One metaphor for geriatrics is a set of chopsticks—one labeled “chronic disease care” and the other “gerontology.” Both need to work in coordination in order to achieve good geriatric care. The latter refers largely to the contents of this book: the syndromes associated with aging, the atypical presentations of disease, and diseases closely linked to aging. Chronic disease management (addressed in Chapter 4) is complicated by the difficulties of managing multiple, simultaneous, interactive problems. Health care for older persons consists largely of addressing the problems associated with multiple chronic illnesses.
Indeed, multimorbidity is the key challenge in geriatric care. Effective responses to the situation should emphasize close monitoring and rapid intervention when there are early signs of change. The goal of chronic disease management is catastrophe prevention. However, medical care continues to be practiced as though it consisted of a series of discrete encounters. What is needed is a systematic approach to chronic care that encourages clinicians to recognize the overall course expected for each patient and to manage treatment within those parameters. The fee-for-service payment system encourages routinely scheduled doctor visits, when good care would utilize frequent monitoring observations at a distance. Chapter 4 traces a number of strategies designed to improve the management of chronic disease. Geriatricians have long recognized that care in one sector affects care in other areas. For example, nursing home residents use fewer hospital resources than older persons receiving home and community-based care, even though they are likely frailer.
Several initiatives are under way that may help address this interdependence. The Patient Protection and Affordable Care Act specifically addressed attention to transitions for patients discharged from hospitals. Payments for hospital readmissions are denied in some situations, and penalties for excessive rates of 30-day readmissions are being levied. The accountable care organization concept calls for better integration of hospital care, primary care, postacute care, and nursing home care. It may extend to recognizing the need for better social integration as well. The health-care home effort to incent practices for more comprehensive care represents a step in this direction.
A prerequisite for effectively coordinating medical and social care is shared goals. Care for frail older persons has been impeded by an artificial dichotomy between medical and social interventions. This separation has been enhanced by funding policies, such as the auspices of Medicare and Medicaid, but it also reflects the philosophies of the dominant professions. Until the differences in goals are reconciled, there is little hope for integrated care. Medical practice has been driven by what may be termed a therapeutic model. The basic expectation from medical care is that it will make a difference, whereas the goals of a social model are directed more at compensation and coping with extant limitations. But both can converge in a common commitment to maximizing people’s quality of life.
With frail older patients the difference is typically not reflected ...