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Interdisciplinary Geriatric Teams
Care of the elderly population cannot be fully complete without the input of all the interdisciplinary professional teams. The American Geriatrics Society (AGS, 2011), noted that geriatric care promotes preventive care that is centered on care coordination and management to maintain functional independence. I currently do my practicum in one of the VA Community Living Centers (CLC), and I noted that the Program of All-Inclusive Care for the Elderly (PACE) Model is being utilized by the facility. The PACE Model was developed to “promote effective and efficient treatment of patients with multiple chronic conditions outside of the hospital setting” (Casiano, 2015). The AGS, (2011) also noted that, this model empowers the individual to live independently in the community with a high quality of life. The interdisciplinary geriatric care team comprises of the unit physician, advanced nurse practitioner (ANP), registered nurse, physical, occupational, speech, and recreational therapists, neuropsychologist, psychiatrist, nutritionist, and podiatrist. All these professionals work together to provide high quality care for the veterans, keeping them out of the hospital, and making them independent in their activities of daily living.
With regards to other sites of care such as the hospital, the nursing homes and the rehabilitation centers, different models of care are used. For instance, in the hospital, the Geriatric Resource Nurse (GRN) is used based on the “belief that the primary nurses know the most about the daily patterns and needs of the older adults in their units” (Flaherty & Resnick, 2011). Although the nurses work hand in hand with the physicians and the nurse practitioners, they carry the workload of the patients and serve as resource for geriatric practices. I also noted that, the primary care clinics use the Guided Care Model where a registered nurse assists three to four physicians in providing care for the patients.
Differences on ANP roles based on sites
At CLC levels, the NP practices in collaboration with the unit physician, but in the absence of the unit attending, the NP practices independently. In some primary care clinics, NPs are independent practitioners, but in some clinics, though they are independent, there is a physician overseeing their activities. During my Primary care practicum a few months ago, one of the physicians was telling me that when he practiced outside the VA in the primary care clinic, his team of caregivers included NP, RN, LPN, and a tech. He stated that, the NP had her own patients that she was seeing, but he had to oversee her practices per the policy of the facility. He added that “but that NP was great, in my absence she took care of all my patients including hers”.
Model of care for Case Study #2
Mr. William certainly has multiple chronic diseases which requires an interdisciplinary team to manage his care. The PACE Model, which was developed to promote effective and efficient treatment for patients with comorbidities like Mr. William will be effective in managing his care as well as empowering him to live independently in the foster home. Mr. William will need the care of a physical and occupational therapists for muscle strengthening and ADLs. His history of benign prostatic hypertrophy (BPH) can also cause him to use the bathroom frequently, and given his unsteady gait, he is at risk for falls. Therefore, he will also benefit from a urologist. Buttaro, Trybulski, Polgar Bailey, & Sandberg-Cook (2013) noted BPH is common among elderly men and symptoms include urinary frequency, urgency, and nocturia. The other team that should be involved in Mr. William’s care is the ophthalmologist to evaluate and treat his sight.
American Geriatrics Society. (2011). The principles of geriatric care. Retrieved from
Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2013). Primary care: A
collaborative practice (4 ed.). St Louis, MO: Mosby.
Casiano, A. (2015). PACE: A model of care for individuals with multiple chronic conditions
Flaherty, E. & Resnick, B. (2011). Geriatric nursing review syllabus: A core curriculum in
advanced practice geriatric nursing (3rd ed.). New York, NY: American Geriatrics Society.
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