The role of Geriatricians in nursing homes: Reflections of a Geriatric Senior Resident

What is the role of a geriatrician in Nursing Home (NH) care? How can I best contribute to this meaningful piece of work in community geriatrics? Coming into this posting as someone who is interested in NH care, I sought to seek answers to these questions. I am grateful to the members of the GeriCare team for journeying with me as I glimpsed into the excellent and purposeful work that is being done for the NH residents.

Nursing homes

Thanks to the comprehensive schedule planned for me by the GeriCare team, I had the privilege of attaching myself to various stakeholders involved in NH care this month. This ranged from tagging on NH visits conducted by our specialist nurses and doctors from the geriatric and palliative care team, to interacting with directors of nursing from various nursing homes and clinical psychologists who were instrumental in designing the NH landscape, as well as observing NH locum general practitioners during their routine reviews of the residents. The excellent work carried out in these nursing homes continues to inspire me deeply. There is a strong spirit of collaboration and education that is aimed at empowering and partnering our NH colleagues, and this is consistently seen in the GeriCare model of care delivery.

So, what is the role of a geriatrician in the NH? Where, and how, can I come in?

We are trained to be highly discerning in the biopsychosocial care of the older adult, where performing comprehensive geriatric assessments and driving coordination of care is almost always instinctive. Perhaps this was what shaped my initial naïve and altruistic perception of my role in the NH – to care for all these residents, to perform comprehensive needs assessments of the residents and manage them holistically as I would for any other older adult in the hospital setting. I hence entered this posting thinking that a geriatrician can be embedded in the NH 24/7 but have come to the realization that this will not only be difficult to justify from a financial or resource point of view, but also, that perhaps this piece of NH work is not solely “ours” alone to hold. Through my 1-month journey with GeriCare, I have come to opine that our role as geriatricians in the NH is 3-fold - management of complex patients with complex medical issues, developing training programs aimed at educating and empowering NH staff, and involvement in clinical governance practices. It is a partnership (with the other stakeholders in NH care) that we are partaking in, and our competencies in synthesising a multitude of issues in the older adult with clarity to deliver a person-centered care plan, is perhaps what enables us to do this well.  

While I have come to realize that the ideal geriatric assessment and management is onerous, demanding from a resource and financial point of view, and demonstration of outcomes may be difficult and intangible, I still believe that geriatricians have an instrumental role to play in the management of complex cases beyond what a general practitioner can handle, along with education and empowerment. Through my many visits to the NH with the geriatric and palliative care doctors from the team, and through my attachments with the TeleGeriatrics clinics, I have come to appreciate that a large proportion of NH residents suffer from dementia (or some form of cognitive impairment). Consequentially, their challenging behaviors need to be addressed; the management and assessment of these behaviors of concerns is perhaps something that geriatricians are best positioned to tackle. Also, we know that NH residents are at the tail end of the frailty spectrum, majority have moderate to advanced global frailty. Hence, given their multi-morbidities, right-siting of care and advocacy is another crucial role we can play in the care of these residents.

During my daily visits to the NH with our team nurses, I found myself struggling to identify what additional benefit, a doctor would afford to the already outstanding work these nurses were doing. Our nurses had already performed needs assessments of the patients and were educating NH staff on basic nursing care – wound care, aspiration precautions, bowel clearance measures etc. This was the case for every physical nurse visit to the NH – the same reiterative set of nursing procedures were being conveyed to the NH staff (of course, tailored to the individual patient). It dawned upon me that this was simply because these were the care needs for majority of the residents. We know that incontinence, dementia, and functional decline are top predictors of a NH admission – unfortunately these issues are often “irreversible” (most residents are incontinent on diapers and are chair to bed-bound) and what we are dealing with are the complications of these conditions – pressure injuries, risk of aspiration, constipation etc. “SOBB” (skin, orifices, bladder, bowel) is an acronym that our nurses consistently educate the NH care staff with on basic nursing care, and indeed many of the complications of advanced frailty and immobility can be mitigated by good nursing care. I was asked a very poignant question half-way into my posting – “are the cases you see in the NH a result of sub-optimal care in the NH, or do they arise from a true need for medical attention?” After 4 weeks of on-site NH visits with our nurses and doctors, I can conclude that the needs of most NH residents can be met with good nursing care. This underscores the importance of education of the NH staff – equipping them with knowledge and skills to be able to perform targeted need’s assessments, providing basic nursing care catered towards the older frail resident in the NH, and basic end of life care assessment and management. As we aim for our NH residents to age in place and leave in place, NH staff must be competent in providing quality care for residents with palliative care needs at the end of life. Beyond the inculcation of nursing knowledge and skills, efforts have also been taken to introduce Advanced Care Planning (ACP) to the NH staff, many of whom have been trained as ACP facilitators. All in all, I was fortunate to have witnessed first-hand, the fruits of labor of the GeriCare team, in the efforts taken to build up clinical knowledge and competencies of the NH staff. It is indeed heartening to see how NH staff can take on roles of both caregiving and advocacy. Developing training programs that are aimed at equipping and empowering NH staff to continue doing the good work they are already doing, is perhaps a way in which we can contribute. Indeed, building up competencies of our NH colleagues is essential for sustainability, but beyond that, we must remember that the delivery of person-centered care demands a collective effort – and every member of the team counts.

I was fortunate to have had the opportunity to observe Tele-mortality audit sessions conducted by the team with various NHs. Amongst a variety of cases discussed, one which stood out to me was the demise of a resident following a potentially mispositioned nasogastric tube. An open discussion with the NH staff involved in the event, allowed for identification of potential care-gaps, be it in terms of knowledge, competence, or performance. This also gave us the opportunity to render emotional support to the staff directly involved in the care of the resident. The Tele-mortality session was an eye-opening experience for me; it felt like a coming together of hearts and minds of various stakeholders to see how we can improve care for the NH residents. After all, care for the residents in NH is a collective effort, it is a partnership we are partaking in. There is substantial heterogeneity in the quality of healthcare services provided by NHs, and this is not surprising. As geriatricians we are well versed with evidence-based knowledge of care for the frail adult, we can work together with the NH staff to streamline standards of care to improve outcomes for the residents.

In summary, while I may have hoped to provide 24/7 care for NH residents, I have come to the humble conclusion that this NH piece of work is not solely mine to hold. There are many stakeholders involved in delivering good care to the NH residents and all hold distinctly different, yet vital roles. The general practitioners do excellent work managing chronic diseases for the stable residents, advocating for routine vaccinations, and reducing polypharmacy. Palliative care physicians are skilled in managing symptoms towards the end of life. Furthermore, let us not forget the very definition of a nursing home – “an institution providing nursing care 24 hours a day”, this is a poignant reminder of the fundamental and critical role our nursing colleagues play in the day-to-day care for the residents. NH residents reside in a place they have been inevitably placed in because of their illness, frailty, or disability. While nursing homes may be the last port of call for many, we can do our part to help make this one where they can spend the final years of their lives meaningfully. Delivering person-centered care requires all of us to play our part. This requires a collaborative effort, with intentional steps taken to create a community of practice of healthcare professionals working in and with nursing homes. As a geriatrician, I will continue to endeavor to partake in this journery of hearts and minds, alongside the other stakeholders involved in NH care, to deliver meaningful care to the residents. Together, we must aim to allow NH residents to age, and leave, in a place they now call their home - this requires a partnership, a collaboration.

 The Article was written by Dr Ting YL, a Geriatric Senior Resident working in Singapore.