Small practices lack support personnel for frail elderly patients

June 5, 2019 6:50 pm

Despite recommendations for practices to add support personnel to coordinate the care of their frail elderly patients, few small, independent practices employ such staff, new research found.

Based on a 2018 survey of 410 clinicians in 363 practices that provide care for Medicare-age patients, researchers found 63% of independent solo or two-physician practices had neither registered nurses (RNs) nor social workers to help coordinate care. Practices of that size comprised nearly half of all those surveyed. The results were published in the June issue of Health Affairs.

An October 2018 study in the Journal of General Internal Medicine was the latest to recommend such staff to ensure comprehensive care for geriatric patients.

Karen Donelan, senior scientist at the Mongan Institute for Health Policy at Massachusetts General Hospital, and one of the new study’s authors, said many newer care models — such as patient-centered medical homes and the Program of All-inclusive Care for the Elderly (PACE) — rely on having both RNs and social workers in practices.

“And yet, we saw that in a few of these practices those are rarely both there,” Donelan said this week in Washington, D.C., during a discussion of her research.

Larger practices were much more likely to have such staff. For instance, such staff were lacking in only 13% of practices with three or more physicians and 14% of practices owned by a hospital, health system or medical school.

Other findings of the study included:

  • Practices with social workers use them to assess patients’ social issues.
  • Practices use clinicians for such assessments when not employing RNs or social workers.
  • Of clinicians in surveyed practices, 38% had enough time in their schedules to manage the social needs of their frail elderly patients.

RNs, social workers reduce burden on physicians

Surveyed physicians reported spending fewer hours in weekly communication with other providers about care coordination if RNs and social workers were in their practice.

Donelan said there can be a reduction in physician workload with better employment of RNs and SWs.

“We think it really does matter to understanding efficiency and practice by looking at who’s there and what they are doing,” Donelan said. “It’s a complex thing to do, but we do feel there are savings there, especially for higher-cost providers, if they expand their teams, include other workers with other competencies and put them to work in practices improving care for older adults.”

A specific area of potential savings was the coordination of transitions to and from hospitals among elderly patients.

In practices with both social workers and RNs, the nurses were most likely to coordinate such transitions. In practices with an RN but no social worker, the physician was most likely to coordinate the transitions. In practices with social workers but no RNs, nurse practitioners (NPs) were most likely to coordinate the transitions. And in practices with neither social workers nor RNs, the physician was overwhelmingly likely to do the coordinating.

Approaches to caring for seniors with chronic-care needs

In contrast to the growing role of allied health staff in some aspects of complex patient care management, physicians reported that they played a clear leadership role in complex chronic-care management, and that finding did not vary by practice staffing.

Other findings included that practices with a significantly higher share of revenue from Medicaid were more likely to have social workers and RNs. The finding suggested that practices serving a poorer population may see value in including such staff members.

However, a higher proportion of surveyed clinicians in all practice types would add more physician and NP labor compared with other types. Community health workers were seen as desirable especially by practices with both RNs and social workers. Social workers were highly valued by practices with RNs and no social workers.

“Nurses, social workers, and other licensed and nonlicensed staff bring different types of preparation and skill sets to complex chronic care management, care coordination, and social issues assessment, which may include responding to complex social concerns such as food and housing insecurity in addition to medical concerns,” the authors wrote. “Understanding how best to staff ongoing programs may help ensure that these activities are provided most effectively and efficiently.”

The study authors were surprised to find that in all types of practices, the share of clinicians saying no one was providing assessment of social issues ranged from 3% to 10%.

“It may be that these issues are addressed solely outside of the practice or that the practice simply has no formal process in place,” they wrote.

The research indicated that the best patient outcomes happened when providers threaded the needle between too strictly adhering to professional boundaries, which can allow vulnerable patients to fall through the cracks, and inefficiently duplicating efforts to address social needs.

The authors echoed the expectation of some industry leaders that going forward, nurses and other health professionals will provide a growing share of care management, care coordination and social-issues assessment in primary care and geriatric settings.


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