Policy implications and future research

Information about the use and effects of geriatric care by this important patient population should aid policymakers, health professionals, and researchers as they seek to determine the most effective ways to use the existing supply of geriatricians and whether additional resources for geriatric training may be worthwhile. More generally, this research has implications for the role of geriatricians in models of care for elders with geriatric conditions. Our results showed that geriatric care is used by very few elders who are likely benefit from such care. Among those who receive geriatric care, geriatric care tends to

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substitute for care from FM/IM physicians. Primary care was the dominant model of geriatric care for users of geriatric care residing in NHs. RCTs have generally shown that geriatric interventions that provide ongoing care are more effective than those that provide

consultative care. This suggests that substitution of geriatric care for FM/IM care, and in particular the focus on geriatric primary care in the NH setting, is appropriate. However, the provision of geriatric primary care limits the clinical impact of geriatric care; the more geriatric primary care that is provided, the fewer the number of elders who receive any level of geriatric care. The results of Study 2 suggest that geriatric consultative care may be no less effective than geriatric primary care in preventing ED use by both community and NH

residents. If geriatric care can be effectively provided in communities and nursing homes as consultative care, then the existing supply of geriatricians could be more broadly spread across the elderly population. More generally, Study 2 suggests that increasing the supply of geriatricians may lead to improved health outcomes for elderly Medicare beneficiaries with geriatric conditions.

Because of the lack of existing literature on the topic, additional studies are needed to further elucidate the use and effects of geriatric care in real-world clinical settings.

Researchers should examine additional outcomes and other samples. This is particularly true for the nursing home population which has not been addressed by the literature on geriatric interventions. The specific mechanisms by which geriatric care may reduce ED use are unknown. Researchers should continue to assess whether differences exist in the effects of geriatric primary and consultative care. Future studies should determine the circumstances under which substitution of geriatric care for FM/IM care or specialty care is most effective. For example, in light of the very low supply of geriatric psychiatrists, a comparison of

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outcomes for patients with conditions such as depression who receive geriatric care to those who receive care from a traditional psychiatrist would be useful [134]. If an effect of geriatric care exists in that context, it could be compared to other situations in which geriatric care substitutes for specialty care (e.g., patients with dementia who receive geriatric care

compared to those who receive neurological care). Also, beyond examining which processes of geriatric care play the largest role in improving outcomes (e.g., medication management versus coordination of care), research should examine whether quality of care differs between FM/IM physicians who are in group practices or other organizations that include a geriatrician and FM/IM physicians who do not have ready access to a geriatrician. In

addition, little is known about care from gerontological nurse practitioners and circumstances under which gerontological nurse practitioners may be effective substitutes for geriatricians.

The efficient use of the existing supply of geriatricians is a goal worth pursuing, and much still needs to be understood about the use and effects of geriatric care. However, regardless of the effects of geriatric care on health outcomes, our results suggest that the impact of clinical practice at the population level is very minimal. An enormous increase in the supply of geriatricians would be required for geriatric care to have a sizeable effect through clinical practice. Effects of a recent change in Medicare reimbursement for geriatric care on the supply of geriatricians are not likely to occur in the short-term (if any effects occur at all). For geriatric medicine to have a population-level impact on the health and health care of older adults, its focus needs to be on teaching, research, and

advocacy/policymaking. The Patient Protection and Affordable Care Act opens some new avenues for this type of work. It authorizes geriatric education center grants (e.g., for practitioners to increase their knowledge about geriatrics), and the use of geriatric

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assessments and comprehensive plans to coordinate care are among the payment and delivery reform models to be given priority by the Center for Medicare and Medicaid Innovation [127]. As the number of elderly Americans increases, funding for Medicare as well as Medicaid and Veterans Affairs will put enormous pressure on the federal budget. Finding ways to improve the quality of care for elders with geriatric conditions and also reduce health care expenditures per beneficiary is critical to ensuring the financial health of the federal government.

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