The Journal of the Arkansas Medical Society Med Journal Dec 2019 | Page 10

and on, as you know. Between the pressing, the
hearing, the seeing the numbers on the phone,
he’s going to give up.”
Dr. Jennings has taken stock of how the na-
ture of geriatrics conflicts with the current state
of medical practice. “I think the message that
most health systems don’t want to hear is that
the system is rigged against the senior patient.
When things are driven by productivity and tech-
nology, even of necessity, the physician spends
more time looking at the computer than when
things were on paper. That changes the dynamic
with patients. Younger patients are better able
to accommodate that. Their attention spans are
different, and the acuity of their needs are differ-
ent. They’re happy to play on their phones while
you’re typing and pecking. With an older patient,
they’re not coming in with a cell phone. They’re
there to look their physician in the face and take
some time, and very frequently, must hear things
several times.”
Though
she
doesn’t fault physi-
cians who aren’t “turn-
ing themselves inside
out to accommodate
older patients” due
to time constraints,
Dr. Jennings sees the
Holly Jennings, MD
need for empathy for
the elderly. “Small conveniences make such a
difference,” she said. “How fortunate for these
patients when they’re able to access an office
where things are set up in a more geriatric-
friendly style. How fortunate when they can hear
‘Yes, we’ll schedule your follow-up appointment
right now, face to face,’ or ‘That test we said you
needed? Sit with this person here, and she’s go-
ing to write down where you need to be and at
what time, so you’ll have that appointment be-
fore you leave.’”
Challenges and Rewards
Partly due to the slow nature of the practice,
geriatrics isn’t a lucrative specialty per se. “To
make a decent living, many geriatricians prac-
tice at senior health center facilities,” noted Dr.
Brooks, who before joining NEA Baptist ran an in-
dependent practice. “These facilities receive ad-
ditional resources from state and federal govern-
ment. When I was in private practice, I did several
[additional] things to make ends meet – nursing
home care, hospice, and inpatient rehabilitation.
My bread and butter was Medicare, and at the
first of the year there are deductibles for the pa-
tient to cover. The first four months were always
the hardest for me because many of my geriatric
patients weren’t always able to pay their first-of-
the-year deductible immediately.
“We’re all facing the challenges of getting
paid for what we do. It would be wonderful if more
doctors took Medicare, but there are certainly
hoops to jump through with Medicare.”
Despite these challenges, the job isn’t with-
out its endearments. “Most of my patients are
The Daunting Task of Providing Geriatric
Care for Community-Based Small Practices
Adapted from a submission by Darrell R. Over MD, MSc, FAAFP
Darrell R. Over MD, MSc, FAAFP is the associate professor and
associate residency director for UAMS (South Central) Family Medi-
cine Residency. He expressed concerns over how to incorporate geri-
atrics into patient centered medical homes (PCMH). He noted that an
AMA report indicated that the majority of U.S. physicians (about 57%)
still work in small practices of 10 or fewer physicians. This coupled
with the mandates of the Medicare Access and CHIP Reauthorization
Act of 2015 (MACRA) Merit-Based Incentive Payment System (MIPS)
has presented considerable challenges for small-practice physicians
Darrell Over, MD
who are trying to provide health care to community-dwelling elders
with complex medical needs.
The PCMH model was first introduced as a means for providing patient-centered, comprehen-
sive, coordinated, and accessible care through a systems-based approach that is continuously im-
proved. Within this model, the potentially frail elderly represent a patient group with highly complex
health care needs who require intensive medical services that must be coordinated across multiple
providers and a broad range of social support agencies to maintain health and ability to function
independently in the community.
Dr. Over explained the hardships small practices face in such situations, “The transformation
of a practice to PCMH standards has been a virtually insurmountable burden for smaller practices
where simply managing the daily workload is a struggle. These practices typically have limited
financial reserves, administrative infrastructure, and staff time to support the efforts of practice re-
design to PCMH standards.” The American Academy of Family Physicians’ National Demonstration
Project showed that even highly committed small practices working toward PCMH transformation,
with support from transformation facilitators, were unable to incorporate all basic components of a
medical home during the two-year demonstration.
Small practices, unlike larger practices, are unable to draw upon a considerable number and/or
breadth of personnel such as nurse practitioners, pharmacists, dieticians, social workers and other
allied health professionals to assist in the care of complex patients.
A further challenge for small-practice physicians is that often there is a diverse range of com-
plex patients but with a low prevalence. Few small practices can either financially afford the extra
investment or have the capacity to maintain and build the expertise to effectively serve a low vol-
ume of diverse complex patients. Considering the wide array of medical specialists, social service
agencies, and home health service providers that comprise the “health care neighborhood,” it is
not conceivable that without considerable support, the community-based small practice physician
is going to be able to identify, organize and track the necessary services for this diverse population
of complex patients.
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