استعرض مصدر Geriatric medicine and pharmacy practice: a historical perspective



Shared care models

As the average age of hospital inpatients climbed during the second half of the 20th century, and the prevalence of multi-morbidity and polypharmacy grew, geriatric expertise was increasingly needed outside of geriatric units. Geriatric consultation services (in which a geriatrician reviews patients on referral) exist in many hospitals; however, this model of care is associated with poorer outcomes compared to models in which the geriatrician is directly responsible for patient care.[30, 31] Therefore, shared care models of practice have been developed within various specialty areas and settings, especially those with a high proportion of older patients (Table 2). In these models a physician or surgeon shares patient management with a geriatrician, usually in conjunction with a multidisciplinary team, utilising the CGA approach.

Table 2. Examples of shared care models of geriatric medicine

Model	Medical practitioner collaborating with geriatrician	Patient group
RACF = residential aged care facility.

a Hospital-based geriatric service that provides consultation, assessment, planning and/or short-term management of older people in residential aged care facilities (also known as residential care outreach).[38]

b Time-limited package of restorative and personal care delivered in the patient's home or at a residential aged care facility following discharge from hospital.[77]

Cardiogeriatrics	Cardiologist	Heart failure

Oncogeriatrics	Medical oncologist	Cancer

Orthogeriatrics	Orthopaedic surgeon	Hip fracture

Psychogeriatrics	Old age psychiatrist (psychogeriatrician)	Mental illness or dementia

Surgegeriatrics	General or specialist surgeon	Surgical needs

Acute care of the elderly (ACE)	General medicine physician	Acute medical illness

Emergency geriatrics	Emergency medicine physician	
Acute illness or trauma

Residential in-reachb and Transition careb	General practitioner	RACF residents at imminent risk of hospital admission; patients discharged from hospital with functional decline

The emphasis in these models is on early assessment of function, cognition and co-morbidities, medical optimisation before surgery, prevention and early detection of complications (e.g. delirium), prevention of functional decline, management of comorbidities, early discharge planning and avoidance of re-admissions to hospital.[36-38]

The oldest and most widespread examples are psychogeriatric and orthogeriatric services, which were described over 25 years ago.[8, 39] Acute care of the elderly (ACE) units were introduced in Australia from the late 1990s,[40] but are not widespread.[12, 13] Other models such as oncogeriatrics, cardiogeriatrics and residential in-reach are more recent developments.[38, 41, 42]

There is evidence for the effectiveness of some of these models. For example, ACE units can improve patients’ functional outcomes, and reduce readmissions to hospital and discharges to residential care.[43, 44] Hip fracture patients who receive orthogeriatric care tend to have lower in-hospital and long-term mortality and lower rates of delirium





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