Multidisciplinary Teams and Holistic Care for Frail Elders

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 For most of us, for most of our lives, healthcare involves doctor visits for routine and acute care, and sometimes visits to specialists when dealing with complex or advanced illness. To be sure, many of us also find health and healing beyond the walls of a clinic or the contents of a medicine cabinet—attention to diet, exercise, spirit and community can also strengthen us. For the very old, the very frail, managing health becomes less a process of preventing and treating illness, and more a concern of maintaining function and enjoying quality of life. To this end, very frail adults often shift focus as their needs and situations change. And while medicine remains part of the equation, other services become tantamount: long-term care, for instance, as well as good nutrition, access to affordable and safe housing, reliable transportation, and ways to remain connected with the larger community.

MediCaring Communities will work to meet these needs by helping to align the needs of frail elders and their families with the mix of health care and social services a community can provide. The MediCaring model would ensure that all members of a multidisciplinary team would know all enrolled individuals: these individuals and their families would be real to professional caregivers, who would understand their situation and priorities, in part, through the presence of a comprehensive care plan.

The MediCaring model includes all covered services under Medicare and Medicaid.  However, by working with elders and their families to understand the realities of what they face, the benefits and costs of treatments, and strategies to achieve goals and priorities, MediCaring elders may be less inclined to opt for very expensive and burdensome medical treatments and more likely to choose options that enhance quality of life, maintain comfort, and ensure dignity. The MediCaring model would not bar choices or limit access; rather, it would aim to ensure that elders and family members clearly understand the degree to which a treatment or procedure will offer any help, and the costs (i.e., physical, emotional, financial) of pursuing it. Elders would never find themselves barred from medical treatments that they want. Rather, they and their families would be part of an informed and thoughtful decision-making process and able to understand and decide which treatments and procedures to pursue, and which to avoid.

The following list highlights key characteristics of a prototypical MediCaring community.

Multidisciplinary Team. A multidisciplinary team whose sole focus is frail elders will coordinate person-centered care in the community. Teams would include clinicians and practitioners trained and skilled in diagnosis and treatment; medication management; rehabilitation; self-care; nursing care; mental health; caregiver assessment, training, and support; nutrition; community services; and housing.  Teams would include a physician, nurse, and social worker, as well as ongoing and reliable access to pharmacists, rehabilitation specialists, mental health experts, housing services staff, caregiver support personnel, and legal advisors. The team’s capabilities and functioning would be measured and certified as meeting standards that reflect well-coordinated care, rather than adherence to a requirement for certain disciplines doing certain tasks.

Care Plans. The MediCaring team will work with elders and their families, and with one another, in developing comprehensive care plans. The local authority charged with implementing MediCaring would ensure that adequate and appealing community resources were available to meet the many needs elders have, including the need for services such as hospice and palliative care. The scope of care planning must respect limits that the person or surrogate prefer, while also addressing any issues that arise in terms of particular services, e.g., housing, finances, caregiver support, medications, and various therapies.

Primary Care. MediCaring builds on and ensures primary care for elders who live with advanced, serious, and complex conditions. Primary care for frail elders is not primary care as usual–doctor who provides routine prevention, chronic disease self-care education, and coordination of services from specialists. Rather, this is primary care writ large, responsive and responsible in recognizing and meeting the array of physical, psychosocial, and spiritual needs elders and families encounter. Although MediCaring builds on geriatric principles and palliative care standards and approaches, it is not limited to simply medical aspects of care for frail elders.

Continuity of Round-the-Clock Services. MediCaring includes continuity of services across time, settings, and providers, with round-the-clock coverage and real-time availability to the elder and  his or her caregivers. A MediCaring team would be charged with providing medical and nursing advice and support. In the case of an urgent phone call (or text or email) with a pressing health concern, a team member with appropriate skills for the problem would respond within ten minutes. Ideally, the team member on call would know the elder and caregivers, and would always have immediate access to an up-to-date care plan.

Home Visits. Very frail elders and their caregivers can be taxed and stressed by the challenge of simply getting to a physician’s office. Whenever feasible, urgent home visits to assess emerging situations should occur within three hours of a call (or, in rural or remote areas, telemedicine should be used). The process of developing care plans for MediCaring elders should include honest and forthright understanding about when and if to call 911, or to go an emergency department. For frail, homebound elders, many technical and supportive services, built on a competent physical examination, can be safely done where the elderly person lives, including simple diagnostic x-rays and imaging tests, blood and urine tests, skin biopsies, electrocardiograms, and more. This spares frail elders the difficulties and sometimes trauma of being moved to another setting simply to receive good care, especially when that care can so effectively be delivered to them. Home visits are a wise, safe, and effective alternative to preventing or delaying hospitalizations and nursing home placements.

Comprehensive services. In some cases, urgent issues created by crises of housing, nutrition, transportation or family caregiving arise, and, unchecked, can have a significant effect on health. MediCaring will focus on preventing such crises by having a sort-of disaster preparedness approach to frail elders: direct care workers will be on standby to cover a caregiver crisis; safe housing will be readily available for emergency placement; short-term funding will be provided for heat or air conditioning needs; reliable and safe transportation will be available for necessary appointments and other responses for addressable issues. Addressing the social determinants of health ensures an approach that avoids the current challenges many frail elders and their families endure.

key words: MediCaring book, Janice Lynch Schuster, Joanne Lynn, eldercare

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