Models of geriatrics practice: Outpatient geriatric evaluation and management

OBJECTIVE: To describe the development and operation of a practical model of outpatient geriatric evaluation and management (GEM) for high-risk, community-dwelling older adults. PARTICIPANTS: Community-dwelling Medicare beneficiaries age 70 years and older who were medically stable but had a high probability of repeated admission to hospitals (P(ra) > .40) in the future (n = 248). INTERVENTION: Outpatient GEM. MEASUREMENTS: Demographic, clinical, and use-of-hospital characteristics of patients; nature and quantity of GEM services; satisfaction of patients and their established primary physicians. RESULTS: At enrollment, the average patient was 78.7 years old, took 5.0 long-term prescription medications and was unable to perform 0.5 (of six) activities of daily living (ADL) and 1.4 (of seven) instrumental ADL. Many patients (71.3%) reported hospital days during the previous year. Each of three interdisciplinary teams (geriatrician, gerontological nurse practitioner, nurse and social worker) performed comprehensive assessments and then provided primary care and case management to a case load of 45 to 52 patients. On average, GEM required 6 months, during which patients visited the GEM clinic 7.4 times, had 10.4 active problems addressed, spoke to GEM staff members weekly by telephone, and were referred to two other providers. Most patients (94.4%) completed the GEM program; 66.7% completed advance directives. Satisfaction with GEM was high among the patients and their established primary physicians. The cost of the GEM personnel averaged about $1540 per patient treated. CONCLUSIONS: This model of outpatient GEM provided 6 months of targeted intensive care at a reasonable cost. The satisfaction ratings of patients and their primary physicians were high.