Clinical Geriatrics

Healthcare professionals are generally trained in isolation and continue their practice in much the same way. Geriatrics has historically embraced an interdisciplinary team approach to training and practice. The importance of a well-balanced interdisciplinary team has been shown to be beneficial in the care of the elderly; however, payers and government regulators are attempting to lower one aspect of healthcare cost by making decisions that will directly affect the balance of the care team. Our current geriatric care system is under increasing pressure to find efficient and effective systems of care, so building the right team for our aging population is crucial. Intelligent regulations and appropriate incentives are a critical part of this.

Nurse Practitioners
One important component of a geriatric care team is the nurse practitioner (NP). NPs are advanced practice nurses, a field that was born in 1965 at the University of Colorado. Today, there are more than 115,000 practicing NPs, with an additional 6000 added annually as a result of programs at over 300 academic centers. NPs are able to reach patients in a unique manner by blending nursing and medical care.

This unique care, combined with the increased availability of NPs, has not been lost on the Governor of Pennsylvania, Ed Rendell, who believes strongly in the value of NPs. The governor stated that, “We should employ nurse practitioners in the delivery of health care services far more than we do.” A major reason for this support is an estimate by academics that an NP can perform approximately 70% of the functions that a primary care physician can—often at 50% or less of the costs. The Pennsylvania plan calls for expanding the scope of NPs through unlocking of regulations that restrict their scope of practice.

Federal legislators are also attempting to expand the scope of NPs with an aim toward long-term care involvement, as current law requires that all care in a skilled nursing facility be provided under the direct supervision of a physician. The Long-term Care Quality and Modernization Act of 2006 would amend this to include, “at the option of a State, under the supervision of a nurse practitioner, clinical nurse specialist, or physician assistant who is working in collaboration with a physician.” This would expand the role and responsibilities of NPs in skilled nursing facilities. In addition, this legislation would amend current law that does not permit nonphysician practitioners to be employed by the skilled nursing facility. This would enable NPs to be employed by a skilled nursing facility and supervise resident care.

Unfortunately, many of these moves to advance the role of NPs are being questioned by organized medical associations that fear that the increased scope of practice of nonphysician professionals will decrease the role of the physician. As geriatric care providers, we need to work together to support each other’s efforts, with the goal of improving patient care.

Geriatricians
The American Geriatrics Society (AGS) describes geriatricians as physicians who are initially board-certified in Family Practice or Internal Medicine and who, since 1994, have been required to complete fellowship training in geriatrics beyond their residencies. This makes them uniquely qualified to provide expertise within a care team, especially in dealing with advanced medical treatments.

The last several years have seen a decline in the number of physicians trained in geriatrics each year to less than 350, which does not even keep up with the number of geriatricians retiring from active practice.¹ This trend was worsened by Congress eliminating in fiscal year 2006 funding under Title VII for Geriatrics Health Professions Programs, which supports geriatric education.