Better geriatric care isn't an 'impossible dream'.

As I review the literature regarding the need for more medical direction in America's nursing facilities (and, increasingly, assisted living), I'm reminded of Don Quixote as he sets forth on his quest through the Spanish countryside with his trusted companion Sancho Panza. Readers of Cervantes' great novel will remember: Don Quixote's delusions are many. As he attempts to combat the world's injustices, his imagination transforms windmills into giants, flocks of sheep into enemy armies, and country inns into castles. And, true to the chivalric model, Don Quixote dedicates his actions of valor to a noble love whom he calls Dulcinea.

So, where are the parallels here? One, certainly, is the injustice of having an increasingly frail long-term care population desperately in need of a dwindling supply of expert medical care. This windmill is indeed a giant, and a formidable one at that. Another parallel might be Quixote's romantic dedication to Dulcinea. Those who have spent their careers tilting at the windmill of physicians' inadequate geriatric training display all the nobility of Don Quixote as they continue to dedicate their energies to upgrading quality of care in America's long-term care communities.

But I fear there is a less encouraging parallel here--one that reflects the real focus of Cervantes' novel: the often frustrating dialogue between idealism and realism. Our struggle to facilitate the growth and involvement of trained geriatricians in resident care is idealism at its very best. And it flies in the face of anyone's definition of realism.

Certainly, the need for geriatricians is indisputable. A recent report by the Association of Directors of Geriatric Academic Programs (ADGAP) put some pretty stark numbers on the table. The 7,500 trained geriatricians in practice today constitute barely one-half of those needed. And, given the geometric growth in America's elderly population, the 14,000 we need today will balloon to 36,000 25 years from now. Worse yet, the numbers of geriatricians actually in practice are diminishing--dramatically so. ADGAP estimates that 2,730 fewer certified geriatricians are practicing today than in 1998, a more than 29% decline.

It gets even worse. We don't have sufficient numbers of academicians necessary to train those few medical students who might have an interest in the field. We need 2,400 of these teachers. We have 900. And while the Institute of Medicine suggests that each medical school should have at least nine geriatricians on its teaching staff, ADGAP estimates that only 30% of all schools meet that criterion. Only 27 of the more than 100 nonpediatric residency and fellowship training programs in our medical schools even have a curriculum requirement in geriatric care. (And forget about departments of geriatric medicine--at last count, only six existed in the entire country.)

Yet, in the face of this stark reality, ADGAP's recommendation (mirrored by other professional associations interested in the problem) is simply that "new initiatives are required to ensure that adequate numbers of physicians trained in geriatrics will be available in the future."

Way to go, Don Quixote! Way to go, Sancho!

Let's get back to reality. If we, in long-term care, are going to meet the need for expert medical direction in the field, we need to understand the underlying causes of and cure for the supply problem, and not simply "tilt at windmills" with bromides and halfhearted solutions.

We already know we need "initiatives" to generate more trained geriatricians. What we need to know is why medical schools don't create them.

Ask any physician and you'll get one answer. Ask any student of American medicine, and you'll get another. And both will be right.

Let's start with the physician's response: "It's all about reimbursement." There is little question that Medicare reimbursement is the single most influential force shaping medical practice in the United States, accounting for 27% of all physician income in 2000. Because geriatricians limit their clinical practices to older adults, most of their compensation comes from Medicare--and, unfortunately, many of the time-intensive services geriatricians provide are not adequately reimbursed. The growing gap between Medicare reimbursement and the actual costs of delivering geriatric care seriously affects the willingness of young physicians to consider careers in this field. And who can blame them?

What about our answer from the student of American medicine? Well, he or she might suggest that geriatric medicine is out of tune with the core philosophy underlying American healthcare--the focus on "healing." American medicine is oriented toward improvement, not decline. But aging is, more often than not, a graphic and sobering reflection of decline. As Vander, Sherman, and Luciano have suggested (in Human Physiology: The Mechanisms of Body Function), aging is "a gradual deterioration in function and the capacity of the body's homeostatic systems to respond to environmental stresses." Gary Applebaum, medical director at Erickson Retirement Communities, suggested to my students at Johns Hopkins that aging is "the diminution of an individual's physical, psychological, and/or social reserves."

Deterioration? Diminution? Not the stuff American medicine is made of. And certainly not the stuff to entice medical students into geriatrics.

There is nothing to be ashamed of in either of those responses. What is discouraging is the propensity of many to assume that those two barriers can be easily overcome simply by launching "new initiatives." I, for one, think we are dealing with systemic barriers that are not easily surmountable. Reimbursement for geriatric care has not kept pace with the increasing complexity and volume of cases. Is that really likely to change? Well, I served for 13 years in senior positions at the Health Care Financing Administration (now CMS), and my advice is: Don't hold your breath. Between 1999 and 2002, total compensation for geriatricians in private practice increased by all of 3.1%. One percent per year--the lowest percentage increase among 12 specialties surveyed by the Medical Group Management Association.

As for the optimistic medical philosophy of American healthcare professionals--the emphasis on the possible rather than the inevitable--I'm not at all sure we can (or even should) attempt to change it. While it has, perhaps, worked at cross-purposes with the need to grow more geriatric practitioners, it has been the stimulus for much of what is good about American healthcare.

So it is time that we stop tilting at wind-mills and rethink the essential configuration of medical oversight and management in today's long-term care community. That doesn't mean supplanting the medical director or substituting for her. It simply means recognizing the fact that we might never achieve the goal of filling the unmet need for trained geriatricians; that attempting to do so simply directs our energies toward activities that are likely to be unsuccessful and away from those that might prove fruitful. If we can't fill the gap with trained geriatricians, let's better support those we have. And, to me, that means increased use of advanced nurse practitioners--not as a substitute for medical direction, but as an enhancement of it.

There's really nothing all that new about the concept. It has its counterparts in physician assistants and pediatric nurse practitioners, who have been around for some years now. In fact, more than 157,200 registered nurses have been prepared to practice as nurse practitioners, clinical nurse specialists, or both. While only 3% of them are currently certified in geriatrics, 55 programs across the country in a variety of colleges and universities prepare advanced geriatric nurses. The potential benefits they bring to long-term care can be significant within the contexts of both quality and cost.

The advanced (or, in this case, geriatric) nurse practitioner assesses and manages medical and nursing problems involving the elderly, with an emphasis on health promotion, maintenance, disease prevention, and disease diagnosis and management. In an article in the American Society on Aging newspaper Aging Today, Mathy Mezey and Priscilla Ebersole point out that geriatric nurse practitioners (GNPs), working with physicians, have already been shown to deliver high-quality primary care to frail nursing home residents. In long-term care, especially, GNPs improve quality outcomes and limit unnecessary hospital admissions through extensive case management, health promotion activities, quick response to changes in the resident's health status, improved immediacy of care, and enhanced training and support for licensed and unlicensed nursing staff. In some nursing homes, GNPs are employees of the facility; in others, they collaborate with primary care physicians to manage a caseload of residents.

Recognized as major service providers in the care of older adults, GNPs are trained in graduate nursing programs that include intensive classroom work and interdisciplinary clinical practice. It is thought that approximately 60% of GNPs already work in long-term care facilities. These nurses have the authority to prescribe medications in all state jurisdictions and receive 85% of the reimbursement rate that Medicare sets for physician services.

What does this all mean in practice? Let's take an example provided to me by Judith Ryan, a colleague and director of Prime Health Group's nurse practitioner program in Owings Mills, Maryland:

  Mrs. K is an 82-year-old nursing home resident with Alzheimer's
  disease. This morning she fell in the dining room. She complained of
  pain in her left hip, and after the nursing home contacted her
  physician, she was transported, unaccompanied, by ambulance to the
  local hospital for an x-ray. In the unfamiliar and frightening
  environment of the emergency department she became agitated, was
  incontinent of urine, would not cooperate, and was subsequently
  medicated to "calm her down." Although the hip x-ray was negative,
  Mrs. K became more confused and aggressive, would not drink any
  fluids, and was admitted to the hospital.

In reviewing the situation as described, it might have turned out quite differently if a GNP had been present. Following Mrs. K's fall, the GNP would have evaluated her extensively. If the GNP decided that a hip x-ray was indicated, a portable x-ray might have been taken in the nursing home itself and, possibly, interpreted by the GNP. Mrs. K would more likely have remained in the facility, where the environment is familiar to her and she and her medical condition are known to the staff; she would not have become agitated, incontinent, or inappropriately medicated, and she would have remained hydrated. The on-site GNP could order medications for pain management and would be immediately available should Mrs. K's condition change. In addition, the GNP would have explained the resident's status to family members and participated in a subsequent review of the community's fall prevention program. If Mrs. K's hip had been fractured, the GNP would have contacted her physician regarding admission to the hospital.

By decreasing hospital admissions, a facility can improve its financial performance. Identifying and treating bronchitis before it becomes pneumonia, or urinary infection before it becomes sepsis, and closely monitoring drug therapies to prevent untoward reactions are just some of the ways that hospitalization can be avoided in this frail population.

Involvement of the GNP can dramatically decrease the amount of time staff spends trying to communicate with the off-site primary care physician. Survey deficiencies related to "physician not notified of change in resident status," often because of missed or missing callbacks, are less likely to be a problem when the GNP is on-site. Other nurses in the facility get their questions answered or necessary medical orders written directly by the GNP, rather than having to wait for the physician to show up. Rehabilitation therapists, dietitians, and wound specialists all can have care orders written directly by the GNP and do not have to seek out the physician for this.

In short, we're talking here about both improved quality and reduced cost--not at the expense of the physician, but collaboratively with her. Increasing use of the GNP combines the best of both our idealism and our realism, when it comes to geriatric care, and knocks down a few windmills in the process.

No, Don Quixote wouldn't be envious--he was too big for that. But perhaps he'd feel vindicated.

Paul R. Willging, PhD, was involved in long-term care policy development at the highest levels for more than 20 years. For 16 years as president/CEO of the American Health Care Association, Dr. Willging went on to cofound the successful Johns Hopkins Seniors Housing and Care postgraduate program (cosponsored by the National Investment Center for the Seniors Housing & Care Industries), and later served as president/CEO of the Assisted Living Federation of America. He has enjoyed an equally long-lived reputation for offering outspoken, often provocative views on long-term care.

To comment on Dr. Willging's views, as expressed here, e-mail [e-mail].