Article
Embedding Dermatology in a VA Geriatric Primary Care Clinic
The authors describe an exportable dermatology specialty care model to address aging veterans’ needs for same-day appointments.U.S.
Dr. Guzman-Clark is a gerontologic nurse practitioner and nurse researcher at the VA Greater Los Angeles Healthcare System, Geriatric Research Education and Clinical Center, Los Angeles, California; the clinical nurse advisor for the VA Office of Nursing Services, Geriatrics and Extended Care Field Advisory Committee; and an assistant clinical professor at the UCLA School of Nursing in Los Angeles. Dr. Johnson is a family nurse practitioner at the Hunter-Holmes McGuire VAMC in Richmond, Virginia and adjunct faculty at South University in Glen Allen, Virginia. Ms. Mather is a nurse manager at the Primary Care South Texas Veterans Health Care System. Ms. Williams is a nurse practitioner at the Ralph H. Johnson VAMC in Charleston, South Carolina.
A tool that takes into account daily function is the Vulnerable Elders Survey-13 (VES-13). As measured by the VES-13, functional ability has been shown to be a strong predictor of decline and death in older adults independent of gender or comorbidities.12 Integration of the VES-13 into the evaluation of older veterans could assist PACTs in considering patients’ current function and life expectancy in their care plans along with patient and family goals.
Another potentially useful tool for the PACT team is the SPICES mnemonic (Sleeping, Problems with feeding/eating, Incontinence or urinary problems, Confusion, Evidence of falls, and Skin breakdown).13 Although SPICES is not comprehensive, this mnemonic highlights potential problems facing older patients that may not be brought up routinely. It provides a concise, formalized format that can be used by clerks or patient support assistants as part of the check-in process.
This tool has been used successfully by the Geriatric Evaluation and Management Clinic of the South Texas Veterans Health Care System (STVHCS) to improve communication between the PCP and nurse so that pertinent patient information is relayed concisely. SPICES was helpful in identifying patients needing interventions for fall risk. In a retrospective chart review of 100 randomly selected patients aged 75 to 90 years enrolled in the clinic, a 75% reduction in falls was noted during the first year of implementation (STVHCS unpublished data, 2012).
Additional tools that focus on identifying specific geriatric syndromes are available online from the Hartford Institute for Geriatric Nursing, which provides evidence-based information and training on how to assess, evaluate, and manage common geriatric syndromes such as depression, dementia, and delirium.14 The site also includes videos on how to use common brief geriatric assessment tools that can be performed by nurses and health care associates while the patient is in the waiting room. Though promising, further research is needed to study the effects of these tools on patient, provider, and system outcomes.
Infusing quality of care indicators (QI) can play an integral role in achieving PACT goals while improving the older veterans’ quality of life. For example, polypharmacy and medication-related injuries in older adults continue to pose both a safety and economic challenge to patients and the health care system.15-17 The 2012 Beers criteria for Potentially Inappropriate Medications in Older Adults lists 53 medication classes that have been identified as potentially inappropriate medications for use in older adults.17 Use of this tool by PACTs in the development of patient care plans has the potential to reduce medication-related adverse reactions and improper prescribing.18,19
Assessing Care of Vulnerable Elders (ACOVE ) also provides QIs that are specific to vulnerable older persons.20-24 The most recent version, ACOVE-3, includes 392 QIs for 26 conditions and 14 types of care processes and covers all domains of care.20 Findings from a study applying QIs involving vulnerable elderly patients in 2 managed care programs revealed that recipients of better-quality care had a 10% higher survival rate over 3 years.25
The VA currently monitors 6 frail elderly QIs based on ACOVE criteria via reviews of medical records in veterans aged > 75 years. These QIs cover falls, incontinence, functional assessment, and the presence of a surrogate decision maker. PACT staff, unfortunately, do not receive feedback on these, because they are still QIs and not part of the performance measures (K. Shay, personal communication, February 12, 2013). Though some VA sites have adopted these QIs to some extent, until these frail elderly QIs become performance measures throughout VA, other competing priorities may be more at the forefront of quality improvement projects done by PACT teams.5
The American Geriatrics Society recently published recommendations on the care of older adults with multiple chronic conditions, to aid PCPs in practicing a more individualized, patient-centered care in complex cases.26 In addition to focusing on a patient’s primary concern during a clinic visit and eliciting preferences, considering prognosis in deciding on treatment options allows patients to better weigh the potential benefits and burdens in their daily living.26 A discussion on how aggressive potential treatments are and what the patient is willing to undertake is an important component of patient-centered care and should be incorporated during routine PACT clinic visits.
VA Geriatric Programs
It is important for PACT clinicians to be familiar with the geriatric programs and resources available within the VA medical home “neighborhood,” which can supplement care. One such resource is the Geriatric Research Education and Clinical Centers (GRECCs). There are currently 19 GRECCs throughout the nation that serve as Centers of Excellence in the care of older veterans.27 The GRECCs provide training for clinicians, test innovative ways to care for older veterans, and collaborate with other staff to improve the care provided. Some have also developed Geriatric Primary Care Clinics (or Geri PACTs) to provide team care to very frail and high-risk older veterans. Since not all VA facilities have access to Geri PACTs, the GRECCs play an important role in making geriatric expertise and training available to the PACTs.3
The authors describe an exportable dermatology specialty care model to address aging veterans’ needs for same-day appointments.U.S.
Nearly 14 million Americans served in the U.S. military during World War II.
Despite routine screening in the VHA for depression, posttraumatic stress disorder (PTSD), and substance abuse, anxiety (not due to PTSD) has...