Feature Article
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Physician Knowledge of Community-Based Care: What's the Score? Context:Currently, community-based care is central to much of geriatrics. Physicians are traditionally educated in hospital-based clinical practice, yet primary care medical practitioners are called to assess older patients' needs in relation to a wide range of community resources.
Objective: This research was designed to ascertain the knowledge required for appropriate community-based care referral and physicians' current level of knowledge regarding community-based geriatric services.
Design: This research surveyed 22 key community-based care providers in Los Angeles on the involvement of physicians in their services. After detailing common physician misconceptions and referral problems, they participated in focus groups. The focus groups developed four core areas for the physician survey: identification of key services, familiarity with services, frequency of referral to services, and understanding of the physician role in community-based care. The physician survey was taken of a convenience sample of physicians attending either the 1997 Annual Meeting of the American Association of Medical Directors or the UCLA Family Practice Refresher Course (N = 193).
Measurements: The physician survey consisted of (1) identification of 12 community resources by matching definitions with service types; (2) physician self-reported familiarity with and frequency of referral to community-based care on a Likert scale; (3) physician understanding of common payment sources for services; and (4) physician roles in the referral process. Physician identification and knowledge were scored based on correct answers. The univariate descriptive analysis is presented, as well as the correlation of these findings with physician background variables.
Results: Seventy percent of physicians scored in the A or B categories, based on identification of services. In contrast, only 35% of physicians scored in the A or B categories in knowledge of their role in community-based care. Community-based services with the highest identification levels were as follows: medical equipment (95%), home health care (93%), hospice care (92%), and skilled nursing facilities (95%). The lowest identification score was for adult day health care (40%), followed by residential care alternatives such as board and care (58%) and assisted living (72%). Physicians were most unclear of their role in social-model programs: adult day health care, home-delivered meals, and in-home supportive services. Factors significantly influencing physician knowledge of community-based care were differences in educational preparation based on years in practice (P < 0.05) and geographic location of practice (P < 0.001).
Conclusion:Continuing physician education and training are needed to help physicians adequately assess and appropriately refer older adults to community-based care. Many physicians have inadequate knowledge of and underutilize social-model services, such as adult day care, housing options, and congregate meals. Providers of these services need to clearly communicate their admission criteria, including financial eligibility. A national randomly selected survey would be helpful to determine factors related to differences in physician preparation for community-based care practice.
Introduction
Community-based care is central to geriatrics.1 Consumer choice for the elderly, as well as cost savings, are strong rationales for focusing on noninstitutional care.2 The current health care crisis is marked not only by increasing cost but also by decreasing access to needed services and frequent episodes of inappropriate care.1 Primary care physicians prepared to function within the community care environment must be prepared to efficiently utilize the full range of supports available to older persons.
The Pew Health Professions Commission and the California Primary Care Consortium3 projected that in the next century health care must emphasize the connection between the community and the health care system. This emerging perspective on practice, which emphasizes the coordinating role of primary care, is particularly relevant to older adults with multiple and changing needs over time. Primary care will require a dramatic increase in well-prepared physicians in family practice and general internal medicine with knowledge in geriatrics. The Institute of Medicine4 defines primary care as follows: "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community."
The Pew Health Professions Commission5 reported that 59% of the physicians and other health professionals surveyed (n = 1,501) asserted that their education did not prepare them to "understand and support the important role that community service agencies play in meeting the health needs of patients." Only 8% of the health professionals reported that their education did an excellent job of preparing them for community-based practice. According to the commission, 36% of the respondents stated that they were not adequately prepared for their role in communicating care plans to their patients and families.5 Yet, family caregivers are essential to long-term community-based care, providing 85% of the support to older persons needing assistance.
Though primary care physicians are required to be knowledgeable in community-based care in order to manage their older patients, community services are not integrated into a system of care.3 Differing admission and reimbursement criteria make it difficult for physicians to efficiently utilize community-based care for their older patients. Families may not be aware of community resources and look to the physician to link them with the help they need. Cohen and associates6 have called for a physicians' reference guide to social resources, but as yet no comprehensive and physician-oriented reference has been developed. Additionally, there is no research describing physician knowledge of community-based care.
The Physician's Role
Home health care is a prime example of the physician's increasingly complex and expanding role in community-based care.7ú9 The physician serves as a key gatekeeper to access home health care.10 Without the physician ordering home health nursing and other professional services, the older patient may go without needed services upon hospital discharge. Understanding Medicare and Medicaid requirements for reimbursement of home care services is imperative if the primary care physician is to appropriately transition patients from hospital to community-based care.
Physicians who enter practice with a foundational knowledge of community-based services, skill in accessing and prescribing community services, and the ability to communicate with patients' formal and informal supports would be expected to provide more effective elder care than those without such knowledge. This research identifies physicians' current knowledge of community-based care services and their role in linking older patients and their families with needed services.
Community-Based Care
Community-based care programs are those avenues of long-term care that are primarily outside of institutional settings.11 Though community-based care services are available for health promotion for well older adults, physicians are most likely to refer ill or frail elderly to community resources.
Community resources have been classified in a variety of ways. Brody and Masciocchi12 described services from most to least restrictive. Long-term care services have frequently been viewed as existing along a continuum from home to nursing home. However, emerging health care delivery systems and the burgeoning numbers of older adults requiring long-term care present patterns that are increasingly fluctuating between different levels and types of services.13 Physicians and other health professionals must be able to access services for older adults as they are needed and not only for a final placement.14 Family and informal supports are the primary long-term care supports for elders living in the community.
Figure 1 presents core community-based service alternatives. With the older adult and the family as the focus, the services are presented by location. In-community services are potential enhancers of both home and residential care. The provider and physician surveys used in this study are based on the model in Figure 1.
Design
The study consisted of a community-based care provider survey, provider focus groups, and a physician survey.
Community-Based Care Provider Survey and Focus Groups
A telephone survey was conducted of 22 key community-based care providers in Los Angeles. The providers represented 2 home health care agencies, 1 hospice agency, 2 medical supply companies, 2 area agencies on aging, 2 adult day care programs, 3 mental health agencies, and 2 assisted living facilities. Also included were 2 hospital discharge planners, 2 residential housing representatives, 1 caregiver, 1 long-term care consultant, and 1VA hospitalúbased home care social worker. The telephone survey queried providers on what services their agency or they themselves provided, admission criteria, a general profile of patients, how physicians refer patients to them, and the physician's role in providing community-based care, as viewed by them.
Providers identified specific concerns regarding physician involvement with their community-based care service. These problems included (1) inappropriate referrals, (2) not making referrals, and (3) physician misconceptions about what their service provided. In addition, providers gave recommendations for what physicians needed to know about their agency or service.
After the telephone survey, the providers participated in focus groups. The focus groups discussed case presentations of older adults with concomitant medical and social problems. From the focus groups, the following content areas emerged and were used as focuses of the physician survey: (1) knowledge of key services; (2) physician familiarity with community services; (3) frequency of referral to community-based services; and (4) knowledge of the physician role in community-based care.
Physician Survey
A convenience sample was created of physicians attending either the 1997 Annual Meeting of the American Association of Medical Directors or the 1997 UCLA Family Practice Refresher Course (N = 193). The surveys were distributed at the meetings and were returned either on site or by mail. Analysis of data was predominantly descriptive. Correlational analysis (chi-square) was used to examine the relationships among physician background variables and measures of physician knowledge of community-based care.
Measurements
The majority of physicians surveyed were male (88%) and had practiced medicine for 11 years or more (75%). The physicians who reported locale were almost equally divided in practicing between urban (29.5%), suburban (35.8%), and rural (30.1%) areas. The majority of physicians were in family practice or internal medicine (54.3%), whereas the remainder practiced mostly geriatrics (18.7%), geriatrics/internal medicine (16.1%), or geriatrics/family practice (10.9%). Seventy-two percent of the surveyed physicians had a fee-for-service practice. The majority had office-based (80.3%) rather than hospital-based (33.2%) practices (a few physicians reported having both hospital and office-based practices). Almost two-thirds of the physicians spent half or more of their time caring for adults between ages 65 and 79. In contrast, only 25% spent more than half their time with individuals 80 years and older, or the old-old (Table). Physicians were asked to match community services with their definitions for 12 community resources: adult day care, adult day health care, assisted living, board and care residences, congregate meals, durable medical equipment, home-delivered meals (meals on wheels), in-home supportive services, home health care, hospice care, senior centers, and skilled nursing facilities.In addition to physician identification of resources, physicians reported their familiarity with services and their frequency of referring to those services through a 4-point Likert scale. Also, the physicians' knowledge of their role in the referral process, of payment sources for each type of service, and whether a physician order was needed to begin services was surveyed.
Results
The results of the community-based care provider survey and the physician survey are as follows.
Community-Based Care Provider Findings
Results of the telephone survey indicated that providers had experienced many physician misconceptions about what community-based care provided. One misconception identified was that physicians thought that financial reimbursement for home care was ongoing. Providers stated that physicians have the perception that home health care can "last forever," apparently ignoring restrictions created by the rules of funding sources. The available types of care and services are, in fact, restricted by the patient's income level and by third-party rules.
An additional issue in home care was the perception that patients played a passive rather than an active role in their community-based care. Providers reported that physicians often confused the role of residential care with nursing home care, sometimes considering board and care as a "warehouse." Overall, providers described physicians' view of the doctor's role as very limited, essentially restricted to referral to the community-based service.
Another salient concern was disruption in the continuity of care caused by physicians not referring patients appropriately. Some physicians reportedly referred patients too late to maximize the effectiveness of services--eg, hospice benefits--or did not utilize home health care or adult day care soon enough. The providers identified physicians inappropriately referring patients to community-based care--for example, referring patients with advanced dementia to a senior center, assisted living/residential care, or an outpatient mental health clinic when more specialized care was needed; or, on the other hand, for instance, referring non-homebound patients to home health care for custodial care or social needs when skilled care was not needed. Providers wanted to enhance physician knowledge of the availability of different services and the different levels of care provided. Providers wanted to emphasize that patients can be evaluated by the agency in their own home to see if community-based care is a feasible option for them. Providers reported that mental health services, particularly for older adults with depression, were underutilized as physician referrals.
Physician Survey Results
Results are given for four core areas of the physician survey.
Identification of Services. The survey required physicians to match basic definitions of community-based services with their respective provider type. Physicians' correct answers in identifying board and care residences (only 48%) and assisted living (50%) demonstrated a low level of recognition for those services. For the other community-based services, 70% of physicians correctly identified 12 of the services. As seen in Figure 2, the highest percentages of correct physician answers were for hospice care (99%), durable medical equipment (98%), home-delivered meals (98%), and senior centers (98%).
The range of correct matches was between 5 and 12. The mean was 9.89, with a standard deviation of 1.87. Thirty-five percent of the physicians scored an "A" (11ú12 correct out of 14), 33% scored a "B" (10 correct), and about 27% scored a "C" (9 correct or below) or worse. Whereas more than two-thirds of the physicians recognized at least 10 of 12 services, one-third did not correctly identify these services (Figure 3).
Familiarity and Frequency of Referral. The next portion of the survey inquired as to the physician's self-reported familiarity with and frequency of referral to community-based care. The physicians were asked to rate their responses on a Likert scale of "1" (very familiar or frequently referred) to "4" (not familiar or did not frequently refer).
Self-reported responses generally paralleled the results of the matching section for identifying community-based care. Physicians reported high familiarity with medically oriented resources, such as durable medical equipment (95%), skilled nursing facilities (95%), hospice care (94%), and home health care (91%). Less familiarity was reported with such community-based services as congregate meals (34%) and adult day health care (33.6%) (Figure 4).
Services with the highest reported frequency of referral included durable medical equipment (91%), home health care (91%), and skilled nursing facilities (90%). Conversely, the services with the lowest referral rates were adult day health care (20%), congregate meals (20%), and board and care residences (39%). These findings show a congruence between low levels of familiarity and low referral to these services (Figure 5).
An exception to the general congruity of identification and reported familiarity with services was seen with residential care options--confusion about assisted living, board and care, and skilled nursing facilities (SNFs). In this case, physicians reported familiarity and yet were unable to identify the basic definitions of these services.
Familiarity and frequency reports often closely paralleled each other. Physicians are familiar with and frequently refer patients to commonly used medical services (eg, durable medical equipment, skilled home health care, and subacute and custodial skilled nursing facilities). They are less familiar and refer less often to such services as adult day health care and congregate meals. An incongruence appears between their familiarity (modestly high) with many community-based services and their rate of referral (low) to these services, notably adult day care and adult day health care, senior centers, and board and care residences.
Prayer Sources. The survey asked physicians to identify payer sources for community-based care. Physicians selected 5 payer options--Medicare, Medicaid, managed care, private payment, and no charge--and designated which source paid for each service. Whereas some payer sources may differ by state, general trends can be extrapolated from the data. One exception to payer variability is Medicare, which has the same requirements across the states. Physicians showed great variability in designating primary payer sources.
Small numbers of physicians incorrectly indicated that Medicare and Medicaid paid for social-model programs, such as adult day care (Medicare, 8.3%; Medicaid, 15%) and senior centers (Medicare, 4.7%; Medicaid, 6.2%), although these payers do not reimburse for those services. Larger numbers of physicians thought that Medicare paid for in-home support services that are Title XX programs linked to the Medicaid program. Physicians responded that federal and state subsidies supported assisted living (Medicare, 7.3%; Medicaid, 17%) and board and care residences (Medicare, 5.7%; Medicaid, 28%), but these services are predominately privately paid expenses and not medically reimbursed housing arrangements.
Physician Role. Physicians were surveyed on their ability to identify community-based services that required physician authorization, recommendation, or monitoring. This survey portion listed 14 community-based services, and physicians were to mark whether the services did or did not require an active physician role. In-home supportive services were distinguished between skilled in-home supportive services and custodial or attendant care. Skilled nursing facilities were similarly demarcated between rehabilitation or subacute facility and custodial care.
Physicians responded most often correctly in determining the physician role for the following services: skilled nursing facilities (99%), congregate meals (99%), and durable medical equipment (98%). Physicians were less clear in their role with regard to home-delivered meals (20%), in-home support services (42%), and adult day health care (42%) (Figure 6).
Scores for physicians' knowledge of their role in referral to community-based care are described in Figure 7. Only 7% of responding physicians had a higher than average (13ú14 correct) knowledge of physician role, whereas 32% had above average (12 correct) and 52% had 10 to 11 correct in this area.
Relationship of Background Variables to Physician Knowledge
Gender, specialty, type of practice, and percentage of physician practice time seeing older persons did not significantly influence physicians' scores on identification of community-based care or on knowledge of third-party rules regarding physician role in these services.
Geographic location was a significant (P < 0.001) predictor for the number of correct answers in the identification of community-based services. Suburban and then rural physicians had the most correct answers, with urban physicians having the lowest scores.The number of years in practice was significantly related to the score on knowledge of the physician's role in community-based care (P < 0.05). Physicians with 11 to 20 years of service scored the highest. The physicians with the fewest years of experience scored the lowest. Physicians with more than 20 years in practice had a wide variance in scores.
Conclusion
Some of community-based care providers' concerns regarding physicians' knowledge of community-based services are substantiated in this preliminary investigation. Physicians have a high sense of familiarity with home, residential, and community services. Their self-reported familiarity is less for more social-model programs. Physicians' sense of familiarity is validated by the ability to define the key types of services provided in the community. However, almost one-third of the physicians did not correctly define the services. Referral frequency varied, with the more medical services having higher rates of referral.
Payer sources for community-based care were a source of confusion. Differentiating Medicare and Medicaid reimbursement from private payment was difficult. Additionally, the physician's role along the spectrum of community-based care was not clear to the majority of physicians. Again, the role was clearer in the medical-model programs, such as accessing medical equipment and ordering home health care.
The medical services that received the highest ratings of familiarity, identification, and referral were medical equipment, home health care, hospice, and then nursing homes. Residential care alternatives were the least likely to be correctly identified by physicians. Assisted living, a relatively new residential alternative, was particularly indistinguishable. Physicians were most unclear of their role in adult day health care, home-delivered meals, and in-home support services.
A disparity exists between physicians' reporting a higher level of familiarity with services and a lower level of referral for those services. Thus, knowledge of available services does not by itself lead physicians to refer patients to those services. Patients may not need referrals to those services. Additionally, certain services may not be available in all areas.
Continuing physician education and training are needed to adequately evaluate and appropriately refer older adults to community-based care. Differences in physician educational preparation based on years in practice appear to be an important consideration in creating interventions for community-based care.
Implications
The limitations of this research restrict drawing strong conclusions or implications. The small convenience sample (N = 193) potentially limits representativeness. The physicians surveyed identified with geriatrics to a much higher degree than the general physician population. A nationally randomly selected survey that would include urban and rural physicians would be instructive.
These pilot data support the earlier finding that physicians' ability to develop a sustained partnership with patients and to practice in the context of family and community is challenged by a lack of knowledge of community-based care.4 Earlier studies by the Pew Health Professions Commission3,5 that describe the lack of preparation for community-based care are also supported by this research. Education--undergraduate, graduate, and continuing--should provide knowledge of community-based models of care.15 Education should focus on the contribution that community-based services make to the physician's role in managing chronic illness.16
The physician's role is to order specific services, such as home health care and hospice, and to assess functional levels for in-home support services or home-delivered meals. These roles cannot be delegated to other team members. This role is complemented by team members who can assess family supports in relation to patient needs and provide care management for patients who have intense or multiple needs over time. An interdisciplinary team may especially help the physician serve the complex needs of older persons with multiple problems and their caregivers.
Physicians' experience and locality would be considerations in designing education programs. Regional influences related to the available resources demand consideration.
More involved physician roles are related to reassessment of the continuing need for community-based care. These roles may include home visits, home care medical direction, and active monitoring of patient functioning. Providers of community-based care can facilitate appropriate utilization of their services through outreach, clear statements of admission criteria and of the physician's role, and timely progress reports to physicians of referral outcomes.
Emerging health care systems require "the provision of integrated, accessible health care services."4 Both social and medical services are essential to meeting the long-term care needs of older individuals.1 Physicians must be prepared to play their role alongside those in other disciplines in accessing and integrating care from the hospital or office to the community.
Acknowledgment
This study was funded by an award from the University of California Office of Health Affairs Geriatric Resource Program.
About the Author
Dr. Damron-Rodriguez is Associate Director, VA Geriatric Research, Education, and Clinical Center (GRECC), West Los Angeles, California, and Assistant Professor, School of Public Policy and Social Research, University of California at Los Angeles (UCLA). Dr. Frank is Assistant Director of Academic Programs, Multicampus Geriatric Medicine and Gerontology, UCLA, and Director, California Geriatric Education Center. Ms. Heck is an Extended Care Social Worker, VA Palo Alto Health Care System, Palo Alto, California. Mr. Liu is a Geriatric Education Specialist, VA GRECC, West Los Angeles. Ms. Sragow is a Long-Term Care Consultant. Dr. Cruise is Executive Director ofSunbelt Home Health Care. Dr. Osterweil is Professor of Clinical Medicine and Geriatrics, Department of Internal Medicine, UCLA. Address for correspondence: JoAnn Damron-Rodriguez, LCSW, PhD, GRECC (IIG), VA Medical Center, 11301 Wilshire Blvd, Los Angeles, CA 90073.
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