Geriatric care has been in the spotlight for being understaffed and in high demand. And a new movement is pushing hospitals and nursing facilities to work harder to treat dementia patients.
The shortcomings of geriatric care were first brought to light in the 1970s and 1980s by Robert Butler, MD, who noticed gaps in his education when caring for older adults, the complex needs of this patient group and the lack of training physicians received. However, little progress has been made. By 2034, the number of adults 65 and older is expected to grow 40%, yet the geriatric care field is already short-staffed.
There are fewer than 7,300 physicians who are board-certified geriatricians. This means there is about 1 geriatrician for every 10,000 older adults in the U.S., and few residents are entering geriatric care. In 2023, fewer than 42% of geriatric medicine fellowship positions were filled.
Nursing homes have also struggled to provide enough care hours per day — an even more difficult feat for many facilities with the new CMS hour requirements that went into effect this year.
Some systems are working to address this need for care on a state and system level. For example, Biddeford, Maine-based University of New England received nearly $5 million to educate and train Maine's healthcare workforce in geriatric care.
However, CMS and other organizations have taken a special interest in dementia care in recent months with new care models.
Addressing dementia
In July, CMS launched a dementia care program that will be piloted by 400 organizations. The Guiding an Improved Dementia Experience Model focuses on comprehensive, coordinated care designed to improve the lives of people with dementia, reduce strain on their unpaid caregivers and enable people with dementia to remain in their homes, according to the agency's website. It is a voluntary, nationwide model that began July 1 and will run for eight years. The program will also test alternative Medicare payments for delivering key services, including comprehensive, person-centered assessments and care plans, care coordination and 24/7 access to a support line. The program will include care navigators and nonclinical services such as meals and transportation.
This program has been years in the works with systems such as Charlotte, N.C.-based Advocate Health studying different dementia care models to help inform CMS' new program.
The focus on dementia care has been due to a growing need among patients and families over the past couple of decades, Mia Yang, MD, associate professor of gerontology and geriatric medicine at Winston-Salem, N.C.-based Wake Forest University School of Medicine, told Becker's.
"The payment model of GUIDE has allowed a lot of widespread interest in terms of implementing evidence based dementia care models," she said. "And in parallel, the development of new Alzheimer's drugs has really brought earlier diagnosis and detection of dementia and mild cognitive impairment to the forefront."
In the last few years, hospitals have focused on ways to reduce hospitalizations. Some have launched at-home programs and others have turned to disease-specific care to reduce care needs.
"That's what GUIDE is trying to do, prevent negative, potentially avoidable hospitalizations and inpatient use," Dr. Yang said.
Experts have high hopes for the GUIDE Model, but it will be several years until results come in.
What is needed next
Experts said CMS' GUIDE Model is a good first step in shifting the way dementia is treated by supporting other payment models, but there is more to be done.
"We want CMS to continue to focus on things like telehealth and recognize that there are other ways to engage patients other than traditional brick-and-mortar clinical visits," Jennifer Houlihan, vice president of policy and research application and enterprise population health at Advocate Health, told Becker's. "I think GUIDE is a great first step, and I would like to see more of that nontraditional thinking incorporated by CMS going forward, as well as from other payers."
Dr. Yang added that building and supporting more community partnership with organizations that are already caring for this population is another worthwhile element.
"We could all work better together in screening for social determinants of health and sharing resources, whether financial or infrastructure, with community organizations that deliver much-needed community-based care," Dr. Yang said.
There could also be more done to support the informal caregivers, such as family members and friends, who help those with dementia.
"Patients and their families often pay out of pocket for this care because these caregivers are not necessarily licensed certified nurse assistants, but they are the people the person with dementia trusts to be in their home," Dr. Yang said. "For people to actually use respite services — both for the caregiver and the patient living with dementia — they need the flexibility to use respite payments for someone who may not be certified but is still providing a service."