How the principles of geriatric care can be used to improve care for medicare patients

Initially established in 1935, the field of geriatrics has grown considerably and has made important contributions to understanding the nature of older adults and issues related to health service delivery for them. As Medicare turns fifty, this is an opportune moment to consider how principles of geriatrics care can be leveraged to inform Medicare policies and improve the care of older Americans.The Medicare program can exert extraordinary influence on the care of older Americans though its role as a purchaser of healthcare services and products, as a major financial supporter of graduate medical education, through its ability to devise payment incentives, and through the regulatory process. Medicare can promote desired behaviors that would enhance the capacity and competency of the healthcare system, broadly writ, to help healthcare providers and care delivery systems recognize, acknowledge, and address the unique features of challenges faced by older adults. And in doing so, Medicare can create a more compassionate, competent, and efficient delivery system.There are number of key principles of geriatric medicine that should be in the forefront of policy makers' minds as they guide the continued evolution of the Medicare program. This article describes these key principles and their implications for improving the Medicare program for older adults.Appreciate the Value of Geriatric SyndromesAging is a highly variable process that leaves some older adults robust and highly functional and most others with diminished physiologic reserve and increased vulnerability to illness, injury, and disease. Reduced physiologic capacity among older adults contributes to the development of "geriatric syndromes" (Inouye et al., 2007). These syndromes are common in older adults and reflect perturbations of multiple organ systems. Examples include falls, delirium, and frailty. Geriatric syndromes often go unrecognized in a medical culture that tends to focus on organs and classic diseases. These syndromes have profound effects on key outcomes such as functional decline, hospitalization, and healthcare use.Yet, despite Medicare playing a central role in the financing of graduate medical education, most physicians complete their training woefully deficient in recognizing and addressing the principles of geriatric care and geriatric syndromes. Medicare should mandate a greater emphasis in healthcare professionals' training on the aging process and issues related to the care of older adults and those with multiple chronic conditions (Bardach and Rowles, 2012). Incorporating geriatric syndromes into diagnostic coding systems, pay-for-performance models, and decision support tools in electronic medical records will further enhance integration of these syndromes into routine clinical practice.Incorporate Functional Assessment into All Aspects of CareFunctional assessment of the geriatric patient pays close attention to an individual's mobility and functional capacity-his or her ability to perform basic activities (e.g., walking, bathing, and using the toilet), and instrumental activities (e.g., shopping, cooking, and managing finances or medications). With advancing age, many adults may be less concerned with the particulars of their illness and more worried about the impact of their illness on their ability to function in the community. Reduced mobility (often presaged by a person's slowed walking speed) and impaired functional capacity are highly predictive of falls, healthcare use, and mortality (Keeler et al., 2010). Considering function should alert healthcare providers to changes in health, inform their prognosis, and guide them in gauging the appropriateness of healthcare interventions.Despite their importance to older adults and to health outcomes, mobility and functional status are not routinely measured or monitored in clinical practice. Exacerbating this problem, the healthcare community lacks uniform standards for assessing or reporting older adults' function. …