Computerized geriatric assessment for geriatric care management.
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Medicare reimbursement for geriatric assessment: report of the American Geriatrics Society Ad Hoc Committee on Geriatrics Assessment.
This ad hoc committee report from the American Geriatrics Society proposes the prompt initiation of Medicare reimbursement for geriatric assessment (GA) services (also termed comprehensive geriatric assessment or geriatric evaluation and management services). Despite an extensive body of literature documenting the effectiveness of GA for improving health care outcomes in many settings for identifiable groups of frail elderly patients, no explicit Medicare reimbursement mechanisms currently exist to cover GA services provided by either hospital or physician. We believe that new physician reimbursement codes specific for geriatric assessment should be established in the Current Procedural Technology (CPT-4) manual and that reimbursement for GA should be specifically provided under Part B of Medicare. Further, we believe that hospital reimbursement within the Medicare prospective payment system should be modified to encourage GA during inpatient stays for appropriate patients. This paper summarizes the background for these recommendations. It defines the major content of GA at three levels of intensity--screening, intermediate, and comprehensive. It describes the major sites for conducting GA--hospital, office, home, nursing home. Finally, it proposes criteria for targeting patients most likely to benefit from GA.
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[Preserving of independence: effectiveness of multi-dimensional geriatric assessment].
Comprehensive geriatric assessment (CGA) is defined as the process of determining an elderly person's medical, psychosocial, functional, and environmental resources and problems, linked with an overall plan for treatment and follow-up. The principles of geriatric assessment, including the advantages and disadvantages of using quantitative instruments for multi-dimensional evaluation, are reviewed. The findings of a recently published meta-analysis on comprehensive geriatric assessment are discussed and its policy implications addressed. The meta-analysis includes data of 28 controlled trials comprising 4959 subjects allocated to one of five CGA types, and 4912 control subjects. Original investigators provided additional unpublished data from published reports to supplement the data base of this meta-analysis. The combined odds ratios of outcomes in CGA-assessed patients versus control patients were obtained by pooling data from individual trials with a multivariate logistic regression approach. The combined odds ratio (95% confidence interval) of home survival at 1 to 4-year follow-up was 1.7 (1.2-2.3) for inpatient geriatric evaluation and management units, 1.5 (1.1-2.0) for post-discharge home assessment services, and 1.2 (1.1-1.4) for preventive in-home assessment services. Based on these research findings, the establishment of interdisciplinary units with staff trained in multidimensional geriatric assessment for inpatient evaluation and management of frail elderly patients, is recommended. In addition, research to improve geriatric assessment technology and promote its integration into primary care has a great potential for disability prevention and nursing home use reduction in older persons.
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[Geriatric assessment].
The geriatric assessment includes the evaluation of the patient's functional capacity, and it can be applied at any health care level, even at home. This allows to approach to the biological, psychological and social aspects, and facilitates the systematic observation of the therapeutic process and of the results from medical and social interventions with the aim of preventing, or at least, delaying the occurrence of functional disabilities. In addition, this evaluation allows to design an adequate programming of nursing care at any health care level, including the patient's home.
Activities of Daily Living↗
A polar diagram for comprehensive geriatric assessment.
Comprehensive geriatric assessment has become synonymous with geriatric practice. This includes evaluation of the older person's physical and mental health, and the functional and social status. We propose a new way of representing a person's condition, called the "polar diagram". This shows the subject's scores on the evaluation scales that are arranged in radial positions inside a circle. The outer part of the circle corresponds to the best condition. Gaps between the best condition and the actual scores are easily identified. The diagram can be employed to monitor the subject's condition and to assess any changes in outcomes.
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The value of comprehensive geriatric assessment.
Comprehensive geriatric assessment (CGA) provides guidance in planning care for elderly patients. The goals of CGA include reduction of health care cost, early recognition and treatment of geriatric syndromes and improved survival and quality of life for patients. Evidence from randomized controlled studies has identified the value of CGA and some of its limitations. Studies of CGA in institutional settings and in home care provide the basis for specific interventions to targeted groups of high-risk patients. Strategies for fall prevention, appropriate use of pharmacotherapy, and prevention of in-hospital delirium have grown out of the application of this multidisciplinary tool. Future research focused on a more precise definition of the potential financial benefits of CGA may facilitate the task of communicating its value to decision makers.
Accidental Falls↗
Geriatric assessment.
A comprehensive geriatric assessment involves the evaluation of the physical, psychosocial, and environmental factors affecting the health of an elderly person. In the office setting a geriatric assessment is best accomplished by the use of screening questions, which are incorporated into the patient's medical questionnaire; the use of validated, brief screening tests that measure the patient's performance of daily living activities, cognition, nutritional status, and risk of falls; and a review of the patient's personal values and social support network. The screening assessment can be completed in an average of ten minutes by using self-administered questionnaires and brief performance-based measures of physical functioning. The comprehensive assessment performed on the initial visit with an elderly patient will help to (1) improve diagnostic accuracy, (2) guide the selection of interventions to restore or preserve health, (3) recommend an optimal environment for care, (4) predict health outcomes, and (5) monitor clinical change over time. The effectiveness of geriatric assessment has been demonstrated in clinical trials and is likely to be most effective when conducted by the patient's primary care physician.
Accidental Falls↗
Geriatric assessment teams.
In geriatric care, a form of teamwork is the recommended modality because of the complex biopsychosocial needs of the patient. The goal of geriatric assessment programs is to establish an intensive assessment of older adults which requires the competencies of several coordinated disciplines. Not only do teams have the capacity to assess patients in much greater depth but also patients share different information with different providers. The composition of the team is dictated by the needs of the patient population in accordance with resources available. Next, one must identify a method of team practice in order for interactions to take place. The method of functioning determines what kind of team it is, ranging from independent functioning with minimal formal interfacing to interdependent activity interspersed with formal and informal interactions. In initiating a geriatric assessment program, one needs to determine which tasks demand interdisciplinary collaboration, which require interdisciplinary consultation, and which can be performed using a matrix or extended team model. In this model, the core team is supplemented by other disciplines as determined by the team, predicated on patient problems. Teams can profit from training, which can help with choosing an appropriate model, establishing a manual of procedure, and managing interactive issues and problems. This can occur early in the team's formation, or when a team takes on new members. The minimal level of team development would include establishing program goals, delineating professional responsibilities and roles, and implementing a system for exchanging and documenting information about patient plans. Saving input to share only in team meeting is inefficient, so health care teams need to recognize the importance of informal interchanges. It is still a matter of conjecture about what team works best with which patients under what circumstances or conditions. Multiple randomized clinical trials with teams will give us more information in this regard. In the meantime, organizers of geriatric assessment programs will have to make decisions based on clinical practice in the team development field and extrapolations from related health care team studies.
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Predictors of patient refusal to participate in ambulatory-based comprehensive geriatric assessment.
BACKGROUND: Comprehensive Geriatric Assessment (CGA) in ambulatory settings can be effective only if patients who need this intervention are willing to participate in the evaluation and follow the indicated therapy. METHODS: To learn whether older persons' health beliefs and perceptions influence participation in ambulatory-based CGA, we studied subjects who failed a screening assessment offered through a community-based outreach program and were deemed appropriate for CGA. All subjects were interviewed in person following a structured sequence including questions from the RAND Current Health (CH) and Health Worry/Concern (HWC) scales, the Health Locus of Control Scale (HLC), and scales developed to measure health risks and perceived benefits of geriatric assessment. RESULTS: In univariate analysis, the following variables were associated with refusal to participate in CGA status at the p < .05 level: increased worry on HWC and higher scores on three new scales constructed to measure Global Health Risk (GHR), Perceived Global Health Benefits (PGHB), and Perceived Specific Health Benefits (PSHB). For GHR, higher scores indicate greater risk; for PGHB and PSHB, higher scores indicate greater perceived benefit. In multivariate analysis, only educational level, GHR, PGHB, and PSHB scores were independently predictive of refuser status. Correlations with other established health perceptions scales provided support that global health risk and perceived global and specific health benefits are unique constructs. Furthermore, high scores on these scales predicted participation in health improvement programs. CONCLUSIONS: Patients' beliefs about perceived risk and benefit can be measured and predict willingness to participate in ambulatory-based CGA.
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The emergence of geriatric assessment units. The "new technology of geriatrics".
Previous studies have suggested that geriatric assessment units may provide important benefits to the care of elderly persons. In early 1985 we surveyed personnel at 104 (91%) of the existing 114 geriatric assessment units associated with medical schools and Veterans Administration medical centers for information on the units' development and operation. Although almost 80% of the units were hospital based, most (61%) provided care for outpatients. Nearly half (47%) began operation in 1983 or later; of those in existence before 1983, two thirds have increased their capacity since then. The types of personnel and their training differed substantially among units. Fifty percent of the physicians had had no formal training in geriatrics. Of the 104 units, 99 (95%) did routine assessment. The estimated time spent per new patient in outpatient units was 2.7 +/- 2.1 (SD) hours. These data suggest that geriatric assessment units are proliferating rapidly, have differing structures, and consume substantial resources. Further efforts are needed to define their optimal structure, targets, and function.
Geriatrics↗
[Geriatric assessment--the Vienna model].
Geriatric Assessment is a structured interdisciplinary process for the diagnosis of the functional status and potential for rehabilitation of geriatric inpatients. This paper describes the possibilities and scope of the Vienna Model of Geriatric Assessment oriented in terms of practicability and focused implementation of resources. By using this multidimensional proceeding the rehabilitation-quotient of patients has increased more than 39%. From this point of view Geriatric Assessment in a geriatric hospital is a practical instrument to prevent hospitalization, to increase survival at home, and to improve functional status in elderly patients.
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The performance of simple instruments in detecting geriatric conditions and selecting community-dwelling older people for geriatric assessment.
BACKGROUND: comprehensive geriatric assessment (CGA) appears to be less effective when performed in outpatient clinics than in hospital settings. The effectiveness of outpatient CGA might be improved by selectively targeting frailer community-dwelling elderly people. The purpose of this study was to evaluate the clinical performance of rapidly-administered standard screening measures for geriatric syndromes in selecting community-dwelling older people for outpatient CGA. METHODS: urban-dwelling older people were screened for CGA at community sites using a self-administered questionnaire containing standardized measures for each of four geriatric target conditions: depression, urinary incontinence, falls and functional impairment. The study sample included all 150 consecutive subjects who were screened, failed on one or more of the four target criteria and completed community-based, academically administered CGA. Diagnostic accuracy of the screening instruments was assessed using CGA diagnoses as the 'gold standard'. In addition, patients' potential for benefiting from CGA was determined by whether they received major medical recommendations for further evaluation or treatment. RESULTS: after completing CGA, 60.2% of those failing on functional impairment, 53.5% of those failing on depression, 30.7% of those failing on falls and 92.7% of those on urinary incontinence, were confirmed as having these or highly related conditions as clinical problems. Overall, 81.3% of the subjects completing CGA received the least one major recommendations for further medical intervention; most of these recommendations (79.5%) were for a target-related condition and the further remainder (20.5%) addressed another significant medical condition. CONCLUSION: simple screening instruments used in community settings have variable degrees of accuracy, but may be markers for frailty and thus can identify older people likely to benefit from geriatric assessment.
Activities of Daily Living↗
[Possibilities and limits of geriatric assessment in general practice].
Geriatric assessment is a means to collect health and functional data of an individual older person in a standard way. It has been developed on the secondary care level in the specialties of geriatric and rehabilitative medicine. Transferring geriatric assessment into primary care may improve health outcomes of older people, especially as it facilitates preventive diagnostic and therapeutic intervention. Yet, it is not possible to use geriatric assessment, as it is carried out in secondary care, under primary care conditions. Several adaptations will be necessary. An assessment instrument will have to be developed which takes epidemiological features of the older population into account. It will have to be tailored to the specific conditions of health delivery in primary care. Moreover, to achieve effectiveness and acceptance by health care providers and users, we see the necessity of creating an algorithmic assessment instrument which allows the use in different health situations with different levels of diagnostic detail. A primary care assessment for older people then would need to be evaluated according to its effectiveness of improving health outcomes. Potential negative effects on health beliefs may be worth considering. The final task lies in the implementation of a primary care assessment instrument into our existing health delivery format.
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Comprehensive geriatric assessment: toward understanding its efficacy.
Comprehensive geriatric assessment (CGA) offers health care professionals a technique for multidimensional diagnosis of frail elderly people to plan medical, psychosocial, and rehabilitative care. In the present paper, we provide a brief history of geriatric assessment, a description of the varied organization of geriatric assessment programs (GAPs), and a review of published effectiveness studies of programs worldwide performing comprehensive geriatric assessment. Program diversity has complicated drawing conclusions about the efficacy of CGA from a literature reporting generally positive, but not uniformly significant, results. We suggest that sample size limitations explain much of the variability in findings. Using the techniques of meta-analysis, we evaluate the effect of GAPs on mortality when all controlled trials are considered cumulatively. Meta-analysis of six-month mortality demonstrates a statistically significant 36% reduction of mortality for inpatient CGA programs (odds ratio = 0.64; 95% confidence interval = 0.50 to 0.83), and a 32% mortality reduction for all CGA programs (odds ratio = 0.68; 95% confidence interval = 0.57 to 0.80). Further use of meta-analytic techniques can be employed to clarify the effect of GAPs on other important outcomes (e.g., reduced hospital and nursing home use, improved functional status), and to identify program characteristics best promoting these benefits.
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[Geriatric assessment].
The emerging procedures for geriatric assessments in various medical and therapeutical areas in Germany are still in an early phase. Tests for assessing elderly patients must be adopted mostly from the English literature; specific items and problem-orientated assessment contents have to be developed. This requires tremendous efforts and may require a long time because of its empirical and scientific complexities. This does not surprise because geriatric assessment is considered a basic geriatric instrument which has to take into account general and problem-oriented aspects of impairments, disabilities and handicaps. In addition, large cohorts are required to test validity and reliability of these procedures as well as efficiency and benefit of therapeutic interventions related to the assessment processes. In addition, rules of informed consent as well as legal requirements must be observed. Regarding results of assessment procedures, it is not sufficient to express them in a mere figure. Instead, it is necessary to make individual test results visible in a feasible visual presentation. The geriatric assessment serves as a major instrument to improve quality of life of geriatric patients, to support their autonomy and stimulate their social contacts.
Activities of Daily Living↗
A comparison of placement outcomes of geriatric cohorts receiving care in a geriatric assessment unit and on general medicine floors.
To assess whether care in a geriatric assessment unit using a multidisciplinary team approach with rehabilitative emphasis impacted on patient placement outcomes, a historical prospective study was initiated using records of geriatric assessment unit patients admitted during a one-year period (n = 62). A second, diagnostically similar general medicine unit cohort was also sampled (n = 62). Placement outcomes of the two groups were compared. All study patients were 75 years of age or older, stratified by source of admission, and controlled for comparability using diagnostic grouping. The geriatric assessment unit admitted 92 per cent of its patients from home; the general medicine unit, 82 per cent. As a result of expanded rehabilitative, respite, and terminal care promoted by the geriatric assessment unit staff, mean length of stay was 36 days, whereas it was 13 days in the general medicine unit (P less than 0.001). There was no significant difference between the two units with respect to hospital deaths, post-hospitalization discharges to home or nursing homes, or patient locations (home versus nursing home) six months after admission. Although improvements in patient independence may have been achieved through the efforts of a multidisciplinary team approach utilizing the geriatric assessment unit, they were not sufficient to significantly increase the proportion of patients placed at home. Superiority in placement outcome may be demonstrated only by geriatric assessment unit use of selective admission criteria.
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Comprehensive geriatric assessment in a day hospital.
OBJECTIVE: To assess the effectiveness of comprehensive geriatric assessment conducted in day hospitals. DESIGN: Retrospective cohort comparison study with restricted inclusionary criteria and adjustment for baseline characteristics. SETTING: A hospital-based geriatric day hospital and geriatric clinic sites (both in the university and in the community). PATIENTS: Four hundred sixty-eight patients referred for comprehensive geriatric assessment during a 12-month period. INTERVENTION: Comprehensive geriatric assessment in a geriatric day hospital compared with assessment received in clinic sites without a day hospital. MAIN OUTCOME MEASURES: Services received in the first 2 weeks; hospitalization, emergency room visits, placement, death, and change in selected health status measures. Follow-up data was obtained from medical records, a telephone survey, and death certificates. RESULTS: Except in the case of rehabilitative services, day hospital patients were more likely to receive interdisciplinary services. The population seen in the day hospital was more functionally impaired and had significantly more dementia and depression. After adjusting for subjects' baseline characteristics and limiting the analyses to subjects meeting specific inclusionary criteria, the day hospital had no significant effect on mortality, use of emergency or hospital services, placement, or change on selected measures of health status. For example, compared with the clinic patients, receiving care in the day hospital was associated with an adjusted odds ratio of 1.01 (95% confidence interval: 0.53, 1.91) of being at a higher level of care at 6 months. The results were not sensitive to the choice of inclusionary criteria. CONCLUSION: Given their cost and uncertain effectiveness, day hospitals need additional evaluation before their further diffusion occurs.
Activities of Daily Living↗
[Geriatric assessment in Norway. Scandinavian guidelines for geriatric medicine].
The Nordic countries have collaborated on reviewing and updating the guidelines of comprehensive case assessment in geriatric medicine. The Norwegian version of the document produced has recently been published as the official guidelines for the Norwegian Geriatrics Association. The document describes the status of geriatric medicine in the Nordic countries and summarizes the available documentation on its effectiveness and management. It also presents a detailed plan for carrying out geriatric case assessment. Scales for clinical use are evaluated and specific recommendations made with regard to their use in clinical practice. In this article the document is briefly described and commented on.
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