Geriatric Consultation and Co-Management Improves Outcomes for Elderly Patients

Innovations in Geriatric Medicine | Fall 2021

Geriatricians at University Hospitals Cleveland Medical Center are strategizing to maximize their impact as demand for eldercare specialists rises. While the U.S. population aged 65 and above has steadily increased, geriatrician capacity has declined nationally over the past decade.

Oliver Glen M. Ancheta, DO, MS, MPH

“Unfortunately, there are insufficient numbers of practicing geriatricians to meet the growing need,” says Oliver Glen M. Ancheta, DO, MS, MPH, Director of Geriatric Consultation and Co-Management at University Hospitals. “It is important from a healthcare utilization standpoint for us to identify interventional targets that demonstrate improved patient outcomes.”

At University Hospitals, one of those targets is pre- and post-operative co-management of older patients. “From a geriatric perspective, this multidisciplinary format is a relatively new area of potential,” Dr. Ancheta says. “For our medically complex patients, we often collaborate with our trauma and orthopedic colleagues in the acute care setting to identify underlying causes for the problems patients are experiencing, such as medication interactions contributing to falls, management of post-operative delirium and safe dispositions for medically complex older adults.”

Addressing age-related issues prior to surgery can reduce complications such as downstream decline. In fact, when geriatricians work in collaboration with fellow specialists, research suggests that patients experience decreased length of stay, readmission and medical errors, and report increased rates of satisfaction. 

Post-operatively, UH geriatricians are also available to consult on a patient’s safe disposition. Would they benefit from additional physical therapy or strengthening prior to returning home? Do they need to transition to a skilled nursing or a rehab facility for continuation of care?

“While surgical intervention for a hip fracture may stabilize an anatomical issue, we also need to be looking at eldercare medical management from a holistic perspective,” Dr. Ancheta says.

Novel Transplant Consultation

In recent months, a novel multidisciplinary initiative at UH has been providing comprehensive evaluation and medical management for elderly individuals seeking renal transplant. As increasing numbers of older patients struggle with kidney failure, their suitability as transplant candidates needs to be considered.

According to the National Foundation for Transplants, the average wait time for kidney donation is 679 days, and the cost for transplant exceeds $414,000. Healthcare organizations have a moral imperative to ensure that patients receiving transplanted organs are well-positioned for successful long-term outcomes.

“There is a delicate balance because patients are living longer, but they may also be coping with chronic disease or multiple comorbidities,” Dr. Ancheta says. “As geriatricians, our role is not to be the sole determiner of who should be on the transplant list but rather to optimize their pre-operative readiness in conjunction with the renal transplant surgical and medical teams.”

Additionally, he notes that age is too often used as a surrogate for health. “Age alone is not a reliable variable in determining whether a patient will do well after transplant,” he says. Instead, it is a proxy for other markers that may better predict outcomes, including:

• Comorbidities and physical status
• Cognitive status and ability to follow post-transplant protocols
• Movement or sensory limitations, including vision and hearing loss
• Frailty and fall history, including home environment risks
• Challenges related to activities of daily living
• Medication history and polypharmacy risk
• Blood pressure, including signs of orthostatic hypotension
• Nutritional status
• Social support and depression risk

Physicians seeking a geriatric consultation for transplant can access a designated order within the UH electronic medical record. “Currently, we are focused on evaluations for renal transplant,” Dr. Ancheta says. “If we are able to demonstrate improved patient outcomes, we will look at how a consulting workflow could be extrapolated for other organ transplants.”

To contact the University Hospitals Center for Geriatric Medicine, call 216-844-2400.

Contributing Expert:
Oliver Glen M. Ancheta, DO, MS, MPH
Director of Geriatric Consultation and Co-Management
University Hospitals Cleveland Medical Center
Assistant Professor of Geriatric Medicine
Case Western Reserve University School of Medicine