Disease Management Care Blog readers may recall this snarky "It's Team Based Care, Not More Experts" speechifying that challenged a John A Hartford Foundation report on the growing need for expert geriatric care. The Foundation's Program Director Christopher Langston responded and, rather than let it languish as a bottom-of-the-page-comment, the DMCB thought it warranted its own separate posting. Dr. Langston makes some good points:
The John A. Hartford Foundation has long recognized (here's an example) that there are only 24 hours in the day and that teams are critical to delivering quality care in a cost-effective way.
So when we reported the results of our recent poll showing that despite the existence of the new Medicare Annual Wellness Visit benefit, older adults still aren’t getting important assessments (like fall risk, mood screening, or medication review) at adequate rates, we weren’t trying to doctor bash or even suggest that MDs should work harder. They just need to be sure that the work gets done by someone.
We are in favor of organized, team-based systems of care and the poll results should include services delivered by non physician-providers. The cognitive interviewing that the survey firm did as part of question development assured us that respondents were saying "yes" when they got services/assessments from a practice regardless of who exactly delivered them (MD, RN, MA, or ??).
So, I don't think we have a real disagreement on this team/delegation issue.
I also tend to agree with the Disease Management Care Blog that we can't really tell from the poll if MORE geriatrics expertise would help or not -- BECAUSE we aren't really using even the limited expertise we have. Models like IMPACT or Guided Care mostly use generalists and incorporate "expertise" in the team model and the protocols they use. Unfortunately, these models are underused.
Perhaps the role of geriatrics expertise is to help practice leaders redesign their work? Respondents on the poll did endorse items that more health professional education would help and even improve their care, but any one perspective, even patients’, on this issue is limited. It was also very interesting that in question development, our polling firm kept trying to focus on the work of the MD. Perhaps the public needs some education too before it buys into the team concept?
Regardless, the Foundation supports more education in geriatric care that can at least teach providers take this part of their work more seriously. I don’t think that we really need to teach MDs HOW in a mechanical sense to do a “get up and go” test of mobility and balance, but we do seem to need to teach WHY they should do one as well as find ways to incorporate such assessments into the work of the team. Ageist attitudes seem to stand in the way of many providers understanding that their care of older adults makes an even bigger and more immediate difference in outcomes than the care of younger adults.