Steven R. Counsell

Effects of a Multicomponent Intervention on Functional Outcomes and Process of Care in Hospitalized Older Patients: A Randomized Controlled Trial of Acute Care for Elders (ACE) in a Community Hospital

BACKGROUND: Older persons frequently experience a decline in function following an acute medical illness and hospitalization.

Recovery of Activities of Daily Living in Older Adults After Hospitalization for Acute Medical Illness

OBJECTIVES: To compare functional outcomes in the year after discharge for older adults discharged from the hospital after an acute medical illness with a new or additional disability in their basic self‐care activities of daily living (ADL) (compared with preadmission baseline 2 weeks before admission) with those of older adults discharged with baseline ADL function and identify predictors of failure to recover to baseline function 1 year after discharge.

Treatment of depression improves physical functioning in older adults

Objectives: To determine the effect of collaborative care management for depression on physical functioning in older adults.

Geriatric Resources for Assessment and Care of Elders (GRACE): A new model of primary care for low-income seniors

The majority of older adults receive health care in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care for low‐income seniors and their primary care physicians (PCPs) was developed to improve the quality of geriatric care so as to optimize health and functional status, decrease excess healthcare use, and prevent long‐term nursing home placement. The catalyst for the GRACE intervention is the GRACE support team, consisting of a nurse practitioner and a social worker. Upon enrollment, the GRACE support team meets with the patient in the home to conduct an initial comprehensive geriatric assessment. The support team then meets with the larger GRACE interdisciplinary team (including a geriatrician, pharmacist, physical therapist, mental health social worker, and community‐based services liaison) to develop an individualized care plan including activation of GRACE protocols for evaluating and managing common geriatric conditions. The GRACE support team then meets with the patients PCP to discuss and modify the plan. Collaborating with the PCP, and consistent with the patients goals, the support team then implements the plan. With the support of an electronic medical record and longitudinal tracking system, the GRACE support team provides ongoing care management and coordination of care across multiple geriatric syndromes, providers, and sites of care. The effectiveness of the GRACE intervention is being evaluated in a randomized, controlled trial.

Cost Analysis of the Geriatric Resources for Assessment and Care of Elders Care Management Intervention

OBJECTIVES: To provide, from the healthcare delivery system perspective, a cost analysis of the Geriatric Resources for Assessment and Care of Elders (GRACE) intervention, which is effective in improving quality of care and outcomes.

Transitions in Care for Older Adults with and without Dementia

To describe transitions in care of persons with dementia with attention to nursing facility transitions.

The Urgency Of Preparing Primary Care Physicians To Care For Older People With Chronic Illnesses

Population trends are driving an undeniable imperative: The United States must begin training its primary care physicians to provide higher-quality, more cost-effective care to older people with chronic conditions. Doing so will require aggressive initiatives to educate primary care physicians to apply principles of geriatrics--for example, optimizing functional autonomy and quality of life--within emerging models of chronic care. Policy options to drive such reforms include the following: providing financial support for medical schools and residency programs that adopt appropriate educational innovations; tailoring Medicares educational subsidy to reform graduate medical education; and invoking state requirements that physicians obtain geriatric continuing education credits to maintain their licensure or to practice as Medicaid providers or medical directors of nursing homes. This paper also argues that the expertise of geriatricians could be broadened to include educational and leadership skills. These geriatrician-leaders could then become teachers in the educational programs of many disciplines. This would require changes inside and outside academic medicine.

A Clinical Index to Stratify Hospitalized Older Adults According to Risk for New-Onset Disability

BACKGROUND: Many older adults who are independent prior to hospitalization develop a new disability by hospital discharge. Early risk stratification for new‐onset disability may improve care. Thus, this studys objective was to develop and validate a clinical index to determine, at admission, risk for new‐onset disability among older, hospitalized adults at discharge.

Improving Medical Student Attitudes Toward Older Patients Through a "Council of Elders" and Reflective Writing Experience

In an effort to reduce “agism” which is prevalent among medical trainees, a new geriatrics educational experience for medical students aimed at improving attitudes toward older patients was developed. Each 90‐minute Older Adult Session included four components: initial reflective writing exercise; introduction to the session; 75‐minute dialogue with the “Council of Elders,” a group of active, “well” older adults; and final reflective writing exercise. The new session was provided to 237 first‐ and second‐year medical students during the 2006/07 academic year at Indiana University School of Medicine. Session evaluation included comparing scores on the 14‐item Geriatrics Attitude Scale administered before and after the session, identifying attitude changes in the reflective writing exercises, and a student satisfaction survey. Student responses on the Geriatrics Attitude Scale after the session were significantly improved in seven of 14 items, demonstrating better attitudes toward being with and listening to older people and caring for older patients. Analysis of the reflective writings revealed changing of negative to positive or reinforced positive attitudes in 27% of medical students, with attitudes not discernable in the remaining 73% (except one student, in whom positive attitudes changed to negative). Learner satisfaction with the Older Adult Session was high, with 98% agreeing that the session had a positive effect on insight into the care of older adults. A Council of Elders coupled with a reflective writing exercise is a promising new approach to improving attitudes of medical students toward their geriatric patients.

Development and Implementation of a Proactive Geriatrics Consultation Model in Collaboration with Hospitalists

Acutely ill hospitalized older adults often experience a decline in function that may be preventable using a proactive, interdisciplinary, patient‐centered approach. Hospitalists are treating an increasing number of these patients. A collaborative geriatrics consultation model to prevent functional decline and improve care for older patients with geriatrics syndromes was developed and implemented in partnership with a large hospitalist group in a community teaching hospital. A team of a geriatrician and a geriatrics nurse practitioner led the new consultation service. The team assisted with identifying cases, provided consultation early in the hospital stay, focused its evaluation on functional and psychosocial issues, and assisted in clinical management to optimize implementation of recommendations. In the first 4 years, the consultation service conducted 1,538 consultations in patients with a mean age of 81 (range 56–103). The most frequent geriatrics diagnoses were gait instability, delirium, and depression; recommendations usually included consulting physical therapy, increasing activity, and changing medications. The number of referrals and referring physicians grew steadily each year. Twenty‐eight of 34 (82%) of the referring hospitalists completed a Web‐based satisfaction questionnaire. All responding hospitalists agreed that proactive geriatrics consultation helped them provide better care; 96% rated the service as excellent. Analysis of hospital administrative data revealed a lower length of stay index and lower hospital costs in patients receiving a geriatrics consultation. The Proactive Geriatrics Consultation Service represents a promising model of collaboration between hospitalists and geriatricians for improving care of hospitalized older adults.