BACKGROUND/RATIONALE:
Underdiagnosis and undertreatment of elderly persons remains a widespread problem. While many innovative geriatric care programs exist within VHA, we still lack a systematic process for identifying at-risk elders from the larger VA population who are likely to benefit from specialized geriatric services.

OBJECTIVE(S):
Our goal is to improve care for at-risk older veterans through a comprehensive system of casefinding, assessment, referral and follow-up within the primary care setting. We hypothesize that subjects receiving this intervention will have more complete evaluation and treatment for selected geriatric conditions (i.e., falls, urinary incontinence, functional status impairments, depression, and cognitive deficits), better continuity of care, less decline in functional status, and better general health than subjects receiving usual care.

METHODS:
This randomized controlled trial is being performed at the Sepulveda VA Outpatient Clinic. The study sample is composed of community-dwelling veterans aged 65 and older who are not receiving VA geriatric services. Veterans are mailed a health screening survey to identify those at risk for decline based on criteria established in pilot work. At-risk respondents who are in the intervention group receive a structured telephone assessment (casefinding) and referral to appropriate geriatric services, including a geriatric assessment and teaching clinic integrated with primary care, and telephone case management. Subjects in the control group receive usual care. Major outcome measures collected by telephone interview at baseline, 12, 24, and 36 months include functional status, self-rated health, satisfaction, and health care utilization. Medical records are reviewed for evidence of evaluation and treatment of the target conditions.

FINDINGS/RESULTS:
A total of 2,722 postal surveys were mailed to eligible veterans, with a response rate of 88 percent. Of respondents, 42 percent were identified as at-risk. A total of 791 subjects have been enrolled into the study: 380 intervention, 411 control. The mean age of subjects is 74 years and 96 percent are male. Among intervention subjects, the prevalence of undiagnosed or suboptimally treated target conditions was 34 percent for falls, 27 percent for cognitive impairment, 28 percent for depression, 20 percent for urinary incontinence, and 20 percent for functional impairments. Overall, 67 percent of intervention subjects received a referral for specialized geriatric assessment and/or care.

IMPACT:
We anticipate that this project will produce significant improvements in one or more of the study outcomes. The results of this project will be extremely important in planning for the care of the increasing older population within the primary care setting.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Hoyl MT, Alessi CA, Harker JO, Josephson KR, Pietruszka FM, Koelfgen M, Mervis JR, Fitten LJ, Rubenstein LZ. Development and testing of a five-item version of the Geriatric Depression Scale. Journal of the American Geriatrics Society. 1999 Jul 1; 47(7):873-8. [view]
2. Alessi CA, Josephson KR, Harker JO, Pietruszka FM, Hoyl MT, Rubenstein LZ. The yield, reliability, and validity of a postal survey for screening community-dwelling older people. Journal of the American Geriatrics Society. 2003 Feb 1; 51(2):194-202. [view]

Conference Presentations

1. Harker JO, Freed SS, Josephson KR, Alessi CA, Rubenstein LZ. Annual postal screening for geriatric problems: what happens after two? Paper presented at: American Geriatrics Society Annual Meeting; 2000 Nov 15; Washington, DC. [view]
2. Alessi CA, Josephson KR, Pietruszka FM, Harker JO, Rubenstein LZ. Recognition of geriatric condition problems in an outpatient geriatric assessment trial. Paper presented at: American Geriatrics Society Annual Meeting; 2000 Nov 15; Washington, DC. [view]

DRA: Aging, Older Veterans' Health and Care, Health Systems
DRE: Diagnosis
Keywords: Access, Primary care
MeSH Terms: Health Services Accessibility, Primary Health Care