Full report published as reference material

The long term conditions agenda is one that is central to our speciality. There is no other speciality that is better served to take the professional lead in this process. Engaging in this process constructively will help the Society strengthen the speciality, not least because it focuses on aspects of geriatricians’ work other than acute internal medicine. More importantly, if case management is a success, then much of what we now understand as geriatric medicine will be done in this process. Geriatricians cannot afford to be left out of it, or even to be side-lined. For this reason we advise the Society to take a major role at all levels to work constructively on the case management agenda. This includes:

• Promoting community geriatricians in support of this process
• Reviewing training of geriatricians for this role
• Examining the CPD for geriatricians in this role
• Taking a lead on the multi-disciplinary education and training of staff involved in these services
• Identifying the R&D needs in this process.

The Department of Health’s focus on case management provides the speciality of Geriatric Medicine with an opportunity to review and strengthen its partnership with primary care (1). The basis of the practice of the speciality is the multi-disciplinary approach i.e. “Comprehensive geriatric assessment” which has been shown to be effective in improving the quality of life in frail, vulnerable older people with complex medical conditions.

The three level pyramid is useful to clarify the conceptual issues but the implementation of case management requires a more detailed model. Although we welcome the introduction of local solutions using community matrons there will need to be established common processes to ensure an equitable delivery of service. Evidence suggests that case management of a population is successful in reducing mortality and institutionalisation rates.

A more integrated model of care encompassing health and social care systems should replace the traditional primary, secondary and intermediate care, see figure 1 below:

Figure 1

Fundamental to any system managing long term conditions is the right of the patient to access appropriate types of treatment, as shown in the model, delivered in a flexible and collaborative fashion wherever the patient lives. These should include:

• Acute treatment
• Comprehensive assessment and review
• Rehabilitation and re-enablement
• Palliative care and end of life care

A considerable number of frail complex older people suffering from long term conditions live in care homes and in some areas account for a disproportionate number of admissions to acute hospitals. The care management system has been demonstrated to be effective in the United States and could be used in the United Kingdom.

The role of the geriatrician should include:

• Management of older people with several long-term conditions as well as common conditions in older people affecting their function for example Parkinsonism.
• Providing advice at times of transition, recognising the limitations of active intervention and the importance of palliation.
• Providing professional support for assessment processes used on older people and regular reports to Primary care trusts and hospital boards regarding performance. Such reporting should inform on rates of institutionalisation, hospitalisation, and access difficulties for community care.
• Leadership of clinical governance arrangements for services outside the hospital.
• Nurturing the multidisciplinary team in the primary care sector
• Teaching and research
• Leading and facilitating the evaluation of services for long term conditions