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• W65820106 abstract "With its emphasis on addressing symptoms and acute problems, primary care is not currently designed to provide comprehensive geriatric care (Bodenheimer, Wagner, and Grumbach, 2002). This situation is likely to lead to over-treatment (Wennberg et al., 2005), undertreatment (Wenger et al., 2003), or incorrect treatment planning with older adults who have multiple interacting chronic medical conditions (Tsilimingras, Rosen, and Berlowitz, 2003). A collaborative approach to treatment planning may help address this challenge. Collaborative treatment is defined as care mat strengthens and supports self-care in chronic illness while ensuring that effective medical, preventive, and health maintenance interventions take place (Von Korff et al., 1997). Collaborative treatment has been shown to decrease acutecare utilization, improve function, increase the ability to live independently, and increase the use of hospice in geriatric rehabilitation and end-of-life care (Tinetti et al., 2002; Casarett et al., 2005). A practical model of implementation, however, has not yet been suggested in the geriatric literature. Although collaborative treatment has been held up as the ideal in primary care, no established method to meet this ideal has been defined (Saba et al., 2006). This paper describes a method, employed in the context of a research study, to facilitate collaborative treatment planning for older patients in primary care. BALANCING LENGTH OF LIFE AND QUALITY OF LIFE Medical interventions are generally life-extending or life-enhancing. The balance between treatments that extend life and treatments that enhance quality of life shifts with increasing age and worsening health status. Planning care for patients at the extremes of this age and health status continuum is fairly straightforward. However, many older adults have a mix of life-extending and life-enhancing concerns that makes care planning more complicated. Achieving the optimal balance for a given individual may be facilitated through collaborative treatment planning and use of our priority-setting approach. THE PROCESS OF GENERATING CLINICAL PRIORITIES In a randomized controlled trial testing an intervention to improve the care of older adults in primary care, we integrated a geriatric team-consisting of a geriatrician, a gerontologie nurse practitioner, and a geropharmacist-into several primary care practices. The team had consultative and comanagement functions with primary care providers and developed care plans for frail older adults with multiple coexisting conditions. Such patients typically have a long list of medical problems (commonly referred to among Healthcare providers as the list). Developing a treatment plan that took the lengthy problem list into account was a central challenge that the geriatric team faced with these patients. We refer to the approach adopted by the team to meet this challenge as priority-setting. How was clinical priority-setting accomplished? The team established clinical priorities with a patient over two visits. At the first visit, the nurse practitioner conducted a standardized assessment that included a review of chronic medical problems, medications, functional status, physical and social activity levels, along with screening for pain, depression, dementia, urinary incontinence, balance problems and falls, completion of advance directives, substance use, and goals and preferences for care. The nurse asked the patient to consider which of the identified problems were most important to him or her. The patient was then scheduled for a follow-up visit in two weeks. At the second visit, the geriatrician met with the nurse and the patient to review findings from the first visit, and classify each identified problem into one of these three categories: 1. Threats to quality of life and safety (e.g., shortness of breath, pain, dementia, depression, falls). 2. …" @default.
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• W65820106 date "2006-10-01" @default.
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• W65820106 title "Collaborative Treatment Planning for Older Patients in Primary Care" @default.
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