range of specific challenges in caring for the aging. These include development of:

Policies affecting older adults with multiple, serious chronic conditions: Costs of care; differential impact of healthcare costs and access by race, ethnicity, gender, socioeconomic status; improvements in the healthcare system models of care coordination, integrated mental health, and preventive health
Policies affecting the economic and physical security of vulnerable and disadvantaged older adults: Access to low-income benefits (i.e., Medicare, Medicaid, food stamps, etc.); pensions and retirement income; employment and transitions to work; consumer protections (i.e., predatory lending, telemarketing fraud, etc.); financial literacy; nutrition education; environmental and transportation issues affecting older adults
Policies that promote civic engagement (i.e., volunteerism) and community engagement by older adults and caregivers to improve the healthcare system and the well-being of all older adults
(HAPF, 2020)

Models of Care

There is a need to shift from episodic acute illness care to a population health approach in the fields of geriatric and palliative care. Such an approach is an example of a model of care, which defines the way health services are delivered and outlines best-practice care and services to improve access to and quality of healthcare, improve the patient’s quality of life, and moderate healthcare costs. Such models must integrate physical and mental health, long-term services and supports, social services, and home- and community-based services. Examples of models of care are described below.

ACUTE CARE FOR ELDERS (ACE)

Acute Care for Elders is a continuous quality improvement model of care designed to prevent the patient’s loss of independence in the performance of activities of daily living from hospital admission to discharge.

An ACE hospital unit consists of several core components:

Patient-centered care with proactive geriatric assessments
Nurse-driven care plans for the prevention and management of geriatric syndromes
Comprehensive care transition planning beginning on admission
Medical care review to prevent iatrogenesis and incident geriatric syndromes
An environment modified to promote safe mobility and cognitive stimulation
(Palmer, 2018; Flood et al., 2018)

GERIATRIC SYNDROMES

The term geriatric syndrome refers to common health conditions in older adults that do not fit into distinct organ-based disease categories and often have multifactorial causes. They may include:

Cognitive impairment
Delirium
Incontinence
Malnutrition
Falls
Gait disorders
Pressure injuries
Sleep disorders
Sensory deficits
Fatigue
Dizziness
(Ward &Reuben, 2020)

Using the ACE model, care is delivered by an interprofessional team that conducts frequent team meetings (rounds) to develop the geriatric care plans for each patient. In most ACE units, a geriatrician or geriatric advanced nurse practitioner either participates in the team meetings and/or is an attending practitioner for patients (Palmer, 2018; Flood et al., 2018).

This model encourages patients to be mobile. The physical design of the hospital unit is adapted to a patient’s age-related changes and includes special features to enhance a patient’s mobility and independence. The goals are to prevent or reduce:

Delirium
Functional decline
Cognitive decline
Falls
Skin breakdown
Immobility
Constipation
Use of indwelling catheters
(URMC, 2020)

PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)

A coordination model, PACE provides comprehensive medical and social services to certain frail, community-dwelling older adults, most of whom are dually eligible for Medicare and Medicaid benefits. An interdisciplinary team of health professionals provides PACE participants with coordinated care, enabling them to remain in the community rather than receive care in a nursing home. Eligible individuals must be age 55 or older, be eligible for nursing home care, and be able to live safely in the community. At a minimum, PACE centers must provide:

Primary care services (physician and nursing services)
Social work services
Restorative therapy (physical and occupational therapy)
Personal care and supportive services
Nutritional counseling
Recreational therapy
Meals
(CMS, 2020)

GERIATRIC RESOURCES FOR ASSESSMENT AND CARE OF ELDERS (GRACE)

The GRACE model is designed to address healthcare challenges faced by low-income older adults with multiple chronic conditions. It is a home-based care model led by a geriatrician and including a nurse practitioner, social worker, pharmacist, and mental health liaison. This model supports office-based care management, with the goal of preventing unnecessary emergency department visits, hospitalizations, and long-term nursing home placement. The target population is 65 years or older with functional limitations and/or geriatric conditions (e.g., falls, depression, dementia) and a high risk for hospitalization. With this model, patients and families participate in the development of an individualized care plan (Health Innovation, 2018).

CARE COORDINATION MODEL

Care coordination in primary care practice involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient to achieve safer and more effective care (AHRQ, 2018).

COMMUNITY HOME HOSPICE-BASED CARE

This model is an intensive, bundled form of home-based care for patients whose life expectancy is defined in months and who are no longer benefitting from disease-directed intervention. Care is provided by nurses, physicians, social workers, chaplains, and home aides (Twaddle & McCormick, 2020).

CERTIFIED NURSING FACILITY MODELS

Nursing homes are facilities that serve as healthcare residences for those who require a higher level of care than can be provided at home or in an assisted-living facility. One such nursing home model, the “household model,” combines elements of traditional nursing and a physical environment that is homelike, the goal being to create real community within a space that older adults recognize as home (PHI, 2018).

Nursing Models of Care

Nursing models of care emphasize maximizing the role of nurses and advanced practice nurses in the provision of care to older adults.

NURSES IMPROVING CARE FOR HEALTH SYSTEM ELDERS (NICHE)

NICHE is a nurse-led program designed to improve the quality of care for older adults. Components include:

Nursing care models to support specialized geriatric care delivered by nurses, nursing assistants, and other frontline clinical staff
Research-based clinical practice protocols for common nursing problems and syndromes experienced by hospitalized older adults
Staff development, quality improvement, and care coordination models to identify barriers and promote effective geriatric care within and across hospital nursing units
(Witkoski Stimpfel & Gilmartin, 2019)

GERIATRIC RESOURCE NURSE (GRN)

The GRN model of care focuses on identifying older adults for nonemergency, geriatric-specific needs by nurses educated in geriatrics and emergency department nursing. A GRN may partner with a social worker, who will offer referrals and information on skilled nursing home care, home healthcare, hospice, respite care, and other resources. Adoption of the GRN program:

Provides excellent bedside nursing to older adults
Develops a core group of nurses to serve as a resource to other staff
Stimulates interest in gerontological care and elder care services
Develops incentives and improves morale for nurses caring for the older adult
Provides a mechanism for professional growth of nurses
Enhances the nurse-patient relationship and patient satisfaction
Promotes the effectiveness of interdisciplinary teams
Increases implementation of evidence-based clinical practice
Provides optimal utilization of hospital services
Facilitates safe and effective discharges
(MHS, 2020)

TRANSITIONAL CARE MODEL

The transitional care model is a nurse-led hospital discharge and home follow-up program for chronically ill older adults designed to prevent complications and rehospitalizations. The care is coordinated by a master’s level transitional care nurse trained in the care of people with chronic conditions. Two main focuses of subsequent home visits and phone contacts are:

Identifying changes in the patient’s health
Managing and/or preventing health problems, including making any adjustments in therapy in collaboration with the patient’s physicians

The nurse also accompanies the patient to the first physician visit following hospital discharge to ensure effective communication (Social Problems That Work, 2018).

Healthcare Goals for the Individual

Healthcare goals relate to the values and activities that matter most to individuals and that help motivate them to sustain and improve health. There is often a gap between what care team members know about what matters to their patients and what care these patients receive in accordance with their goals and preferences. When identified in a specific, actionable, and reliable manner, patients’ health outcome goals can guide decision-making.

COMMON CONCERNS

Discussions with older adults about what matters to them have identified the following five common themes:

A need to access information about what services are available, how to access services, and how services can be paid for.
A need for better communication between patients and care providers, as well as among care providers. Older adults experience care as fragmented and disease-focused, which can cause feelings of isolation and of being reduced to individual body parts—not the whole person. (See also the box below).
A desire for care to be delivered by providers who know them, listen to them, spend adequate time with them, and offer the opportunity to be involved in decisions about care and treatment options.
Support from family and staff in the community to cope with chronic disease and to continue to age in place.
Smooth transitions between acute and community services. Discharge from the hospital is a concern when community support is inadequate.
(William-Roberts et al., 2018)

GOAL SETTING

Older adults are able to attain health-related goals through collaborative goal planning, which enables professionals, patients, and researchers to monitor effects of care and support and to quantify the impact of the interventions. The goals of community-living older adults mostly aim at improving health and managing problems concerning physical health, mobility, or support, and can be attained through patient-centered care that:

Puts the person in the center
Matches the person’s needs and preferences in a holistic way
Involves assessment, goal-plan development, and goal-plan evaluation

The SMART framework is one means to help set patient-centered goals (see table).

“SMART” FRAMEWORK
Label	Characteristic	Description
(Rietkerk et al., 2018; Thornberry Ltd., 2019)
S	Specific	State the goal clearly.
M	Measurable	Identify and quantify the observable markers of progress.
A	Achievable	Break the goal down into smaller, actionable steps. Identify expected barriers and make a plan to address them.
R	Realistic	Be certain the goal reflects what is important to the individual.
T	Time-bound	Define the period in which the goal is to be attained and agree when to check progress.

Key strategies to ensure that older adults’ expressed goals and preferences are incorporated into the plan of care should include:

Patient education as part of care planning. Education is necessary to discuss harms and benefits of various treatment and care options.
Understanding the patient’s rejection of options or plans presented. In some cases, preferences may conflict with the clinician’s medical advice. Both clinician and older adult may need to re-evaluate perspectives and work together to find alternatives.
Leveraging interdisciplinary resources that are outside the clinical sphere to address older adults’ needs, such as housing, food, or access to social services.
Engaging with community resources for addressing needs beyond the health system that may include support for social determinants of health such as transportation, financial support, and behavioral health.
(IHI, 2019)

COMMUNICATING EFFECTIVELY WITH THE OLDER ADULT

For the older adult, the ability to communicate effectively is central to self-esteem, identity, and quality of life. For the healthcare provider, effective communication is essential for understanding and assessing older adults and promoting their health.

Therapeutic communication is a person-centered interaction that involves using eye contact, open body language, and active listening. There are three separate subcategories to communications:

Seeing the individual
Being respectful
Showing empathy and compassion

Older adults often report being treated with lack of respect and negative attitudes and receiving insufficient information. It is important to remember that older people are not a homogeneous group but have a wide range of life experiences that influence their perception of illness and their ability to communicate with healthcare professionals. Ineffective communication can cause older people to feel inadequate, disempowered, and helpless. It is important for providers to treat older people as individuals and to monitor and adapt communication accordingly.

It is helpful for healthcare providers to recognize whether they are communicating by talking with the older adult or talking to them. Older people need and are entitled to be recognized when matters involve them. Even if a person has dementia or memory loss, attention and comments should be directed to the patient.

Following are examples of practices to enhance communication with the older patient:

Addressing the patient by last name, using the title the patient prefers (e.g., Mr., Ms., Mrs.) until told otherwise
Avoiding familiar terms such as “Dear” and “Hon”
Introducing oneself and showing an interest in wanting to hear the person’s concerns
Assessing and matching the person’s communication style by listening to the volume, pace, pitch, and tonality (expressive or reserved) of their speech
Being alert to and compensating for deficits in hearing or vision
Not rushing and speaking more slowly so that the person will have time to process what is being asked for or said, since feeling rushed often leads to people believing they are not being heard or understood
Avoiding interrupting, since once interrupted, an older adult is less likely to reveal all of their concerns
Using active listening skills by facing the patient, maintaining appropriate eye contact, and using brief responses to indicate one has been listening
Demonstrating empathy by watching for opportunities to respond to the person’s emotions
Avoiding medical jargon and using common language
Introducing information by first asking patients what they already know about their condition
Asking if clarification is needed, such as having something written down
Asking patients to state what they understand about their presenting problem and what they think needs to be done
Using family history to gain insight into an older patient’s social situation as well as risk of disease
Asking about living arrangements, transportation, and lifestyle to help determine appropriate interventions

(Jack et al., 2019)

Healthcare Reform Initiatives

Healthcare initiatives are planning documents establishing strategic priorities for tackling the nation’s most pressing health problems. Initiatives that address issues of concern to older adults include:

Restructuring healthcare delivery systems
Regulation of nursing homes and long-term care facilities
Improving quality through financial incentives
Strategies for chronic care coordination
Mental health and preventive healthcare Medicare benefits
Providing care for aging U.S. veterans
Addressing disparities among various populations
(HAPF, 2020)

NATIONAL PLAN TO ADDRESS ALZHEIMER’S DISEASE

This plan establishes five goals to prevent future cases of Alzheimer’s disease and related dementias:

Prevent and effectively treat Alzheimer’s disease by 2025
Optimize care quality and efficiency
Expand supports for people with Alzheimer’s disease and their families
Enhance public awareness and engagement
Track progress and drive improvement
(CDC, 2020a)

HEALTHY AGING IN ACTION (HAIA)

This initiative’s aim is to increase the length of people’s lives and ensure their lives are healthy and productive. HAIA is an effort to call attention to existing policies and programs that reflect the National Prevention Strategy’s approach of targeting prevention and wellness efforts to promote healthy aging, and offers recommendations that could further the strategy for an aging society (CDC, 2020a).

AGE-FRIENDLY HEALTH SYSTEMS

The Age-Friendly Health Systems initiative recognizes that older adults in the United States deserve safe, effective, and patient-centered care that aims to follow an essential set of evidence-based practices, cause no harm, and align with what matters to the older adult and their family caregivers. Age-Friendly Health Systems include the “4 Ms”:

Matters: Know what matters to the older adult concerning specific outcome goals and care preferences, and align care with them across settings of care, including end-of-life issues.
Medications: If medications are necessary, prescribe age-friendly ones that do not interfere with what matters to the older adult, their mentation, or mobility across settings of care.
Mentation: Prevent, identify, treat, and manage delirium across settings of care.
Mobility: Ensure that each older adult moves safely and on a daily basis to maintain function and what matters to them.
(IHI, 2020)

OLDER AMERICANS ACT (OAA) OF 2020

The OAA of 2020 provides policy direction, principles, and financial support for home- and community-based services for older adults through discretional funding programs. Occupational therapy interventions, programs, and practices that target community-based interventions, health promotion, and disability prevention are suited to support the initiatives through the OAA (Marfeo, 2020).