Commentary: The Safety Net Needs to Be "Geriatricized"
Key findings
- The safety net—a collection of public hospitals, federally qualified health centers and publicly funded community clinics—is an essential component of the health care system for low-income and uninsured people
- Patients who seek care at safety net facilities include many Medicare-insured adults, as well as adults younger than Medicare age who are experiencing geriatric conditions such as functional impairment, frailty, falls and dementia
- In the coming years, the safety net will have to serve more adults with geriatric conditions because of the aging of the population, the increasing racial/ethnic diversity of older adults and the economic disparities that affect people of color
- A number of strategies can help safety net institutions provide better geriatrics care, including better assessment and identification of patients with geriatric conditions and integration of effective geriatrics care models into safety net systems
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The "safety net" is a collection of public hospitals, federally qualified health centers and publicly funded community clinics that serve low-income and uninsured people. That population includes many Medicare-insured adults and adults younger than Medicare age who are experiencing geriatric conditions such as functional impairment, frailty, falls and dementia.
In the coming years, the safety net will care for more older adults because of the aging of the population, the increasing racial/ethnic diversity of older adults and the economic disparities that affect people of color. In the Journal of General Internal Medicine, Christine Seel Ritchie, MD, MSPH, director of research in the Division of Palliative Care and Geriatric Medicine and director of the Mongan Institute Center for Aging and Serious Illness at Massachusetts General Hospital, and colleagues discuss four ways in which clinicians in safety net settings can optimize services for adults who need geriatrics care.
Target the Right Patients
Rather than focus on chronic diseases alone, ask middle-aged and older patients about their functional status and geriatric conditions. As needed, make referrals to services such as cognitive assessment, home safety evaluation and hearing or vision screening.
Be Relevant
Geriatrics programs must be tailored to the populations the safety net serves. These include older adults who:
- Are experiencing homelessness or are at risk
- Have an alcohol or drug use disorder
- Are transitioning out of prison
- Are living with HIV
- Have limited English proficiency
- Require culturally competent approaches to care, such as in addressing advance care planning
Work Around the Shortage of Geriatrics-trained Professionals
Most parts of the U.S. are undersupplied with geriatricians and gerontologists. One solution is to partner with one of the federally funded Geriatrics Workforce Enhancement Programs (GWEPs). These bring in-person and remote geriatrics training to primary care providers and community social service workers.
GWEPs also support systems-level changes, for example by implementing fall screening programs in primary care and partnering with pharmacists to stop dispensing medications that are risky to older adults.
Another option is to work toward becoming recognized as an Age-Friendly Health System. This initiative, developed by the John A. Hartford Foundation and the Institute for Healthcare Improvement, requires a commitment to measure and improve care for older adults by implementing an evidence-based framework.
Adopt A Geriatrics Clinical Model
Models that have improved outcomes for low-income adults in safety net settings include:
- Acute Care for Elders units (team-based inpatient care)
- Geriatrics Resources for the Assessment and Care of Elders (GRACE; interprofessional geriatrics co-management in outpatient primary care)
- Aging-Brain Care (for adults in the community who have dementia and depression; care is provided by community health workers)
- Programs of All-Inclusive Care of the Elderly (PACE; provides comprehensive home and community-based services to Medicaid recipients who would otherwise require nursing home placement)
The success of these programs relies on community partners that provide services such as in-home support, transportation, home health care, caregiver support and legal services.
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