Optimal integration of primary care for elders: Annual physicals and interdisciplinary team care

Background: Faced with unfavorable Medicare reimbursement, a shrinking geriatrician supply, a growing aging population, and a fragmented delivery system, healthcare organizations must find innovative ways to achieve optimal integrated quality primary care (PC) for elders. This research focuses on a PC physician network in southern NH, which in 2001 invested in an interdisciplinary team-based PC senior health center (SHC). The SHC is an excellent site to study elderly PC clinical integration because it is one of a few sites in the US offering many services for elders in one location.

Objectives: The study has three objectives: 1) Evaluate the relationship between annual physical exam receipt and recommendations for preventive services. 2) Assess potential differences between the SHC and the traditional PC model in the receipt of referrals for physical therapy and geropsychiatric care. 3) Measure the SHC's financial viability via patients' use of ancillary services in the healthcare system.

Methods: All patients aged 65+ years during the 2000-07 period in the PC network were selected into the study. Objective 1 was conducted by a GEE method in SAS using proc Genmod with a logit link (n=38,198 person-years.) Objective 2 was performed using a difference-in-differences model in two different sampling designs: a posttest-only comparison group with 6 post periods (n=2050 patients) and a pretest-posttest comparison group (n=966 patients). Objective 3 was analyzed using Tooze's two-part correlated model (n=7155 person-years).

Results: Patients receiving an annual physical exam were more likely than patients without one to receive preventive services (p<0.0001). The post-periods difference-in-differences regressions suggest that SHC patients were more likely than the matched patients from the comparison group to receive a referral to physical therapy or geropsychiatric care for stroke/osteoarthritis or dementia/depression, respectively (Pr>|Z|:<0.0001). The pre-post comparison group design is expected to yield similar findings based on the results from post-periods analyses. The Tooze regressions suggest that the SHC financial contribution to its system is positively linked to uses of physical/occupational therapy and geropsychiatric evaluation services (p<0.01).

Conclusion: Physicians are more likely to reserve annual physical visits to discuss preventive services than other visit types, suggesting that Medicare should cover annual physical exams to better promote preventive care. A team care model is likely to yield better integrated care for elders than the traditional PC model. To finance geriatric team care services, healthcare organizations should consider how the team-care model impacts use of other services in the system.