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Service evaluation and quality improvement of a geriatric evaluation and management program

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Service evaluation and quality improvement of a geriatric evaluation and management program

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SERVICE EVALUATION AND QUALITY IMPROVEMENT OF
A GERIATRIC EVALUATION AND MANAGEMENT PROGRAM
by
Ying-Chun Li
A Thesis Presented to the
FACULTY OF THE LEONARD DAVIS SCHOOL OF GERONTOLOGY and
THE SCHOOL OF PUBLIC ADMINISTRATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degrees
MASTER OF SCIENCE IN GERONTOLOGY and
MASTER OF HEALTH ADMINISTRATION
August 1996
Copyright 1996 Ying-Chun Li
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UMI Number: 1381594
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UNIVERSITY OF SOUTHERN CALIFORNIA
LEONARD DAVIS SCHOOL OF GERONTOLOGY
under the director of h is Thesis Committee and approved by all its
members, has been presented to and accepted by the Dean of the Leonard
Davis School of Gerontology and the Dean of: the School o f__________
Public Administration________________________________________
in partial fulfillment of the requirements for the degree of
Master of Science in Gerontology____________________________
University Park
Los Angeles, CA 90089
This thesis, written by
YING-CHUN LI
/
Dean
Dean
Date_____
THESIS COMMITTEE
Chairman
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ACKNOWLEDGMENTS
I wish to thank my chairperson, Dr. Phoebe Liebig, for all of her instruction, support,
and patience. I also wish to thank Dr. Kathleen Wilber for her helpful suggestions.
Special thanks are to the staff of GRECC, VA Medical Center West Los Angeles. They
provided enormous assistance and kindness to help me complete the survey. Finally, my
gratitude goes to my wife, Chin-Hsiang and my family for their continuous support and
encouragement.
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TABLE OF CONTENTS
Chapters Page
L INTRODUCTION............................................................................................. 1
Statement o f the Issue................................................................................. I
Rationale o f This Study............................................................................... 2
Key Processes o f a GEM Unit................................................................ 3
Quality Improvement and Marketing Research...................................... 6
Research Questions..................................................................................... 8
Purpose of the Research.............................................................................. 9
Organization of the Thesis........................................................................... 10
H. LITERATURE REVIEW.............................................................................. 12
Demographic Trends and Health Care Utilization of the Elderly................ 12
Demographic Trends............................................................................... 12
Health Care Utilization for the Elderly.................................................... 13
Overview of the Geriatric Assessment Program......................................... 14
Origins of Geriatric Assessment Program.............................................. 16
Delivery System o f Geriatric Assessment............................................... 17
Geriatric Assessment Team..................................................................... 18
Types of Geriatric Assessment Programs................................................ 21
Purposes of Geriatric Assessment Programs.......................................... 22
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Effectiveness and Problems of Geriatric Assessment Programs................. 23
Effectiveness............................................................................................ 23
Problems................................................................................................. 26
Patient Selection in Comprehensive Geriatric Assessment Programs 27
Concepts ofthe Study................................................................................. 29
Quality Improvement................................................................................ 29
Marketing Research................................................................................. 31
Coordination and Communication.......................................................... 33
Summary of Literature Review.................................................................... 35
HI RESEARCH METHODOLOGY..................................................................... 37
Key Assumptions......................................................................................... 37
Research Hypotheses.................................................................................. 38
Operational Definitions............................................................................... 39
Research Design.......................................................................................... 40
Procedures in Research Design................................................................... 40
IV. RESULTS AND DISCUSSION.................................................................... 49
Part One— Answers to Research Questions................................................. 49
Information about the Respondents........................................................ 49
Relationship Between Respondents and the GEM Unit.......................... 51
Respondent Knowledge of the GEM Unit’s Admission Criteria 53
Reasons for Referring Patients to the GEM Unit.................................... 55
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Reasons for Not Referring Patients to the GEM Unit............................. 56
Respondent Satisfaction and Images of the GEM Unit........................... 57
Most/Least Beneficial Aspects of the GEM Unit................................... 58
Difficult Type of Elderly Patients to be Discharged or Transferred
within VAMC/WLA................................................................................ 59
Summary of Part One............................................................................. 61
Part Two— Tests of Research Hypotheses.................................................. 63
Impacts of Training................................................................................. 63
Knowledge about Admission Criteria...................................................... 68
Reasons for Not Referring Patients to the GEM Unit............................. 72
Level of Satisfaction Related to Number of Patient Referrals to the
GEMUnit............................................................................................... 73
Other Findings....................................................................................... 74
Summary of Major Findings........................................................................ 75
V. RECOMMENDATIONS................................................................................ 77
Limitations of This Study........................................................................... 77
Recommendations....................................................................................... 77
Conclusions.................................................................................................. 85
REFERENCES....................................................................................................... 87
APPENDIXES....................................................................................................... 93
A. The Survey of Geriatric Evaluation and Management Unit................... 94
B. Researcher’s Cover Letter..................................................................... 97
C. Admission Criteria for Geriatric Evaluation and Management Unit 99
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LIST OF TABLES
Table Page
1. Types of Geriatric Assessment Programs............................................................ 21
2. Purposes of Geriatric Assessment Programs....................................................... 22
3. Departments ofthe Respondents in VAMC/WLA.............................................. 50
4. Average Years of Service in VAMC/WLA, by Different Services.................... 51
5. Percentage of Respondents Having Received Patients From the GEM Unit... 53
6. Respondent Knowledge of Patient Admission Criteria for the GEM Unit 54
7. Top Three Reasons Why Respondents Refer Patients to the GEM Unit 56
8. Reasons Why Respondents Had Not Referred Patients to the GEM Unit 57
9. The Most Beneficial Aspects ofthe GEM Unit, As Reported by
Respondents......................................................................................................... 59
10. The Least Beneficial Aspects of the GEM Unit, As Reported by
Respondents........................................................................................................ 59
11. Difficult Types of Elderly Patients to Discharge or Transfer in the
VAMC/WLA...................................................................................................... 60
12. Chi Square Test for Relationships between Training and the Number of
Patient Referrals to the GEM Unit...................................................................... 64
13. Chi Square Test for Relationships between Training and the Awareness of
the GEM Unit’s Functions.................................................................................. 66
14. Chi Square Test for Relationships between Training and the Awareness of
Patient Referrals of the GEM Unit...................................................................... 67
15. Average Score of Correct Answers Re: Patient Admission Criteria for the
GEM Unit by Different Service Professions....................................................... 69
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LIST OF FIGURES
Figure Page
1. Relations Between A GEM Unit and Other Health Care Services................... 3
2. Identifying Patients Appropriate for Geriatric Evaluation and Management
(GEM) Programs.......................................................................................... 4
3. Model of Key Processes ofthe GEM Unit’s Daily Operations................... 5
4. Health Care Professions of the Respondents.............................................. 51
5. Percent of Respondents Who Referred Patients to the GEM U nit 52
6. Correct Responses on Patient Admission Criteria Questions...................... 55
7. Percentage of Respondent Satisfaction Scale ofthe GEM Unit................. 58
8. Average Score of Correct Answers in Patient Admission Criteria of the
GEM Unit by Respondents with Varied Years of Service........................... 70
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CHAPTER I
INTRODUCTION
This thesis examines the services and working processes of a Geriatric Evaluation
and Management (GEM) Unit, which is one kind of Comprehensive Geriatric Assessment
Program. The main issues under investigation are the relationship between patient
referrals and respondents’ knowledge concerning admission criteria, awareness of the
Unit’s functions, problems of referral, and satisfaction with services. A survey was
conducted ofthe health care professionals (for example, physicians, nurses, social
workers, etc.) who usually conduct patient referrals.
Statement of the Issue
Growing aging populations will require an increasing amount of health care services
(Rundall, 1992). Careful assessment of frail elderly patients can prevent the inappropriate
use of health services (Rubenstein et aL, 1982). Comprehensive geriatric assessment,
which provides an interdisciplinary team approach, has been encouraged and has become
a fundamental component of geriatric care. The complexity of the frail elderly patient
requires a multidimensional team approach to arrive at an optimal diagnosis and
treatment plan (Rubenstein et aL, 1991b; Schmitt et aL, 1988).
A growing literature documents many proven benefits of geriatric assessment
programs (Allen et aL, 1986; Applegate et aL, 1983; Applegate, 1991; Gallo et aL, 1988;
Rubenstein et aL, 1984; Rubenstein, 1987; Rubenstein et aL, 1991b; Schmitt et aL, 1988).
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These benefits include better diagnostic accuracy and treatment planning, more
appropriate placement decisions with fewer referrals to nursing homes, improved patient
functional and mental status, prolonged patient survival, decreased quantities of
prescribed drugs, and lower overall use of costly institutional care services. However,
uncertainties remain in research on geriatric assessment programs (Applegate et aL,
1991).
Even with clear interventions and reasonable outcomes, the effectiveness of
interdisciplinary geriatric team care can be diminished when the patients most likely to
benefit from geriatric assessment programs are not selected (Schmitt et aL, 1988).
Therefore, patient selection surfaces as a key issue of geriatric assessment program
(Rubenstein, 1987).
Rationale for This Study
When comprehensive geriatric assessment is coupled with some therapy, then the
term “geriatric evaluation and management” (GEM) is used (Rubenstein et aL, 199 lb).
To enter such a program, patient referral is the initial process. At least five referral
sources can provide patients to GEM programs: inpatient hospitals, emergency rooms,
outpatient clinics, private physicians, and home health care agencies (Applegate et aL,
1991). Since GEM programs have strong relations with other health care organizations
(Figure 1), a determining factor in the success of GEM program is to provide effective
referral access to both health care professionals and health care organizations.
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Figure 1. Relations Between A GEM Unit and Other Health Care Services
Inpatient Hospital
Emergency Room
Outpatient Clinic GEM Unit Private Physician
Home Health Care Agency
Key Processes o f a GEM Unit
Hospital-based inpatient geriatric evaluation and management units are particularly
concerned with selecting patients who have some benefit potential. The potential benefits
include improvement of patient function, successful home discharge, and cost-
efifectiveness of health services over the long run (Wieland et aL, 1994b). Figure 2
outlines the process of patient selection for a given program (Rubenstein et aL, 1991a).
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Figure 2. Identifying Patients Appropriate for Geriatric Evaluation and Management
(GEM) Programs
Elderly Patients
(community, hospital, clinic, etc.)
I
Screening
Targeting
No GEM GEM
(Too sick or too well)
▼
Treatment
Follow-up
Figure 3 presents a model of three key processes of GEM Unit’s daily operations in
the VA Medical Center, West Los Angeles (VAMC/WLA) which is the setting of this
study. The three key processes of a GEM Unit’s daily operations include:
(1) Patient selection and referral
This process is the key factor of a successful GEM Unit (Winograd et aL, 1988;
Winograd, 1991; Winograd et aL 1991; Rubenstein et aL, 1991a). General operational
questions include: Who benefits most from a GEM Unit? Where do the patients come
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from? Who refers the patients? What are the needs and expectations of patients and
referring health care professionals?
(2) Geriatric assessment and intervention
How can the team work more efficiently and more cost-effectively? What procedures
can be used to improve the quality of services? What can be done to promote more
effective communication between team members and other health service organizations?
(3) Discharge and follow-up
Where are patients discharged? How should patient outcomes be followed-up and
evaluated?
Figure 3. Model of Key Processes of the GEM Unit’s Daily Operations
Input 1. Patient Selection and Referral
- Who? (Admission Criteria)
- Where? (Referral Channels, Health Care Facilities, and Health Care
Professionals)
- What? (Needs and Expectations of Patients and Health Care
Professionals)
Process 2. Geriatric Assessment and Intervention
- Patient Evaluation and Management (Interdisciplinary Team Work)
- Quality Improvement (Process Evaluation, Problem Solving)
- Communication and Coordination (Within and Outside the
Program)
— Outcome 3. Discharge and Follow-un
- Where? (Resources of Placement)
- Follow-up (Outcome Evaluation)
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One important factor among these key processes is that they are continuous,
interdependent influences affecting each other. Suitable patient selection will help both to
improve geriatric assessment process and lead to the most appropriate discharge for the
patients. Good follow-up and evaluation of patient outcomes can provide useful
information to improve assessment and intervention by the GEM Unit. At the same time,
the outcomes and modification of working processes also will affect patient referrals and
admission. Therefore, all of these activities need to be carefully evaluated to make sure
that the GEM Unit provides high quality service to targeted groups of elderly patients.
This study will focus on issues of patient selection and referral— the “input” stage.
To provide better services, the GEM Unit must evaluate its performance and
recognize the needs of its customers; in this instance, the customers are health care
professionals. Therefore, this study will examine the concepts of quality improvement
and marketing research in order to improve program effectiveness.
Quality Improvement and M arketing Research
Health care organizations need to change from an emphasis on traditional quality
assurance to quality improvement. The Joint Commission on Accreditation of Healthcare
Organization requires health care organizations to verify quality improvement activities
within an organization with appropriate documentation (Mozena and Anderson, 1993;
Rakich et aL, 1993). Quality improvement (QI) is a management philosophy to improve
the level of performance of key processes in an organization. Several terms are used
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interchangeably with QI, such as: total quality management (TQI) and continuous quality
improvement (CQI) (Flood et aL, 1994). Ratdch and colleagues (1993) indicate that
continuous quality improvement can be defined as an ongoing, organization-wide
framework in which health service organizations and their employees are committed to
monitoring and evaluating all aspects of health service organizations’ activities (inputs
and processes) and outputs (outcomes), with the goal of continuously improving them.
The key to CQI is the existence of and participation in quality improvement projects,
which concentrate on work process and/or customer need (Mozena and Anderson,
1993).
The major methods in CQI include continuous evaluation of work process and
systems; design of and methods for work; analysis of structure, tasks/technology, and
people relationships; training and skill enhancement of human resources; and how
managers manage (Rakich et aL, 1993).
Marketing research links the organization with its market environment. It involves
the specification, gathering, analyzing, and interpretation of information to help
management understand a particular market environment. In addition, marketing research
identifies an organization’s problems and opportunities, and develops and evaluates
courses of marketing action (Aaker and Day, 1990). Health care organizations have
numerous markets/customers, such as: patients, physicians, regulators, alternative
delivery systems, and reimbursement agencies. It is always important for a health care
organization to satisfy the needs of its customers. Customer satisfaction and
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organizational image are two major issues that health care organizations must evaluate in
order to meet customers’ needs. Evaluating a health care organization’s image is a useful
step toward modifying any undesirable aspects. This is done by changing its behavior and
communication. Health care organizations also try to match their performance to
expectations and create high levels of satisfaction for their customers (Kotler and Clarke,
1987).
The Geriatric Evaluation and Management (GEM) Unit is a health care program with
various customers— patients, health care professionals, and health care facilities. Because
patient referral is a key issue of the GEM Unit operation and is conducted by health care
professionals, this study focuses on health care professionals as the customers. The
responses of health care professionals help measure their satisfaction with and image of
the GEM Unit.
Research Questions
Since patient selection (targeting) is a very important factor in the success of geriatric
assessment programs, it is necessary to conduct research on this issue for quality
improvement. The process of patient selection consists of two aspects. One is the
procedure which includes patient selection and patient referral The other are the
components that include patients, health care professionals, and health care
organizations. Patients are referred from other health care organizations to the GEM Unit
through health care professionals. Therefore, the type of information and attitude that the
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health care professionals have about the GEM Unit will affect patient referrals and
service utilization.
There are six research questions:
1. What is the extent ofthe relationship between health care professionals and the GEM
Unit on using services and/or receiving training?
2. To what extent do health care professionals understand the admission criteria of
the GEM Unit?
3. To what extent do health care professionals understand the function and mission
ofthe GEM Unit?
4. What problems do health care professionals have with patient referral to
the GEM Unit?
5. What is the extent of health care professionals’ satisfaction with and image of the
GEM Unit?
6. What type of elderly patients do health care professionals have the most
problem discharging or transferring in the VA Medical Center, West Los Angeles?
Purpose of the Research
The purposes of the research are to:
1 . Identify the knowledge and information that health care professionals have about the
GEM Unit;
2. Evaluate the problems of working processes in the GEM Unit; and
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3. Evaluate the satisfaction of health care professionals with the GEM Unit.
The results of this survey will provide useful information for future research on
helping target patients who will benefit most from the GEM Unit, improve patient
referral access, and enhance CQI o f the GEM Unit.
Organization of the Thesis
This thesis is organized into five chapters. This chapter describes a statement of the
issue, the importance of this issue, as well as research questions and purposes
surrounding this research.
Chapter II presents a review of the literature. Demographic trends and health care
utilization ofthe elderly are mentioned. Geriatric assessment programs are discussed,
including origins, delivery system, team composition, types, and purposes of such
programs. This is followed by a report on the effectiveness and problems of geriatric
assessment programs. Patient selection is a key issue. It is investigated as important part
of a comprehensive geriatric assessment. The literature review also discusses concepts of
quality improvement, marketing research, and coordination and communication. These
concepts help to shape this research.
Chapter HI presents the research methodology of this study. Key assumptions,
research hypotheses, and operational definitions are explicated. The research design and
development of the survey instrument are discussed. Then, the sample and procedures for
collecting data are described.
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Chapter IV presents findings from the research questions and testing the research
hypotheses.
Chapter V discusses major findings, and suggests possible actions in order to improve
the problems of major findings.
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CHAPTER n
LITERATURE REVIEW
This chapter consists of four main sections: (a) demographic trends and health care
utilization ofthe elderly; (b) characteristics of geriatric assessment programs, including
their origins, delivery system, team composition, types, and purposes of the program; (c)
effectiveness and problems of geriatric assessment programs; and, (d) key concepts used
in this study, including quality improvement, marketing research, and coordination and
communication.
Demographic Trends and Health Care Utilization of the Elderly
Demographic Trends
Important changes are occurring to the age structure of the populations in most
economically developed countries, including the United States (Rundall, 1992).
Projections regarding future changes in the population age structure of the United States
suggest that after the year 2010, when the survivors of the Baby Boom generation
become aged 65 and over, the proportion of this age group will increase dramatically
from 13.3 percent in 2010 to over 20 percent by 2030. hi fret, those aged 85 and over
will be the fastest-growing segment ofthe population (Day, 1993). To face such
population changes, the responsibility and challenge for researchers, policymakers, health
care professionals, and gerontologists will be to conduct studies with the hope of
improving health care services for the elderly.
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Health Care Utilization fo r the Elderly
Elderly persons are more likely to suffer from chronic diseases and resultant
disability. The result will be a greater use of health care services, especially those
designed for long-term care (Rubenstein et aL, 1982). Older Americans consume a
disproportionate share of both acute and long-term care resources (Soldo and Manton,
1985).
The elderly population uses hospital services at a higher rate than younger age
groups. In addition, utilization of nursing home services is heavily dominated by older
persons (National Center for Health Statistics, 1995). These data suggest that, regardless
of whatever growth may occur in the size of the older population in the coming decades,
today’s older population is already placing critical demands on the current health care
system (Rundall, 1992).
Some of these demands may be due to an inappropriate use of services, especially in
institutional settings. Inappropriate utilization creates several problems: (a) it is wasteful
of scarce resources; (b) it may create further disability by leading to premature labeling of
a patient as irremediably ill; (c) institutional environments in themselves are often
hazardous for the aged; and, (d) premature or erroneous dispositions from hospitals may
produce health-related recidivism or at least unnecessary nursing home utilization
(Rubenstein et aL, 1982). hi addition to an inappropriate use of services, frail elderly
often receive incomplete diagnostic evaluations, excessive numbers of prescribed drugs,
and inadequate rehabilitative services. Therefore, careful assessment of frail elderly
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patients can often reveal remediable conditions and help to better match services with
needs (Rubenstein et aL, 1982). An innovative approach to meeting the health care
challenges o f an aging population has been the development of comprehensive geriatric
assessment.
Overview of Geriatric Assessment Programs
Geriatric assessment can be defined as a multidimensional— usually interdisciplinary-
diagnostic process designed to evaluate an elderly individual’s medical, psychosocial, and
functional capabilities and problems with the intention of arriving at a comprehensive plan
for therapy and long-term follow-up (Rubenstein, 1987). Specific aspects of geriatric
assessment programs differ, not only from one country to another, but, also regionally
within countries. However, two concepts are firmly held in all countries and regardless of
regional differences: (a) elderly patients need a special, more broadly based and
interdisciplinary approach to their care than do younger patients; and, (b) no patient
should be admitted to a long-term care facility without a careful medical and psychosocial
assessment (Brocklehurst, 1975; Rubenstein et aL, 1982). Rubenstein (1987) also
mentions that assessment has assumed a central role in geriatric care because of the
complexity of the frail elderly patient, the vast number of unmet needs facing the rapidly
growing older population, and because assessment has been increasingly associated with
improvement in care outcomes.
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One important concept is that elderly patients typically present complex, interrelated
medical and psychosocial problems which do not fit neatly into a biomedical model of
care. They fit more closely into a biopsychosocial approach with an emphasis on more
encompassing factors— such as functional, psychological, social, and financial problems-
rather than focusing primarily on disease. In order to address these multiple problems,
geriatric assessment programs have been designed to provide intensive, comprehensive
assessment and therapeutic planning by an array of health care professionals. This
expanded system of care reflects a broader concept of illness and health than that
included in the strictly biomedical model (Campbell and Cole, 1987).
To ensure appropriate care, geriatric assessment teams are concerned about the
therapeutic milieu not only while the patient is in the hospital, but also when the patient is
discharged into a home or community setting (Campion et aL, 1983). Because of such
concerns, it is impossible for only one discipline to address all of these complex, yet
interrelated, biopsychosocial health care needs. This dilemma led to the development of
interdisciplinary teams (Campbell and Cole, 1987).
In geriatric care, teamwork is the recommended modality because of the complex
biopsychosocial needs of the patient. The goal of geriatric assessment programs is to
establish an intensive assessment of older adults which requires the competencies of
several coordinated disciplines. Not only do such teams have the capacity to assess
patients in much greater depth, but patients also share different information with different
providers (Nason, 1983).
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Origins o f the Geriatric Assessment Program
Historically, the health care team was considered to be the physician and patient. In
this biomedical model of care, the emphasis was on disease and cure rather than on a
complex health-illness continuum (Lowe and Kerranen, 1978). However, with the
recognition that many patient problems are nonmedical in nature, and that frequently
illness behaviors, coping strategies, and support systems may be far more influential in
medical outcomes than biological indicators on which physicians had focused, a
biopsychosocial approach to care was proposed to replace the biomedical model of
illness. In this model no one profession is seen as having the wide range of expertise
required to address all of the patient’s problems; therefore, the concept of a team
approach to health care was reinforced (Campbell and Cole, 1987).
The concept of geriatric assessment traces its origins to the British geriatric pioneers
of the 1930s, such as Marjory Warren, Lionel Cosin, and Sir Ferguson Anderson. These
physicians noted a disturbingly high rate of long-term institutionalization among disabled
elderly patients, most of whom had neither been evaluated carefully from a medical or
psychosocial standpoint, nor given a trial of rehabilitation. These early geriatricians
uncovered a high prevalence of readily identifiable and remediable problems among both
institutionalized and noninstitutionalized patients. They also found that most of these
patients often could show dramatic improvement when provided with appropriate therapy
and rehabilitation (Brocklehurst, 1975; Rubenstein, 1987).
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Delivery System o f Geriatric Assessment
When the British National Health Service was founded in 1948, geriatric medicine
was accorded full specialty status, largely based upon the successful experiences of the
earlier pioneers. In the British system, geriatric specialists are in charge of geriatric
services that include acute hospital care for the elderly as well as an assortment of
coordinated special care programs (such as day hospitals, geriatric rehabilitation units,
and home visit services). Under the British system of “progressive geriatric care,” elderly
patients requiring hospital admission (except those requiring intensive medical care) are
generally first admitted to an acute-care geriatric assessment/evaluation unit. In this unit,
each patient receives a comprehensive assessment of medical, functional, and
psychosocial problems during a two- to three- week stay. Care plans are established on
the unit, usually by an interdisciplinary team, and the next level of care and placement is
decided on: whether to discharge to home, to a rehabilitation or chronic-care ward, or to
a long-term care facility. The geriatric assessment units also accept patients in need of
assessment from other institutions, often for periodic reassessment. Several other
countries (including Sweden, Australia, Norway, Israel, and the Netherlands) have built
geriatric care systems with many similarities to the British system, most with centrally
located geriatric assessment units as focal points for entry into the care system
(Brocklehurst, 1975; Kane and Kane, 1976; Rubenstein, 1987; Schouten, 1979; Tilly and
Stucki, 1991).
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Li the United States, growing awareness of the unmet health care needs facing the
elderly, and realization of how Britain and other countries have met similar needs are
promoting the concept of American geriatric assessment programs. An expanding body
of evidence indicates that the most striking of unmet needs— inappropriate
institutionalization, incomplete medical diagnosis, lack of coordination of community
support services, over-prescription of medications, and underutilization of rehabilitation—
can be improved through the use of geriatric assessment services (Rubenstein, 1987).
These programs have been based in acute hospital wards, in outpatient settings, and in
long-term care institutions. Some units provide comprehensive diagnostic assessment
without providing therapy; others provide only minimal assessment but extensive
rehabilitation, and still others combine extensive assessment with therapy and
rehabilitation (Rubenstein et aL, 1982).
Geriatric Assessment Team
Definitions
The terms multidisciplinary and interdisciplinary are often used interchangeably in the
literature; however, there are some differences. A multidisciplinary team is a group of
professionals who work independently in the same setting and interact informally. They
perform separate consultations or assessments with little or no communication between
each other (Campbell and Cole, 1987; Goldberg et aL, 1984). On the other hand, an
interdisciplinary team consists of a blend of different professionals who work
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interdependentlv in the same setting and interact formally and informally. They may
perform separate assessments, but information is exchanged in a systematic manner. They
work in concert to achieve commonly shared and clearly defined goals through
collaboration in planning and implementing patient care (Campbell and Cole, 1987).
Team Composition and Organization
Because of the numerous different professional team combinations, there is no one
perfect mix. When forming a geriatric assessment team, the health care needs of the
patient population will be identified and matched with the expertise and unique
contributions of each professional Ideally, in the establishment of the team, members are
selected because of their interests and competencies in treating geriatric patients, coupled
with a desire to participate on a team Indeed, how team composition is decided plays a
critical role in how the team operates (Campbell and Cole, 1987; Goldberg et aL, 1984;
Lowe and Kerr an en, 1978; Nason, 1983).
I. Core Team Members
When forming an interdisciplinary geriatric assessment team there are two decisions
that must be made: (a) what are the goals for patient care; and (b) what disciplines need
to be involved in achieving these goals, and at what phase. For example, for the geriatric
evaluation unit at the Sepulveda Veterans Administration Medical Center, the first phase
of assessment and planning consists of comprehensive medical, functional, and
psychosocial assessment by individual members of the interdisciplinary team If more
intensive evaluation of vision, hearing, dentition, and rehabilitation are needed, extended
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team members are included for patient consultation. The second phase is for therapeutic
and rehabilitative care. This day-to-day care is typically provided by the core team,
composed of physicians, nurses, and social workers. They see all the patients on the unit
daily and do not belong to other treatment teams. The core team of professionals is
responsible for outlining team procedures and deciding how to include other disciplines in
the assessment and treatment of geriatric patients (Campbell and Cole, 1987).
II. Extended Team Members
Extended team members usually belong to more than one team. They evaluate and
treat patients in more than one setting, but they attend team meetings in order to
incorporate their foldings into the interdisciplinary treatment plan. They may routinely
screen each patient on an assessment unit to make a determination of whether further
treatment is needed from their discipline. Examples of extended team members are
dentists, psychologists, audiologists, speech pathologists, pharmacists, dietitians, and
occupational and physical therapists (Campbell and Cole, 1987).
III. Consultative Participants
The other level of interdisciplinary team participation is comprised of consultants,
who are involved in only those cases which the core team deems necessary and
appropriate. Depending upon the setting, some of the disciplines discussed as possible
extended team members could be used as consultants instead. Consultants may come to
team meetings to communicate their findings and recommendations to the core treatment
team or they may send back written reports (Campbell and Cole, 1987).
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Generally speaking, team care should not operate on the principle that the more
members the better. Rather, team composition and structure are based on a combination
of patient problems together with available staff resources. Structural and procedural
team issues need to be publicly defined, and the purpose and goals of each type of
geriatric assessment team requires explicit agreement (Campbell and Cole, 1987).
Types o f Geriatric Assessment Programs
The major types of geriatric assessment programs are listed in Table 1 (Rubenstein,
1987).
Table 1. Types of Geriatric Assessment Programs
Acute hospital inpatient units
Geriatric assessment/evaluation units
Geropsychiatric assessment units
Geriatric rehabilitation units
Chronic hospital inpatient assessment units
Inpatient geriatric consultation services
Hospital outpatient departments
Home visit assessment teams
Office settings or freestanding units_______
The predominant model is the inpatient unit in an acute general hospital Some
programs have been established in extended care and long-term care facility settings.
Successful outpatient geriatric assessment programs have also been developed. Virtually
all programs provide multidimensional assessment, using one or more sets of
measurement instruments to quantify functional, psychological, and social parameters.
Most programs use interdisciplinary teams to pool expertise and enthusiasm in working
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toward common goals (Campbell and Cole, 1987). Many programs, both outpatient and
inpatient, provide at least limited treatment and are sites for geriatric education and
research (Rubenstein, 1987).
Geriatric units within teaching hospitals exhibit further variations on structure and
theme by adding research and educational programs (Rubenstein et aL, 1981; Rubenstein
et aL, 1982). Such geriatric units combine their therapeutic functions with education and
research in geriatric medicine and gerontology, often through university affiliation and
support. Primary examples are the geriatric units affiliated with Geriatric Research,
Education, and Clinical Centers (GRECCs) and geriatric fellowship programs in several
of the Veterans Administration (VA) facilities (Rubenstein et aL, 1981; Rubenstein et aL,
1982).
Purposes o f Geriatric Assessment Programs
A listing of the primary purposes for geriatric assessment programs is shown in Table
2 (Rubenstein, 1987).
Table 2. Purposes of Geriatric Assessment Programs
Multidimensional diagnostic assessment
Planning therapy
Providing limited or more extensive treatment
Arranging for rehabilitation
Determining optimal placement
Facilitating primary care and case management
Optimizing use of health care resources
Geriatric education and research
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Most existing American programs incorporate at least three or four of these
purposes, and a few attempt to accomplish them all. The structures of geriatric
assessment programs influence their purposes (Rubenstein, 1987).
Effectiveness and Problems of Geriatric Assessment Programs
Effectiveness
The major question facing proponents of a team approach to the assessment and
treatment o f geriatric patients is when and how teams create a significant improvement
over traditional care in patient care outcomes (Campbell and Cole, 1987). One
suggestion is that the way to evaluate a team would be to look at its success in achieving
its stated goals (products); to look at its efficiency in goal achievement as compared to
some other modality (process); to look at its appeal to the client (satisfaction); and to
look at its attraction to professionals (job enrichment). A geriatric assessment team then
needs to define its purpose by specifying its goals and objectives, because performance
can only be measured if specific objectives have been defined (Campbell and Cole, 1987).
Most of the reports from North American geriatric assessment units identified in the
review suggest that comprehensive geriatric assessment and rehabilitation lead to
improved patient outcomes (Rubenstein et al., 1982; Rubenstein, 1987). Several major
findings are listed below.
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1. Improved Diagnostic Accuracy
A consistent area of demonstrated impact from these geriatric assessment programs
has been the improvement in diagnostic accuracy, usually indicated by the diagnosis of
new, treatable problems. Discovery of these new diagnoses stems from several factors,
including the geriatric assessment process itself which includes a careful search for
treatable problems, a longer period of time to evaluate the patient, and from a probable
lack of diagnostic thoroughness in referring services. This improved diagnostic accuracy
had helped produce many of the other reported benefits (Allen et aL, 1986; Applegate et
af, 1983; Rubenstein et aL, 1981; Rubenstein et aL, 1984; Rubenstein, 1987).
2. Improved Placement Location
Williams et al (1973) first reported that a geriatric assessment program could
improve placement location and decrease use of nursing homes. The outpatient
evaluation program assessed patients referred for nursing home placement. The
researchers found that only 38 percent of patients referred for nursing home placement
actually needed such skilled nursing care, whereas 23 percent of the patients were able to
return to their homes and 39 percent were able to go to board and care facilities or
retirement homes, following careful assessment and recommendations for specific
therapy. Expert judgments made by an independent team of observers indicated that
major improvements in placement decisions were being made by the program. Several
subsequent reports have shown similar assessment-related improvements in placement
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locations (Hendriksen et aL, 1984; Lefton et aL, 1983; Rubenstein et aL, 1981;
Rubenstein et al, 1984; Rubenstein, 1987).
3. Improved Functional Status
Several reports have examined patient functional status before and after treatment on
geriatric units, particularly on units providing rehabilitation. These reports have usually
used a validated measure of functional status to document change over time. Reports
conclude that a majority of patients improve during their stay on a geriatric unit
(Rubenstein et aL, 1984; Rubenstein, 1987).
4. Improved Prescribed Medications
Excessive use of medications is a well-known problem facing elderly patients
(Rubenstein, et al, 1982). Therefore, more appropriate use of prescription drugs has
been reported as a measurable parameter of improvement in quality of treatment, hi those
reports, drug-prescribing became more appropriate, usually resulting in a decreased
quantity of prescribed drugs, despite concurrent increases in the number of treatable
diagnoses identified (Allen et aL, 1986; Applegate et al, 1983; Rubenstein et aL, 1981;
Rubenstein et al, 1987; Rubenstein, 1987).
5. Improved Utilization o f Health Services
Use of hospital services involving inpatient units, inpatient consultation services, and
outpatient assessment services has been examined in several studies. All studies that
included long-term follow-up of at least one year report decreased utilization of acute
hospital services and reduced total health care costs over time (Hendriksen et al., 1984;
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Rubenstein et aL, 1984; Rubenstein, 1987). The reduction in acute hospital use and total
health care costs over time from assessment services reflects a reduction in
rehospitalization rates, which stems both from the initial assessment itself and from the
often improved quality of follow-up services (Rubenstein, 1987).
In summary, the various geriatric assessment units discussed have generally claimed
positive effects in many different areas of patient outcomes, including physical, mental,
and social health, as well as functional levels. Several of them have attempted to
document these positive effects using measurable outcome variables. Simple audits of
patient medical records often reveal measurable effects, such as greater than expected
proportion of discharges to homes, increased number of diagnoses, and decreased use of
drugs. Other positive effects, especially the psychosocial ones, are often more difficult to
quantify. Therefore, more sophisticated measurement instruments and research designs
are necessary to document these positive outcomes accurately (Rubenstein, et al., 1982).
Problems
A substantial number of uncertainties remain in the research on geriatric assessment
programs, including the efficacy of assessment in a variety of clinical settings, the relative
importance of assessment when not coupled with specialized geriatric clinical care, and
the type of patient to whom the GEM should be targeted (Applegate et aL, 1991).
Schmitt and colleagues (1988) specifically point out that even with sensible and clear
interventions and reasonable outcomes, effectiveness of an interdisciplinary geriatric team
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care can be diluted by not selecting the sub-populations most likely to benefit, and by not
targeting the team interventions to those specific groups. Some studies of geriatric
consultation services have not found geriatric intervention is effective (Gayton et aL,
1987; Campion et al, 1983; Becker et aL, 1987). One reason often cited for the lack of
effectiveness of these trials has been the failure to target the intervention toward those
individuals most likely to benefit, the frail elderly (Winograd et aL, 1991).
Currently very little is known about the processes and outcomes associated with
systematically organized and implemented interdisciplinary team care. A type of problem
to be considered in judging the effectiveness o f interdisciplinary geriatric team has to do
with the population of patients selected for team intervention (Schmitt et aL, 1988).
Therefore, the issues of appropriate patient selection are important factors in studying
geriatric assessment programs.
Patient Selection in Comprehensive Geriatric Assessment Programs
Patient Targeting is Key Factor for Successful Geriatric Assessment Programs
Researchers generally agree that Geriatric Evaluation and Management (GEM) Units
are effective only when they are targeted to a specific group of frail, elderly patients who
are most likely to benefit (Winograd, 1991). Outcome studies suggest that beneficial
effects of GEM care are more apparent when patients are selected using specific clinical
criteria (Fretwell, 1988; Rubenstein et al, 1991b; Winograd, 1991)
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Admission Criteria
A comparative study of placement outcomes for geriatric cohorts receiving care in a
geriatric assessment unit versus on a general medical floor suggests that preadmission
selection criteria may be crucial to the demonstration of favorable responses to the care
provided by a geriatric assessment unit (Teasdale et aL, 1983).
Rubenstein (1987) indicates that targeting programs to the most appropriate patients
is a key issue to study the effectiveness of a substantial program. Although geriatric
assessment programs clearly can be effective, it is important to identify accurately which
subgroup of patients can be expected to benefit most in order to make maximal use of
scarce resources. The target patient population that various geriatric units serve can be
differentiated in several ways: sex ratios, geographic distance from hospital, level of care
need, and type of problems (Rubenstein et aL, 1982). hi general, the individuals most
likely to benefit from assessment are those who are on the verge of needing
institutionalization, those who are in lower socioeconomic groups, those who have
inadequate primary medical care, and those who have inadequate social support networks
(Rubenstein, 1987).
Targeting is a means of selecting from larger populations of frail older persons those
who have a high probability of benefiting from a geriatric assessment program (Fretwell,
1988). Criteria for admission to the geriatric assessment program can be expressed in
either inchisionary or exclusionary terms (Rubenstein et aL, 1982). Criteria most often
used for inclusion in geriatric assessment programs are patient age, degree of functional
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impairment, presence of geriatric conditions (e.g., falls, incontinence), particular
diagnostic conditions (e.g., multiple disorders), and psychosocial conditions (e.g., living
alone, recent bereavement, low income). Commonly used exclusionary factors are severe
dementia, inevitable nursing home placement, and terminal illness (Rubenstein et al.,
1982; Rubenstein, 1987; Winograd, 1991).
Concepts of the Study
This study emphasizes several key concepts. These include quality improvement,
marketing research, and, coordination and communication.
Quality Improvement
Before the 1990s, quality assurance had been based on two principles: quality
planning (setting the standards of quality) and quality control (monitoring or testing to
determine whether the standards were being met). This resulted in inadequate attempts to
fix quality problems and created frustration and fear. In the 1990s, to face the need for
change, health care quality assurance has incorporated a third, significant principle:
quality improvement which is an active, ongoing study of processes that will be
continuously improved in a never ending quest toward higher quality (Mozena and
Anderson, 1993).
Since 1992, the Joint Commission on Accreditation of Healthcare Organizations’
“Agenda for Changes” has radically changed the method by which health care
organizations are accredited. Accreditation is now based on an organization’s “efforts to
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continuously improve quality,” rather than “the capability to produce quality.” (Mozena
and Anderson, 1993). The establishment of clinical and organizational indicators is
required to verify quality improvement movements within an organization.
Documentation of ongoing quality improvement efforts is now necessary (Mozena and
Anderson, 1993).
Continuous quality improvement (CQI) or total quality management (TQM) are used
interchangeably with quality improvement (QI) (Flood et aL, 1994). Continuous quality
improvement includes process improvement and problem solving (Rakich et aL, 1993).
I. Process Improvement
Usually, the first step in process improvement is to select a process to improve. It is
only afier the process is understood that data about process variables can be collected to
determine if the process is in controL Data collection is continued so the effects of
changes can be measured. There are many formal sources, such as reports, data from
control charts, and customer questionnaires, as well as informal sources (Le., complaints)
from which information can be obtained. These data must be organized so they become
usable for decision making (Rakich et aL, 1993).
2. Problem Solving
Process improvement requires problem solving. Problem analysis and making
assumptions are major factors of problem solving (Rakich et aL, 1993). Applying the
problem-solving model to opportunities for improvement involves collecting and
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evaluating information that recognizes and defines opportunities to improve a process
that is in control (Rakich et al, 1993).
Campbell and Cole (1987) state that in order to maintain a geriatric assessment
team’s maximum efficiency, a periodic diagnosis of team functioning needs to be
conducted. Bruhn et aL (1993) mention that health professionals are encouraged to
design and implement total quality improvement (TQI) systems capable of improving all
aspects of quality care. Creating a positive environment for total quality care requires a
great degree of cross-functional coordination and vertical integration between medical,
managerial, and support staffs. An important concept is that total quality care must
develop within the organization from the bottom up. Everyone must be included because
the entire facility is subject to continuous improvement.
Marketing Research
To insure better services, health care organizations should also conduct marketing
research. A responsive health care organization is one that makes every effort to sense,
serve, and satisfy the needs and wants of its customers (Kotler and Clarke, 1987). One
common point of marketing research for health care organizations is to learn about the
basic orientation or attitude of present and/or prospective customers. The major issues
included within customers’ attitudes are: the information they have, their likes and
dislikes, and their potential behaviors. Three related components form an attitude: (1) a
cognitive or knowledge component, which represents a person’s information about an
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object. This information includes awareness of the existence of the object, beliefs about
the characteristics or attributes of the object, and judgments about the relative
importance of each o f the attributes; (2) a liking or affective component, which
summarizes a person’s overall feelings toward an object, situation, or person, on a like-
dislike, or favorable-unfavorable scale; and (3) an intention or action component, which
refers to a person’s expectations of future behavior toward an object (Aaker and Day,
1990).
Responsive health care organizations are also interested in their image (for example,
the most or least beneficial aspects of the organizations) by their customers, because
people respond to their image. An organization’s image represents the sum of beliefs,
ideas, and impressions that a person or group has of that organization. Measuring an
organization’s image is a useful step in understanding what is happening to the
organization. Organizations can try to modify undesirable aspects of their image by
changing their behavior and their communication (Kotler and Clarke, 1987).
Health care organizations used to think it was sufficient to deliver high-quality
medical or clinical care. More recently, many health care organizations have added
market satisfaction to their list of goals. A person who has experienced a performance (or
outcome) that has fulfilled his or her expectations expresses a sense of satisfaction.
Organizations use various methods to try to measure their success in creating customer
satisfaction. Customer satisfaction surveys are one of the major methods. Questionnaires
are sent or telephone calls are made to a random sample of past users to find out what
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they liked or disliked about the service. Ultimately, responsive organizations match
performance to expectations, thereby creating high levels of satisfaction for their
customers (Kotler and Clarke, 1987).
The goals of marketing research are trying to understand customers’ expectations
and evaluate the program’s outcomes to find out whether or not the outcomes meet the
customers’ needs. If not, the organization should adopt effective actions to improve its
performance.
Coordination and Communication
Casalou (1991) notes that total quality management (TQM) requires breaking down
barriers between departments. Individuals from all departments must be able to
communicate freely. People can work in separate departments, but the goals of different
departments cannot be in conflict.
Geriatric assessment programs have close relations with other health care
organizations. Therefore, coordination and communication are the major issues of the
programs’ daily operations with other organizations. Coordination and communication
are two closely related strategies through which health care managers link together
people and units within their organizations with other organizations and agencies.
Because health care organizations have become increasingly complex internally and have
established a wide variety of external relationships, the establishment and maintenance of
effective linkages are significant managerial challenges. If linkages are not effective,
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organizations may become fragmented, fractionated, and isolated, with concomitant
declines in performance (Longest and Klingensmith, 1994).
Coordination
Coordination is a means of effectively linking together various parts of an
organization or of linking together organizations and dealing with interdependence; it is
one of the most important functions of management (Longest and Klingensmith, 1994).
Conceptually and historically, coordination has been defined as the conscious activity of
assembling and synchronizing differentiated work efforts so that they function
harmoniously in attainment of organization objectives (Haimann and Scott, 1974).
Health care organizations increasingly experience interdependencies with other health
care organizations, as in systems or other multiorganizational arrangements, or with other
elements in their external environments. Whatever the form of interdependence, it
requires management. That means, the focal organization must coordinate and
communicate with other organizations or agencies with which it is interdependent if these
relationships are to be effectively managed (Longest and Klingensmith, 1994).
Communication
A group cannot function effectively unless members can exchange information. It is
incumbent upon group leaders to manage communications within and between the group
and external groups. In fret, the evaluation and design of communication structures is an
important component of many quality improvement projects (Fried and Rundall, 1994).
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Communication provides information people need to make decisions. From the
management perspective, communication has intraorganizational and interorganizational
dimensions. Intraorganizational communication depends on the formal establishment of
channels and networks within the organization. Interorganizational communication
occurs between organizations or between organizations and constituencies outside them.
Both intra- and interorganizational communication can be defined as the creation or
exchange of understanding between senders and receivers. A central component is
“understanding.” Unfortunately, communication seldom results in complete
understanding because there are so many environmental and personal barriers to effective
communication. It is important to realize that information can be easily transmitted to
others but this does not ensure that they will understand it (Longest and Klingensmith,
1994).
Summary of Literature Review
Comprehensive geriatric assessment is an effective program of health care delivery
for the elderly. Patient selection is the key to successful program operation. Adopting
admission criteria to refer patients who benefit most in interdisciplinary team care is an
important operation of health care professionals. Due to a complex mix of health care
professionals and organizations within comprehensive geriatric assessment operations,
effective coordination and communication also are important for program management.
In order to insure consistently better performance, quality improvement is necessary. To
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understand the health care professionals’ satisfaction with and image (for example, the
most or least beneficial aspects) of the program is another valuable method to help health
care programs meet their customers’ needs. Integration of these concepts have shaped
this study.
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CHAPTER IH
RESEARCH METHODOLOGY
la this chapter, the methodology used in this study is described. First, key
assumptions, research hypotheses, and operational definitions are presented. Second, the
research design and survey development are discussed. Third, the sample and
administration of the survey are detailed. Finally, the methods of data analysis are
explicated.
Key Assumptions
This study was based on the following key assumptions:
1. A belief that training by the GEM Unit can contribute to (a) service utilization for
patient referrals, (b) knowledge of admission criteria, (c) awareness of functions of the
GEM Unit, (d) awareness of access for patient referrals, and (e) satisfaction with the
GEM Unit.
2. A belief that relationships exist between (a) service utilization for patient referrals,
(b) awareness of the GEM Unit’s functions, and (c) problems of patient referral and
knowledge of admission criteria for the GEM Unit by health care professionals.
3. A belief that a relationship exists between (a) service utilization for patient referrals,
and (b) satisfaction with the GEM Unit and awareness of functions of the GEM Unit.
4. A belief that a relationship exists between (a) service utilization for patient referrals,
and (b) satisfaction with the GEM Unit and problems of patient referral.
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5. A belief that a relationship exists between service utilization for patient referrals and
satisfaction with the GEM Unit.
Research Hypotheses
Seven research hypotheses were investigated.
1. Health care professionals who received training from the GEM Unit:
(a) refer more patients to the GEM Unit;
(b) have better knowledge of admission criteria of the GEM Unit;
(c) have better awareness of the GEM Unit’s functions;
(d) have better awareness of patient referrals of the GEM Unit;
(e) have higher satisfaction with the GEM Unit.
2. Health care professionals who (a) are physicians, (b) have longer service years have
better knowledge of admission criteria of the GEM Unit.
3. Health care professionals who have better knowledge of admission criteria refer more
patients to the GEM Unit.
4. Lack of knowledge of admission criteria is associated with inappropriate use of the
GEM Unit’s services.
5. Problems of patient referral are negatively associated with numbers of patient referrals
to the GEM Unit.
6. Satisfaction of health care professionals with the GEM Unit is negatively associated
with concerns over long waiting lists.
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7. High satisfaction with the GEM Unit is associated with a high number of patient
referrals to the Unit.
Operational Definitions
Health Care Professionals
* Physicians, nurses, and social workers, etc. who are involved in patient referral
Patient Referral
* The frequency of referring patients to the GEM Unit (le. less than 5— weak
relationship; 5 to 10— medium relationship; more than 10— strong relationship)
Knowledge o f Admission Criteria
* Scores of correct answers of the type of patients appropriate for the GEM
Unit
Awareness o f GEM Functions
* Respondents who chose Interdisciplinary Evaluation, Assure Appropriate
Discharge, Rehabilitation fo r Frail Patients, and Treat Undiagnosed Geriatric
Problems as appropriate reasons for referring patients to the GEM Unit.
* Respondents who chose Discharge Service, Transfer to Nursing Home as
inappropriate reasons for referring patients to the GEM Unit.
Problems o f Patient Referral
* Reasons for not referring patients to the GEM Unit such as: Unaware o f the
GEM Unit, Unaware o f Admission Criteria, No Perceived Benefit fo r Patients,
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Long Waiting List, and Unaware o f Access
Satisfaction
* Scales of satisfaction concerning with GEM Unit, ranges from 1 to 7 (1-2: very
dissatisfied; 3-5: somewhat satisfied; 6-7: very satisfied)
Training
* Education and training programs which are provided by the GEM Unit to
health care professionals
Research Design
This research was an exploratory study, which utilized a survey to collect data to
answer six research questions, previously enumerated in Chapter I. The respondents for
this analysis were health care professionals (e.g. physicians, nurses, social workers, etc.)
from different departments within the VA Medical Center, West Los Angeles.
Procedures in Research Design
( 1 1 Preliminary Information Gathering
This study was conducted as part of the author’s internship at the Geriatric
Evaluation and Management (GEM) Unit of the VA Medical Center, West Los Angeles
(VAMC/WLA). During the internship, the author had opportunities to attend weekly
team meetings to discuss the Unit’s services with health care professionals, and to attend
education programs offered by the GEM Unit to receive advance training regarding
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geriatric care. Based on observations and discussions with staff members, the author
realized that inappropriate patient referral was a key problem in the Unit’s operations.
The literature review (Chapter II) also indicates that patient selection/targeting is a key
factor that affects the performance of any geriatric assessment program. These were the
initial questions that motivated the author to conduct research concerning patient referral
issues.
The first step of this study was to identify the major patient resources of the GEM
Unit. Secondary data analysis was employed using of GEM Unit admission logs, which
were recorded by nursing staff from January 1989 to June 1994. Of the 670 recorded
patients, the largest patient population of the GEM Unit came from the Geriatric
Outpatient Clinic (33.6%). The other major patient population within the VAMCAVLA
came from the Department of General Medicine (25.2%), the Nursing Home Care Unit
(6.3%), the Department of Cardiology (6.0%), and the Department of Neurology (3.9%).
The Geriatric Outpatient Clinic (GOPC) is the clinical program of the Geriatric
Research Education and Clinical Center (GRECC). The physicians, nurses, and social
workers of the GOPC conduct patient referral and patient admission according to the
GEM Unit’s admission criteria. Through daily practice, they understand the admission
criteria and referral channels of the GEM Unit pretty well. Therefore, the GOPC was
excluded from this study. The target groups of this study represent the health care
professionals (the “customers”) from different departments that provide major patient
population for the GEM Unit within the VAMCAVLA.
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The author of this study presented the major concepts and pre-research results
concerning the patient resources of the GEM Unit to the Department of Quality
Management. The representative from this Department agreed to support the survey as
part of the Total Quality Improvement project that was being conducted within the
Medical Center. The next step was to decide the mode of data gathering.
(2) Instrumentation
A survey was selected as the measuring instrument because it is useful for
description, explanation, and exploration purposes (Babbie, 1990). Surveys are especially
helpful in evaluating programs and conducting research when the researcher’s need for
information comes directly from people (Fink and Kosecofl^ 198S).
Questionnaires and interviews are the most commonly used survey devices (Fink and
Kosecof^ 1985). This survey employed a written questionnaire format and was self
administered because of its advantages. Judd and colleagues (1991) indicate that the
advantages of a written questionnaire are: low cost, avoidance of potential interviewer
bias, and less pressure for an immediate subject response. The written questionnaire was
self-administered because it gave respondents a greater feeling of anonymity and
therefore encouraged open responses to sensitive questions.
Since health care professionals are frequently “busy”, the survey design strategy
employed a simple, convenient questionnaire to collect useful data. The survey
instrument was a one page double-sided instrument that was expected to be completed
within 15 minutes.
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(3) Development of the Survey Items
This survey combined two type of questions: close- and open-ended. Close-ended
questions (or fixed-alternative questions) present two or more alternatives, and the
respondents select the choice closest to their own position. Closed-ended questions are
easily coded to produce meaningful results for analysis. On the other hand, open-ended
questions (or free-response) allow respondents to convey the fine shades of their
attitudes to their own satisfaction instead of forcing them to choose one of several
statements that may seem more or less unsatisfactory. The researcher codes the response
in terms of a system of categories (Judd et al., 1991).
(4) The Pilot Test
Self-administered questionnaires are heavily dependent on the clarity of the language.
Pilot testing quickly reveals whether people understand the directions researchers have
provided and whether respondents can answer the questions (Fink and Kosecoff 1985).
The draft of the questionnaire and a cover letter (Appendix B) were sent to five
experts, including the Director of GRECC, the Director of GEM Unit, the attending
physician, the head nurse, and the program educator. Three community health nurses
who had many years of working experience in helping different inpatient departments
refer or discharge patients to the appropriate locations also completed the pretest.
Comments were used to reword closed-ended questions and add open-ended questions.
The purpose of the pretest was to: (a) identify unforeseen problems in question
wording or respondents’ comprehension, question sequence, or questionnaire
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administration so that they could be eliminated before the actual study; (b) indicate the
need for additional questions on some topics and the elimination of others; (c) gather
data for item analysis for any scales included in the questionnaire; and (d) determine the
length of time required to answer the questionnaire (and if necessary, to shorten it) (Judd
etal, 1991).
(51 Description of Questionnaire
The first section of the questionnaire focused on the working relationships within the
GEM Unit and tried to identify the strength of the relationship between respondents and
the GEM Unit. The number of referred or received patients to or from the GEM Unit
represented that relationship. The range of numbers used attempted to avoid vagueness.
“Less than 5” indicated a weak relationship, “5-10” indicated a medium relationship
(neither a strong nor weak relationship), and “more than 10” indicated a strong
relationship. The range of numbers were an arbitrary choice based on the GEM Unit
staffs’ experience. The question about whether or not respondents had received training
from the GEM Unit was designed to distinguish possible differences among the
respondents.
The second section of the questionnaire dealt with the respondent’s awareness of
admission criteria for the GEM Unit. The section sought to determine the extent of
knowledge and information that respondents had about the kind of patients who most
benefit from the GEM Unit. Eight items were designed based on the GEM Unit’s
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Admission Criteria with a True or False form that required respondents to answer all of
the items (See Appendix C).
The third section asked respondents why they refer patients to the GEM Unit to find
out the respondents’ intentions for referring potential patients, and extents of
understanding the GEM Unit’s functions. The purpose was to not only understand the
respondents’ needs but also identify the respondents’ awareness about the services of the
GEM Unit. The respondents were asked to choose the top three items from six reasons
provided concerning patient referrals.
The fourth section focused on the respondents’ problems with patient referrals. Five
possible reasons for not referring patients were asked.
The fifth section addressed satisfaction and explored the respondents’ feelings and
their perspectives of the GEM Unit’s services. A Likert scale from 7 to 1 was provided
to express satisfaction at level 6-7 which means “very satisfied”, 3-5 which means
“somewhat satisfied”, and 1-2 which means “very dissatisfied.” Two open-ended
questions allowed respondents to express the best or least beneficial aspects of the GEM
Unit services as a way to characterize their image of the Unit.
The sixth section of the survey permitted respondents to mention the type of elderly
patients with whom they have the most problems discharging or transferring in the
VAMCAVLA. Because the GEM Unit has strong operational relationships with different
departments, the problems of other units affect the processes of referring or receiving
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patients. Therefore, it was a good opportunity to understand the external problems of the
GEM Unit.
A last open-ended section allowed respondents to express any other comments about
the GEM Unit.
(61 The Study Population
The study population was composed of health care professionals within the
VAMCAVLA who had referred and/or received patients to/from the GEM Unit. Of 150
respondents, 62.7% (n=94) completed the questionnaire.
(7) Administration of the Survey
Three phases of data collection were conducted.
/. Monthly Staff Meetings
An effective method to collect data at one time is to conduct a survey during regular
staff meetings. Therefore, the author conducted the survey at two monthly meetings of
social workers and physicians who came from different departments of the VAMC/WLA.
2. Physicians ’ Mail Box
The attending physician in the Department of General Medicine helped to put the
questionnaire in each physician’s mail box. He also helped remind physicians to complete
the questionnaire and collected the questionnaires.
3. Discharge Planning Meetings
The discharge planning meetings of inpatient departments of the VAMC/WLA
usually are conducted weekly. The members of the meeting include physicians, social
46
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workers, nurses, dietitians, and other health care professionals as needed. The author
attended five of these discharge planning meetings.
The Department of General Medicine is the largest inpatient department for the
GEM Unit’s patient population, and it is located in several places within the
VAMC/WLA. Therefore, the author chose to attend three discharge planning meetings at
different locations.
Other discharge planning meetings are held by the Departments of Cardiology and
Neurology, which are the two larger patient resources for the GEM Unit. Through the
discussion with these health care professionals, the author not only collected the data but
also had opportunities to listen to the respondents’ opinions and complaints about the
GEM Unit.
(8) Data Analysis
On the closed-ended questions, four methods of data analysis were used. The first
method, univariate analysis, was used to measure frequency distributions and averages.
The second method, one-way analysis of variance (ANOVA), was used to test significant
difference between independent variables and dependent variables. The third method, Chi
square test, was used to uncover any significant differences among categorical data. The
fourth method, correlation, was adopted to uncover any significant relationships among
pairs of variables. The STATA System was used to perform the statistical analysis.
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Responses to the open-ended questions were first recorded and interpreted to create
main categories of meaningful themes. Then, these responses were categorized according
to recurring themes.
The next chapter presents the analysis and discussion of the major findings of this
research.
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CHAPTER IV
RESULTS AND DISCUSSION
This chapter presents the results of this research in two sections. The first section
presents answers to the research questions listed in Chapter I. The second section
presents tests o f the research hypotheses listed in Chapter m .
Part One— Answers to Research Questions
Information about the Respondents
The respondents in this study came from different departments in the VA Medical
Center, West Los Angeles (VAMCAVLA). The largest number of respondents were from
the Department o f General Medicine, as shown in Table 3. This finding corroborated the
research result mentioned earlier (See Chapter HI— preliminary information gathering)
concerning patients' source of information about the Geriatric Evaluation and
Management (GEM) Unit, as measured from January, 1989 to June, 1994. During those
five and a half years, the Department of General Medicine was the largest inpatient
department to refer patients to the GEM Unit.
Twenty-five percent of the respondents did not indicate their departments. One of the
possible explanation is that many questionnaires were collected at two monthly meetings
of physicians and social workers. The respondents may not have indicated their
departments so as to prevent their being recognized.
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Table 3. Departments of the Respondents in VAMC/WLA
Department Frequency Percentage (%)
General Medicine 30 31.9
Cardiology 9 9.6
Neurology 5 5.3
Dialysis 4 4.3
Domiciliary Program 4 4.3
Mental Health Clinic 4 4.3
Community Health Nursing 3 3.2
Infectious Diseases 3 3.2
Psychiatry 3 3.2
Community Residential Care 2 2.1
Nursing Home Contract Program 2 2.1
Nursing Home Care Unit 1 1.0
ND* 24 25.5
Total 94 100.0
*ND = Respondents who did not indicate their department
The two largest groups of professionals among respondents were physicians (41%)
and social workers (45%) (See Figure 4). Physicians and social workers are usually core
members involved in referring patients. Therefore, they are especially suited as
respondents for this survey. The average years of service at the VAMC/WLA of all
respondents was 7.7 years. For physicians it was 6.2 years and for social workers it was
9.4 years (See Table 4).
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Figure 4. Health Care Professions o f the Respondents
Nurse Physical therapy
Oettian m 1%
5% ____
Physician
41%
Social worter
45%
Speech pathology
1%
Table 4. Average Years of Service in VAMCAVLA, by Different Services
Services Obs Mean
Physicians 29 6.2
Nurses 4 7.3
Social Workers 36 9.4
Dietitians 4 6.5
Speech Pathologists 1 2.0
Physical Therapists 1 2.0
Total* 75 7.7
* 19 of 94 respondents did not indicate the number of years of
service
Relationships Between Respondents and the GEM Unit
The relationships between respondents and GEM Unit can be described in two ways:
1) whether the respondents had referred patients to the GEM Unit, or 2) whether the
respondents had received patients from the GEM Unit.
The first way shows that forty-eight percent (45 out of 94) of the respondents had
referred patients to the GEM Unit. Among these respondents, 29% of them had referred
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more than 10 patients to the GEM Unit, which indicates a strong relationship; 31% of
them had referred 5 to 10 patients to the GEM Unit, which indicates a medium
relationship; more than 35% o f respondents had referred fewer than five patients to the
GEM Unit, which indicates a weak relationship (See Figure 5).
Figure 5. Percent of Respondents Who Referred Patients to the GEM Unit
40
Using the second approach, 35% (33 out of 94) of the respondents had received
patients from the GEM Unit. Among these respondents, 30% of them had received more
than 10 patients from the GEM Unit, indicating a strong relationship; 15% of them had
received 5 to 10 patients from the GEM Unit, demonstrating a medium relationship; and
more than 40% of them had received fewer than five patients from the GEM Unit, which
represents a weak relationship (See Table 5).
The training program of the GEM Unit provides a clinical environment for teaching
health care professional trainees of all health disciplines about the principles and
techniques of geriatric evaluation and management. However, only 22.3% (21 out of 94)
of the respondents had received training in or about the GEM Unit itself Although
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providing geriatric education for health professionals and trainees is one of the major
goals of the GEM Unit, the percentage of respondents receiving training was low.
Table 5. Percentage of Respondents Having Received Patients From the GEM Unit
Number of
Received Patients
Frequency Percentage (%)
Less than 5 14 42.4
5 to 10 5 15.2
More than 10 10 30.3
No response 4 12.1
Total 33 100.0
Respondent Knowledge o f the GEM U nit's Admission Criteria
The questionnaire also sought to determine the level of information and knowledge
respondents had about the type of patients they expect will benefit most from the GEM
Unit. The results demonstrate that even though many of the respondents could answer
correctly questions about admission criteria for the GEM Unit, there still were some
respondents who were confused (See Table 6).
In Table 6, Criteria a through h represent the true-false admission questions of the
questionnaire, Section II ( see Appendix A for a full copy of the questionnaire). The
correct true/false answers for each question concerning admission criteria for the GEM
Unit are shown beneath Table 6, next to each question.
Comparing answers of respondents with the correct answers, criteria c, f and g were
the three types of patient admission criteria about which respondents were most ill
informed (See Table 6 and Figure 6).
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Table 6. Respondent Knowledge o f Patient Admission Criteria for the GEM Unit
Criteria
Questions
Respondent Answer True Respondent Answer False No response
Freq. % Freq. % Freq. %
a(T) 77 81.9 5 5.3 12 12.8
b(F) 19 20.2 62 66.0 13 13.8
c(F) 44 46.8 34 36.2 16 17.0
d(F) 12 12.8 68 72.3 14 14.9
e(F) 9 9.6 70 74.5 15 15.9
f(T) 57 60.7 24 25.5 13 13.8
g(F)
26 27.7 54 57.4 14 14.9
h(T) 71 75.5 10 10.7 13 13.8
a= Patients who have experienced a recent decline in their physical or psychosocial ability,
jeopardizing their ability to maintain themselves in their present environment (T)
b= Patients who require total nursing care or assistance with all basic activities of daily living (F)
c= Patients for whom extended care has been recommended, or is likely (F)
d= Patients who have a terminal illness (less than 6 months life expectancy) (F)
e= Patients who demonstrate disruptive behavior (F)
f= Patients with failure to thrive, fells, polypharmacy, or incontinence (T)
g= Patients with well-documented dementia (F)
h= Patients with difficulty regaining functional status after acute event 2° to poor vision or hearing
Parkinson's disease, malnutrition, etc.. (T)
1) There were 46.8% of the respondents who answered true to the question, "Patients
fo r whom extended care has been recommended, or is likely" (Criterion c). However, the
correct answer is false. This type of patient is not suitable for GEM Unit services.
Another 27.7% of the respondents said true to the question, "Patients with well-
documented dementia" (Criterion g). The correct answer is also false. This type of
patient is not appropriate for GEM Unit services.
2) There were 25.5% of the respondents who answered false to the question, "Patients
with failure to thrive, falls, polypharmacy, or incontinence" (Criterion £). However, this
is a type of patient that meets the GEM Unit admission criteria.
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Figure 6. Correct Responses on Patient Admission Criteria Questions
Adm Ission Criteria
In addition to those top three that were most frequently incorrect items, one-fifth
(20.2%) of the respondents chose Criterion b (Patients who require total nursing care or
assistance with all basic activities o f daily living) as a suitable patient admission criterion
of the GEM Unit. Actually, this type of patient is more suited for skilled nursing care
facilities. These results demonstrate that respondents in this study not only lacked
information about admission criteria but also did not understand well the function of the
GEM Unit. Moreover, 13% of the respondents had difficulties in distinguishing services
offered by the GEM Unit and hospice facilities, as indicated by Criterion d (Patients who
have a terminal illness-less than 6 months life expectancy).
Reasons fo r Referring Patients to the GEM Unit
The other important part of this survey was to understand why respondents do or do
not refer patients to the GEM Unit.
Respondents were first asked to check off the top three reasons why they would
refer patients to the GEM Unit, in order of priority, from the listed items. Table 7 shows
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the top reasons were: to receive interdisciplinary geriatric evaluation and
recommendations fo r appropriate intervention (item a), to treat undiagnosed/new onset
geriatric problems (item e), and, to provide rehabilitation fo r fra il medical patients
(item d). Those three items meet the goals of the GEM Unit. These results also
demonstrate that most of the respondents surveyed have a basic understanding of the
type of services the GEM Unit can provide for their patients.
Nevertheless, some respondents answered that they refer patients to the GEM Unit
because they want to discharge patients from their departments (item b), or expedite
transfers to a nursing home (item £). These two actions, however, are not an appropriate
utilization of the GEM Unit services. If the GEM Unit receives patients as a result of
these two reasons, the GEM Unit’s burden will be increased and its efficiency reduced.
Table 7. Top Three Reasons Why Respondents Refer Patients to the GEM Unit
Reason
First
priority
Second
priority
Third
priority
Total
% % % %
a. Interdisciplinary evaluation 76.6 9.6 5.3 91.5
b. Discharge service 3.2 3.2 8.5 14.9
c. Assure appropriate discharge 6.4 18.1 18.1 42.6
d. Rehabilitation for frail patients 11.7 33.0 12.8 57.5
e. Treat undiagnosed geriatric
problems
17.0 31.9 29.8 78.7
£ Transfer to nursing home 6.4 1.0 12.8 20.2
Reasons fo r Not Referring Patients to the GEM Unit
When respondents were asked to check off all pertinent factors why they had not
referred patients to the GEM Unit from the listed items, the top two reasons both cited
by somewhat less than one-fourth of all respondents were: Did not know patient
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admission criteria fo r the GEM Unit and D id not know who should be contacted or how
to refer patients to the GEM Unit. A less frequently identified reason was Not Aware
about the GEM Unit and where it is in the VAMC/WLA (See Table 8).
Table 8. Reasons Why Respondents Had Not Referred Patients to the GEM Unit
Reason
Yes
%
a. Unaware of the GEM Unit 14.9
b. Unaware of admission criteria 23.4
c. No perceived benefit 8.5
d. Long waiting list 9.6
e. Unaware of access 23.4
Respondent Satisfaction and Images o f the GEM Unit
Customer satisfaction is an important performance measure for the GEM Unit. As
noted earlier, “customers” include health care professionals using the services of the
GEM Unit. Among the respondents (n=44) who answered this section, the average
satisfaction scale was 5.0±1.4 (The range was from 1 to 7: 1 indicates very dissatisfied
while 7 indicates very satisfied). Over 70% of these respondents reported a satisfaction
level above five (See Figure 7), which means that the majority were satisfied with the
GEM Unit.
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Figure 7. Percentage o f Respondent Satisfaction Scale o f the GEM Unit
Very Dissatisfied •> Very Satisfied
Most/Least Beneficial Aspects o f the GEM Unit
The open-ended questions in this survey allowed respondents to express their
opinions about the most and the least beneficial aspects of the GEM Unit. After carefully
analyzing and integrating opinions from each questionnaire, the main recurring themes
fell into several major categories: seven centered on the most beneficial aspects, while ten
categories referred to the least beneficial aspects. The results are listed in Tables 9 and
10. Of the 36 individuals who responded concerning the most beneficial aspects of the
GEM Unit, more than half (58%) identified providing comprehensive geriatric care and
maximizing the patient's potential On the other hand, of the 25 respondents who
answered the question about least beneficial aspects, 36% identified a long waiting list
most frequently. The limited number of beds (14 beds) in the GEM Unit may help to
explain this concern.
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Table 9. The Most Beneficial Aspects of the GEM Unit, As Reported by Respondents
(N=36)
Description Frequency
Comprehensive geriatric care (Interdisciplinary
assessment)
18
Maximize patient's potential (rehabilitation) 7
Appropriate follow-up of patient's medical-physical
condition (receive continuity of care)
3
Efficiency (it does work) 3
Treat geriatric patients who have serious medical
problems
2
Inclusively teach knowledge and expertise 2
Stabilize patients 2
Table 10. The Least Beneficial Aspects of the GEM Unit, As Reported by Respondents
(N=25)
Description Frequency
Long waiting list (limited number of beds) 9
Need better rehabilitation service 6
No recreation 3
Too restrictive in type of patient accepted 3
Understaffed with RNs 2
Need more social workers 1
Adjacent to hospice 1
Limited clinical research opportunities 1
A lot of resources dedicated to very few 1
Lack of timely consult 1
Difficult Type o f Elderly Patients to be Discharged to or Transferred Within VAMC/
WLA
An additional open-ended question provided respondents with an opportunity to
discuss the type of elderly patients they had the most problem discharging or transferring
within the VAMCAVLA. Since the GEM Unit has strong relations with other
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departments within the VAMC/WLA, it would be helpful for the GEM Unit to
understand the discharge or transfer problems of other departments. The major point to
examine is whether unsuitable patients are referred to the GEM Unit. Somewhat more
than half (N=49) of the 94 respondents answered this question. The answers were
organized into nine categories. Patients with mental and/or behavioral problems was the
most frequently indicated patient type. Patients without social support and Patients with
special medical problems were the next most frequently identified types of patient (See
Table 11).
Table 11. Difficult Types of Elderly Patients to Discharge or Transfer in the
VAMCAVLA
(N=49)
Description Frequency
Patients with mental and/or behavior problems 20
Patients without social support (homeless, low income) 1 1
Patients with special medical problems (i.e., decubitus,
pulmonary, diabetic, stroke, HIV/AIDS, IV antibiotics,
catheters, etc.)
1 1
Patients requiring assistance with ADL and/or high care needs 9
Patients with placement requirement 8
Patients with multiple medical problems 7
Patients with terminal illness (hospice placement) 3
Patients with alcohol and drug abuse 2
Patients with transportation problem 1
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Summary of Part One
The answers to the six research questions can be summarized as follows:
(11 Question I: Relationships between Health Care Professionals and the GEM Unit
The largest department respondenting was General Medicine, and the two largest
groups of respondents were physicians and social workers. The average years of service
for all respondents was 7.7 years. Forty-eight percent of the respondents had referred
patients to the GEM Unit. Only 22.4% of the respondents had received training about the
GEM Unit.
(21 Question II: Levels of Knowledge of Admission Criteria
The average score of correct responses to the admission criteria was 6.1±1.6 (The
range was between 1 and 8; the higher the better). Patients fo r whom extended care has
been recommended, or is likely and Patients with well-documented dementia are the
most misunderstood type of patient referrals to the GEM Unit.
(31 Question HI: Awareness of Functions of the GEM Unit
The top three reasons respondents gave for referring patients to the GEM Unit were:
(a) to receive interdisciplinary geriatric evaluation and recommendations for appropriate
intervention; (b) to treat undiagnosed/new onset geriatric problems; and, (c) to provide
rehabilitation for frail medical patients. Those three items are appropriate functions of the
GEM Unit.
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(4) Question IV: Reasons for Not Referring Patients to the GEM Unit
Did not know patient admission criteria and Did not know who should be contacted
or how to refer patients were the top two reasons why respondents had not referred
patients to the GEM Unit. One in every 10 respondents indicated that a long waiting list
is the reason why they have not referred patients to GEM Unit.
(5) Question V: What is the level of health care professionals’ satisfaction with the GEM
Unit and what is their overall image of the Unit?
The average satisfaction scale score of respondents was 5.0±1.4 (The range was from
1 — very dissatisfied to 7— very satisfied). The most beneficial aspect indicated by
respondents concerning the GEM Unit was that it provides comprehensive geriatric care
(interdisciplinary assessment). The least beneficial aspect identified by respondents about
the GEM Unit was its long waiting list.
(6) Question VI: The Most Difficult Types of Patients for Discharging or Transferring
To answer what type of elderly patients respondents had the most problem
discharging or transferring in the VAMC/WLA, patients with mental and/or behavioral
problems was the top item. Patients without social support and patients with special
medical problems were the other two major items.
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Part Two-Tests of Research Hypotheses
The following section will discuss the tests of the seven research hypotheses listed in
Chapter HI: Research Methodology.
L Impacts of Training
Hypothesis #1
Health care professionals who received training from the GEM Unit:
(a) refer more patients to the GEM Unit;
(b) have better knowledge o f admission criteria o f the GEM Unit;
(c) have better awareness o f GEM Unit’ s functions;
(d) have better awareness o f patient referrab o f the GEM Unit;
(e) have higher satisfaction with the GEM Unit.
The results are as follows.
(a) Relationships between Training and the Number o f Patient Referrals to the GEM
Unit
Respondents identified different numbers of patient referrals depending on whether
they have or have not received training from the GEM Unit: 21 respondents had received
training, while 60 respondents had not. Over 70% of the 21 respondents who had
received training from the GEM Unit have referred patients to the Unit. Nearly half
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(46%) of these respondents indicated that they had referred more than 10 patients, which
represents a strong relationship with the GEM Unit; only 20% of these respondents
indicated that they had a weak relationship with the GEM Unit (Le., they had referred
less than 5 patients). By contrast, 56% of the 60 respondents who had NOT received
training from the GEM Unit have referred patients to the Unit; only 17.7% of these
respondents indicated that they had referred more than 10 patients— a strong relationship
with the GEM Unit; over 58% of these respondents indicated that they had a weak
relationship with the GEM Unit. According to the Chi square test (See Table 12), these
differences are significant (p= .03). The results confirm the hypothesis that respondents
who have received training from the GEM Unit refer more patients to the Unit than those
who have not received such training.
Table 12. Chi Square Test for Relationships between Training and the Number of Patient
Referrals to the GEM Unit
Number of
Patient
Referrals
Training
Total Yes No
% N % N % N
Less than 5 20.0% 3 58.8% 20 47.0% 23
5 to 10 33.3% 5 23.5% 8 26.5% 13
More than 10 46.7% 7 17.7% 6 26.5% 13
Total 100.0% 15 100.0% 34 100.0% 49
Chi Square= 7.0230 P= .03
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(b) Relationships between Training and the Knowledge o f Admission Criteria o f the
GEM Un it
A major finding is that respondents who have received training in the GEM Unit have
higher average scores of awareness of the GEM Unit’s admission criteria than those who
have NOT received training (7.2±0.8 vs. 5.7±1.6). According to the One-Way Analysis
of Variance (ANOVA), the difference is significant (p< .01). This finding confirms the
hypothesis and shows a positive influence of the GEM Unit educational program on
strengthening health care professionals’ knowledge of admission criteria within the
VAMC/WLA.
(c) Relationships between Training and the Awareness o f GEM Unit’ s Functions
Respondents who chose Discharge Service and Transfer to Nursing Home as reasons
for referring patients are categorized as unaware of the GEM Unit’s functions; 9% of the
respondents who received training from the GEM Unit and 18% of the respondents who
had not received training chose Discharge Service. However, according to the Chi
square test (See Table 13a), the difference is not significant (p< .34). Nearly one-fifth
(19%) of the respondents who had received training from the GEM Unit and 18% of the
respondents who had not received training chose Transfer to Nursing Home. According
to the Chi square test (See Table 13b), there is no significance on this result (p< .94). The
results do not confirm the hypothesis and imply that training alone may not lead to a
better understanding of the GEM Unit’s functions.
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Table 13. Chi Square Test for Relationships between Training and the Awareness of
the GEM Unit’s Functions
(a) Training and Discharge Service as a Reason for Referring Patients
Discharge
Service
Training
Total Yes N1 0
% N % N % N
Yes 9.5% 2 18.3% 11 16.1% 13
No 90.5% 19 81.7% 49 83.9% 68
Total 100.0% 21 100.0% 60 100.0% 81
Chi Square= .8960 P= .344
(b) Training and Transfer to Nursing Home as a Reason for Referring Patients
Training
Transfer to Yes N0 Total
Nursing Home % N % N % N
Yes 19.1% 4 18.3% 1 1 18.5% 15
No 80.9% 17 81.7% 49 81.5% 66
Total 100.0% 21 100.0% 60 100.0% 81
Chi Square= .0053 P= .942
(d) Relationships between Training and the Awareness o f Patient Referrals o f the
GEM Unit
The questionnaire inquired why respondents had not referred patients to the GEM
Unit. None of the respondents who had received training from the GEM Unit mentioned
that they did not know the Unit, patient admission criteria, or patient referral access. On
the other hand, many of the respondents who have NOT received training from the GEM
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Unit answered that they did not know the Unit (21.7%), patient admission criteria
(31.7%), or access for patient referral (31.7%). According to the Chi square test (See
Table 14), the differences are significant on the issues of unaware o f the GEM Unit
(p= .02), unaware o f admission criteria (p= .003), and unaware o f referral access
(p= .003). These results confirm the hypothesis and indicate that training is related to
health care professionals’ awareness of patient referral to the GEM Unit.
Table 14. Chi Square Test for Relationships between Training and the Awareness of
Patient Referrals of the GEM Unit
(a) Training and Unaware of the GEM Unit as a Reason for Not Referring Patients
Unaware of the
GEM Unit
Training
Total Yes N0
% N % N % N
Yes 0.0% 0 21.7% 13 16.1% 13
No 100.0% 21 78.3% 47 83.9% 68
Total 100.0% 21 100.0% 60 100.0% 81
Chi Squares 5.4199 P= .02
(b) Training and Unaware of Admission Criteria as A Reason for Not Referring Patients
Unaware of
Admission
Criteria
Training
Total Yes IS0
% N % N % N
Yes 0.0% 0 31.7% 19 23.5% 19
No 100.0% 21 68.3% 41 76.5% 62
Total 100.0% 21 100.0% 60 100.0% 81
Chi Squares 8.6879 P= .003
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(c) Training and Unaware o f Referral Access as a Reason for Not Referring Patients
Unaware of
Referral Access
Training
Total Yes N0
% N % N % N
Yes 0.0% 0 31.7% 19 23.5% 19
No 100.0% 21 68.3% 41 76.5% 62
Total 100.0% 21 100.0% 60 100.0% 81
Chi Square= 8.6879 P= .003
(e) Relationships between Training and the Respondents’ Satisfaction with the GEM
Unit
The average satisfaction scale scores are 5.4±1.3 for those who have received
training, and 4.8+1.4 for those who had NOT received training from GEM Unit; the
higher the score, the more satisfied the respondents. However, according to the One-Way
ANOVA, the difference is not significant (p<. 19). This finding does not confirm the
hypothesis. The training program appears not to be the only factor to affect respondents’
satisfaction with the GEM Unit.
n. Knowledge about Admission Criteria
This section discusses relationships between levels of knowledge of admission criteria
and 1) different professions, 2) years of service, 3) number of patient referrals, and 4)
awareness of GEM Unit functions. The results test three hypotheses.
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Hypothesis #2
Health care professionals who (a) are physicians, (b) have longer service years have
better knowledge o f admission criteria o f the GEM Unit
(a) Levels o f Knowledge about Admission Criteria fo r Different Professions
The admission criteria questions consisted of eight items, for which respondents
received one point for every correct response. Therefore, scores ranged from one to
eight; the higher the score, the greater the respondent’s awareness of admission criteria.
The average score for respondents (n= 82) was 6.1±1.6. Physicians had the highest
average score o f 6.4±1.6, social workers had an average score of 5.8±1.7, and nurses had
an average score of 5.4±1.1 (See Table IS). Although the physicians had higher scores
than other professions, the differences are not significant (p< .48) based on One-Way
ANOVA. Thus the hypothesis can not be confirmed.
Table 15. Average Score of Correct Answers Re: Patient Admission Criteria for the
GEM Unit by Different Service Professions
Professions Obs Mean (SD)
Physicians 34 6.4+1.6
Social Workers 35
5.8±1.7
Nurses 7
5.4±1.1
* Scores ranged from 1 to 8
(b) Levels o f Knowledge about Admission Criteria By Years o f Service
An unexpected trend was that the average score of correct answers was inversely
related to the number of years of service. Thus, those respondents with no more than one
year of service in the VAMC/WLA had the highest average score (6.5±1.5). By contrast,
respondents with more than 10 years of service had the lowest average score (5.6±1.7)
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(See Figure 8). However, according to One-Way ANOVA, the difference was not
significant (p< .26). Therefore, the hypothesis is not confirmed.
One possible explanation for this result is that some of the respondents with more
years of service have been at the VAMC/WLA longer than the establishment of the GEM
Unit (from 1975 to 1980). Perhaps long-term employees have not had the opportunity to
receive training on the GEM Unit. Indeed, 14 of the 22 respondents with more than 10
years of service answered that they never had received training in the GEM Unit. Another
possible explanation is that some of the respondents with many years of service had
already entered senior management levels and were not involved in patient referrals as
frequently as those respondents with fewer years of service. Therefore, senior staff were
probably not familiar with admission criteria for the GEM Unit, hi fact, 10 of the 22
respondents with more than 10 years of service indicated that they do not refer patients
to the GEM Unit. However, due to limitations of this study such as small sample size and
analysis of only one GEM Unit, the results may only for general reference.
Figure 8. Average Score of Correct Answers in Patient Admission Criteria of the GEM
Unit by Respondents with Varied Years of Service
Year>10
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Hypothesis #3
Health care professionals who have better knowledge o f admission criteria refer
more patients to the GEM Unit.
Respondents who indicated that they had referred patients to the GEM Unit tend to
refer more patients when they better understand the patient admission criteria. Average
scores concerning awareness of patient admission criteria were 6.6±1.1, 6.0±1.7, and
5.9±1.6 for those who answered that they have referred “more than 10”, “5 to 10”, and
‘less than 5” patients to the GEM Unit, respectively. However, according to One-Way
ANOVA the difference is not significant (p< .40). Thus the hypothesis is not confirmed.
The results also imply that understanding of the admission criteria is not the only factor
to affect patient referral activity.
Hypothesis #4
Lack o f knowledge o f admission criteria is associated with inappropriate use o f the
GEM Unit's services.
As mentioned earlier, if respondents chose item b (Discharge service) or item f
(Transfer to nursing home) as reasons to refer patients, they were not using the GEM
Unit services appropriately. Respondents who answered these two items had lower
average scores for awareness of patient admission criteria. Negative correlations exist
between these variables: r = - .2130 (p< .06) for Discharge service; r = - . 1020 (p< .37)
for Transfer to nursing home. The results partially confirm the hypothesis.
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IH. Reasons for Not Referring Patients to the GEM Unit
This section examines the relationship between reasons for non-referral to the GEM
Unit (independent variable) and (a) service utilization for patient referrals and (b)
satisfaction with the GEM Unit (dependent variables). The results test two hypotheses.
Hypothesis #5
Problems o f patient referral are negatively associated with numbers o f patient
referrals to the GEM Unit.
Respondents who indicated any reasons for not referring patients to the GEM Unit
had fewer patient referrals than those respondents who did not indicate such reasons.
The results are very consistent. According to the Chi square test, only long waiting list
(p< .01) and Unaware o f access (p< .06) are two significant reasons to affect patient
referrals. The results partially confirm the hypothesis; however, only less than 20% of
those who answered the survey identified these two items.
Hypothesis #6
Satisfaction o f health care professionals with the GEM Unit is negatively associated
with concerns over long waiting lists.
Respondents who gave long waiting list as reason for not referring patients to the
GEM Unit also expressed less average satisfaction (3.9±1.6) with the Unit. There is a
negative correlation between these two variables, r = - .4504 (p< .01). For those
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respondents who have received training from the GEM Unit, the r = - .6637 (p< .01) is
negative and moderately strong. These findings confirm the hypothesis.
The levels of satisfaction with the GEM Unit can be categorized into: very satisfied
(Le., satisfaction scale: 6-7), somewhat satisfied (ie., satisfaction scale: 3-5), and very
dissatisfied (Le., satisfaction scale: 1-2). Nearly a half of the respondents who did not
give long waiting list as reason for non-referral were very satisfied with the GEM Unit.
By contrast, only 25% of the respondents who gave long waiting list as reason for non
referral expressed very satisfied with the Unit. According to the Chi square test, the
difference is significant (p< . 1). The results imply that long waiting list is a major factor
affecting health care professionals’ satisfaction. As mentioned earlier in Table 10, a long
waiting list was most frequently identified by respondents as the least beneficial aspect of
the GEM Unit.
IV. Level of Satisfaction Related to Number of Patient Referrals to the GEM Unit
Hypothesis #7
High satisfaction with the GEM Unit is associated with a high number o f patient
referrals to the Unit.
Satisfaction levels for respondents vary as do their relations with the GEM Unit for
patient referrals. Respondents who indicated that they had a weak relationship (referred
less than five patients) with the Unit had an average satisfaction scale score of 5.0±1.0;
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those with medium relationship (referred five to 10 patients), the satisfaction scale score
was 4.7±1.7; and those with a strong relationship (referred more than 10 patients) had a
satisfaction scale score of 5.7+1.3. Since the results are not consistent and the differences
are not significant (p < . 16) according to One-Way ANOVA, the results do not confirm
the hypothesis. It also implies that health care professionals’ levels o f satisfaction with the
GEM Unit are not a major factor in their patient referral activities.
Other Findings
Other findings emerged from this study that were not related to any hypotheses.
Respondents who gave reasons for not referring patients to the GEM Unit also tended to
have lower awareness o f admission criteria. However, there was no difference in average
scores between respondents who chose or not chose a long waiting list as a reason for
not referring patients to the GEM Unit. This implies that even though respondents
understood which types of patients are best suited for the GEM Unit, they might still not
want to use the services because o f long waiting lists for their patients to enter this Unit.
Respondents with better awareness o f the GEM Unit’s functions tended to refer more
patients to the Unit. Respondents who inappropriately used the GEM Unit’s services also
expressed lower satisfaction than the average. This suggests that awareness of the GEM
Unit’s functions may affect the respondents’ service utilization for patient referrals and
level o f satisfaction with the GEM Unit.
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Summary of Major Findings
L Impacts of Training about the GEM Unit
Respondents who received training about the GEM Unit tended to: (a) refer more
patients to the GEM Unit; (b) have better awareness o f admission criteria; and, (c) fewer
problems with patient referrals to the Unit. The differences are significant and confirm
parts o f Hypothesis #1: (a), (b), and (d). On the other hand, training alone may not lead
to better awareness o f GEM Unit’s functions and higher satisfaction with the Unit.
D L Knowledge about Admission Criteria
Respondents who are physicians tended to be more aware of admission criteria than
social workers or nurses. Unexpectedly, awareness o f admission criteria decreased by
years o f service. Respondents with greater years o f service had less awareness of
admission criteria to the GEM Unit. However, the differences are not significant and can
not confirm Hypothesis #2.
Respondents with better awareness of admission criteria are more likely to refer more
patients to the GEM Unit. The difference, however, is not significant. Thus, Hypothesis
#3 is not confirmed.
Results indicated that respondents have lower awareness of admission criteria when
they identified Discharge Service and Transfer to Nursing Home as reasons for referring
patients to the GEM Unit. Both o f these two items actually are inappropriate uses of the
Unit’s services. The resulting negative correlation partially confirms Hypothesis #4.
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IH. Reasons for Not Referring Patients to the GEM Unit
Respondents who gave any reason for not referring patients to the GEM Unit had
referred fewer patients to the Unit. The results are very consistent. Long waiting list and
unaware o f access are two significant factors that affect the number of patient referrals to
the GEM Unit. These results confirm parts o f Hypothesis #5.
IV. Levels o f Satisfaction
Respondents who gave long w aiting list as reason for not referring patients to the
GEM Unit also had lower satisfaction with the Unit. The results confirm Hypothesis #6
that there exists negative correlation between long w aiting list and respondents’
satisfaction with the Unit, especially for the respondents who have prior training from the
GEM Unit. Moreover, respondents with higher satisfaction with the GEM Unit do not
always refer more patients to the Unit. Thus, Hypothesis #7 is not confirmed.
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CHAPTER V
RECOMMENDATIONS
This chapter first describes limitations o f this study and then presents
recommendations for ameliorating or solving problems that were identified. The major
problems o f the GEM Unit are briefly described. Then possible actions are suggested to
deal with these problems with brief identifications o f the feasibility o f such actions.
Finally, an overall conclusion is presented.
Limitations of This Study
The major limitations o f this study are its small sample size (N=94) and its having
been conducted in only one GEM Unit. This study was part o f the author’s internship at
VAMC/WLA, therefore, it was difficult to get a larger sample size from more GEM
settings due to time and resource restrictions. Because the VAMC/WLA is a teaching
hospital, the results o f this study may only serve as a general guide for other GEM Units.
Recommendations
L Im pacts of Training About the GEM Unit
Findings
The results o f this study indicate that training about the GEM Unit is significantly
helpful for health care professionals to have better awareness o f admission criteria, have
fewer problems o f patient referrals and refer more patients to the Unit. Therefore, it is
important for the GEM Unit to provide education programs continuously for health care
professionals about the Unit.
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Possible Actions
a. Encourage more s ta ff to receive training in the GEM Unit
To provide appropriate training programs for the staff is one o f the major missions of
teaching hospitals such as the VAMC/WLA. The GEM Unit provides a lot of
opportunities for health care professionals to receive training in geriatric services. The
GEM Unit should continuously design and evaluate training programs to meet the needs
o f different health care professionals. Since the action will involve major departments of
the hospital, it is necessary to look for support and coordination from the central
administration office. Therefore, the GEM Unit may provide the results of this survey to
the administration department, and ask for continuous support o f various educational
programs. The major concept is that not only will the GEM Unit benefit from such action
but the whole hospital will also improve its performance by increasing work efficiency.
Advantages: Increase staff’ s recognition of the GEM Unit
Disadvantages: Need more resources from the Unit and higher supports from the central
administration office
b. Continuously provide more education programs and communication channels
In addition to current training programs in the GEM Unit, periodic workshops will
provide learning opportunities for staff who are interested in the GEM Unit. Training
tapes that provide detailed information about the services o f the Unit would provide
another effective education resource to health care professionals. Moreover, the GEM
Unit can cooperate with other departments in providing necessary information during
other departments’ training programs.
Advantages: (a) Training tapes are easy to access, less training space needed, and they
allow flexible time to be used; (b) the GEM Unit can be actively involved
in the routine training programs of other departments and have an
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opportunity to learn the needs o f relevant health care professionals.
Disadvantages: Increased cost for training tapes; increased personnel to participate in the
training programs o f different departments.
IL Knowledge of Patient Admission Criteria for the GEM Unit
Findings
The results o f the survey show that many respondents do not know what kind of
patients will most benefit from the GEM Unit. If this situation persists, two kinds of
problems will occur: (1) other departments may continue to refer patients inappropriately
to the GEM Unit, and (2) the GEM Unit will decrease its working efficiency. Moreover,
respondents who use the GEM Unit’s services inappropriately also expressed low
awareness o f admission criteria. Unexpectedly, respondents with longer service years had
less awareness o f admission criteria o f the Unit. Therefore, how to enhance health care
professionals’ awareness o f admission criteria will be a key issue o f the GEM Unit.
Possible Actions
a. Update patient admission criteria and disseminate to relevant departments
and long-term employees
The GEM Unit should update its patient admission criteria periodically. The new
information should be sent to each relevant department. One way is to put the updated
announcement on a certain place for each relevant department’s office so that every
health professional can find the information when it is needed. Moreover, the GEM Unit
should try to provide necessary and updated information to health care professionals who
have longer service years. The purpose is to help such health care professionals become
more aware o f the admission criteria and refer appropriate patients to the Unit.
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Advantages: Provide updated information to related health care professionals
Disadvantages: Need more cooperation from different departments; involve more
personnel’s efforts
b. Set up a service phone number to answer admission questions
The GEM Unit may set up one phone number to provide recorded information about
admission issues. Health care professionals can search for needed information by keying
to different digital numbers (e.g., “1” represents “Admission Criteria”, “2” represents
“Accesses o f Patient Admission”, “3” represents ‘ Talk to the Staff”, etc.). If it is
possible, a 24-hour service for answering such questions is preferred, since the Unit has
24-hour staff day and night.
Advantages: Convenience for health care professionals
Disadvantages: High cost and need more manpower
c. Contact with Community Health Nurses
Moorhead and Griffin (1989) suggest that one simple strategy for managing group
interaction is to establish a linking role in appropriate position in the organizational
hierarchy. A linking role is a liaison person who coordinates the activities o f two or more
organizational groups. Under the current referral system of VAMC/WLA, the community
health nurses are involved in major inpatient departments’ discharge meetings every
week. Currently, only three community health nurses responded to these issues.
Therefore, the GEM Unit should actively contact these nurses to become the linking role
and pass any new information to relevant departments. The community health nurses can
also play a very effective role in determining which patients are suitable for the GEM
Unit.
Advantages: Easy, cost effective, and efficient
Disadvantages: Total reliance on three nurses
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HL Reasons for Not Referring Patients to the GEM Unit
Findings
The survey results showed that lack of knowledge about the mechanisms for referring
patients to the GEM Unit and unaware of admission criteria were the top two reasons for
non-referraL Moreover, respondents who gave long waiting list as reason for not
referring patients to the GEM Unit had significantly fewer patient referrals and also
expressed less satisfaction with the Unit. The long waiting list for referring patients to the
Unit was indicated as the least beneficial aspect o f the GEM Unit. Therefore, in addition
to enhancing training and awareness o f admission criteria for the health care
professionals, the GEM Unit should also try to improve its patient referral processes.
Possible Actions
1) Short-Term Action
a. Timely consultation
Each department can request geriatric medicine consultations from the GEM Unit for
those patients who seem appropriate for the Unit. Therefore, it is necessary that the
GEM Unit design a timely and effective consultant procedure. First, the GEM Unit may
record its daily activities and evaluate if it is possible to improve the operations to save
more time and still maintain high quality services. Second, the GEM Unit may use
working records to design reasonable and feasible time limits (e.g., 12 hours, 24 hours, or
48 homs, etc.) to respond to a consultation request from other departments. Third, the
GEM Unit may keep records of all referral activities to evaluate and improve any
necessary steps.
Advantages: Improve the working process and clarify the time schedule
Disadvantage: Involves more well-trained staff members who have other daily activities
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b. Inform ation system
One of the modem tools for health care service communication is using an
information system. The GEM Unit should actively join or be involved in the information
system of the VAMC/WLA. When this author implemented this survey, the attending
physician o f General Medicine demonstrated the department's computer systems to the
author. In one such system, General Medicine lists major and necessary information
about admission procedures for referring patients to related departments. Some
departments provide very detailed information about how to refer patients to their
departments. However, the description o f the GEM Unit is very limited and only
mentions putting a consultation request form in the mail box near the General Medicine
office. The information does not indicate the time needed for the whole referral
procedure, and the person to contact. Therefore, the GEM Unit should try to add more
and clearer announcements on the information system to provide necessary information
to the health care professionals.
Advantages: Clear and easy way to provide necessary information
Disadvantages: Need more cooperation with other departments
2) Long Term Action
a. Increase teamwork with more efficiency
Because the GEM Unit currently has only 14 beds and will not expand the number of
beds in the near future, the efficiency o f interdisciplinary teamwork will be the major
factor to improve the treatment process and to reduce the waiting time for relevant
departments referring patients to the Unit. One useful way is to create quality circles
within the interdisciplinary team and the GEM Unit for continuous quality improvement.
Quality circles may be seen as quality improvement teams or process improvement teams
that permit a systematic dissection o f the process being investigated with greater
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understanding (Rakich et a l, 1993). According to the description o f Goldberg and Pegels
(1985), the quality circle process includes four operational steps: problem identification,
problem selection, problem analysis, and recommendations to management. Each o f these
operational steps requires the use o f one or more o f the following techniques:
brainstorming; data gathering, tabulation, and bar diagrams; histograms; Pareto analysis;
cause-and-effect diagrams; and presentation techniques. Depending on the problem under
analysis, these techniques can be applied at each o f the four operational steps. Because
these operational steps and techniques will be, in most instances, new to the staff it is
important that the staff be trained in their use and application. The GEM Unit may also
look for help and support from the Department of Quality Management with such issues.
Advantages: Quality improvement and improve working process
Disadvantages: Increased cost due to need for more well-trained staff to learn and
implement new techniques
b. Easily to be contacted with and give feedback to the request
It is always important for health service organizations to provide services to meet the
needs o f their customers (patients and health care professionals). This study focuses on
the needs o f health care professionals. Therefore, the GEM Unit should set up an easier
system for the health care professionals using its services. As mentioned earlier, a phone
number and specific staff can provide necessary information to persons who need it. The
GEM Unit can also set up an e-mail address for easy communication with external
customers (Le., health care professionals), to provide information, and to answer
questions. The purpose is to provide easy and quick responses for GEM service requests.
However, the program setup and personnel training for these services need further
planning.
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The other important concept that the GEM Unit should have is to give feedback to
the requests and questions. For example, the GEM Unit should explain to other
departments the reasons if it rejects patients referred from such departments. Through
such activities, the GEM Unit staff not only show respect to other departments but also
provide correct information to the departments to prevent referral of unsuitable patients
in the future. This will reduce the working burden and increase performance o f both the
GEM Unit and other departments.
Advantages: Quick response to requests; improve satisfaction of health care professionals
Disadvantages: Increased cost and personnel for phone and e-mail system
IV. Future Research
Problems
This study has demonstrated the need for continuous service evaluation and quality
improvement for the GEM Unit. However, there are some unanswered questions because
(1) limitations o f this study— for example, only looking at one GEM Unit; and (2) some
findings were not significant— due to small sample size. Therefore, the GEM Unit should
continuously conduct more relevant research to improve its performance.
Recommendations
(a) M ore samples and research locations
A larger study can be performed in the future when a greater sample size is available.
It would be helpful to test significant differences between groups. Moreover, it would be
interesting to reevaluate this study among different comprehensive geriatric assessment
programs and compare the different settings. The results would be helpful for continuous
quality improvement o f such programs.
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(b) Conduct follow -up research
During this survey implementation, every respondent received updated admission
criteria and a general introduction to the GEM Unit after they completed the
questionnaire. The purpose was to increase the opportunity for respondents to review
admission criteria and to let the health care professionals know the Unit will continuously
provide suitable training programs for them.
However, to ensure that the actions within the improvement plan maintain the
benefits, the GEM Unit should conduct follow-up research to evaluate its quality
improvement activities. Have the health care professionals increased their awareness of
patient admission criteria? Has the GEM Unit improved its process to make access easier
for patient referrals? Have the services met the objectives o f quality improvement? How
can the process be monitored in the future and what method should be used if another
quality improvement effort is required? All of these questions need to be addressed.
Conclusions
This study represents practical research for service evaluation and process
improvement. The major contribution of this study is suggesting a new means o f
evaluating comprehensive geriatric assessment programs, using quality improvement and
marketing concepts. The purpose of the study was to identify the problems o f the GEM
Unit’s operations and to help the Unit to improve the quality o f its services for its
customers— in this case, health care professionals. Although the study was conducted at a
Veterans Administration setting, the research concepts and recommendations could easily
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be modified to fit other health care organizations with similar geriatric assessment
programs.
The Geriatric Evaluation and Management (GEM) Unit is a Comprehensive Geriatric
Assessment program. Its operations include a complex mix of health care professionals
and health care organizations. No single effort will prevent all problems from occurring in
such health care organizations. However, many operational problems can be prevented
by careful evaluation and can be improved by effective follow-up actions. If this study has
helped to improve the performance of the GEM Unit, it will have served its purpose.
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APPENDIXES
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APPENDIX A
THE SURVEY OF
GERIATRIC EVALUATION AND MANAGEMENT UNIT
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TQ I External Customer Survey
G eriatric Evaluation and M anagement (GEM) Unit
GRECC Clinical Service
W ard :____________________________ Service:_
Length w ith VAMC/WLA_______________
I. Relationship with GEM Unit
Ql. Have you ever referred patients to GEM Unit?
Yes No (If No, Please go to Q3)
Q2. How many patients have you referred to GEM Unit?
Less than 5_____ 5-10 _ More than 1 0 ___
Q3. Has your unit received patients from GEM Unit?
Yes No (If No, please go to Q5)
Q4. How many patients has your unit received from GEM Unit?
Less than 5_____ 5-10 _ More than 1 0___
Q5. Have you received training in the GEM Unit?
Yes (Length of training ) No
II. The following patients are appropriate for the GEM Unit. (Please mark the following items
with True= T; False= F)
Patients who have experienced a recent declined in their physical, or
psycho-social ability, jeopardizing their ability to maintain themselves in
their present environment
Patients who required total nursing care or assistance w rith all basic
activities of daily living
Patients for whom extended care has been recommended, or is likely
Patients who have a terminal illness (less then 6 months’ life expectancy)
Patients who demonstrate disruptive behavior
Patients with failure to thrive, falls, polypharmacy, or incontinence
Patients with well documented dementia
Patients with difficulty regaining functional status after acute event 2° to
poor vision or hearing, Parkinson’s disease, malnutrition, etc..
HI. Why would you refer a patient to the GEM Unit?
(Please choose top 3 items according to priority such as 1,2,3)
To receive interdisciplinary geriatric evaluation and recommendations for
appropriate intervention
To discharge patients from my services
To assure the most appropriate discharge location
To provide rehabilitation for frail medical patients
To treat undiagnosed/new onset geriatric problems, e.g. incontinence, falls,
polypharmacy, cognitive deficit, etc.
To expedite transfer to nursing home
95
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IV. Why haven’ t you referred patients to the GEM Unit?
(Please choose all that are pertinent)
Did not know what or where the GEM Unit is in VAMC West L. A.
Did not know patient admission criteria for the GEM Unit
Did not think it would benefit my patients
Did not want my patients on long waiting list to enter GEM Unit
Did not know who should be contacted or how to refer patients to the GEM Unit
V. If you have referred patients to or received patients from GEM Unit, what is your level of
satisfaction scale?
Very Satisfied Somewhat Satisfied Very Dissatisfied
7 6 5 4 3 2 1
What do you fed is the most beneficial aspect of GEM Unit?
What do you fed is the least benefidal aspect of GEM Unit?
VI. What types of elderly patients do you have the most problem in discharging or
transferring in the VAMC West L.A.?
VH. Comments
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APPENDIX B
RESEARCHER’S COVER LETTER
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Department of
Veterans Affairs
Memorandum
Dole: July 14,1994
Ying-Chun Li, M HA/M SG
S u ° l Questionnaire of survey
To:
Theodore J. Hahn, M .O.
Shawkat Dhanani, M .O.
Andrew S. Chan, M .D.
Diane Dalton, RN
Nancy Grant
1 . Hello! I am USC graduate student in dual Master Degree of Health Service
Administration and Gerontology. From June 2, 1994 to August 31, 1994,1 have the
internship in GRECC, Geriatric evaluation and Management Unit. The major project
is to do GEM Unit Needs Assessment: TQI External Customer Survey. I am working
with JoAnn Damron-Rodriguez, Ph.D, Steve Castle M .D . and Shawkat Dhanani, M .D .
2. The purposes of the survey are:
a. To help selecting target patients who will most benefit from GEM Unit
b. To find out the needs and expectations of GEM Unit users, especially for
the health service professionals who refer patients, and try to meet their
needs
c. To improve the quality of services of GEM Unit
d. To provide useful information for future program development and
decision making processes
3. Your opinions and suggestions of the questionnaire will be very helpful to improve
the quality of the survey. At your convenience, please review the questionnaire and
respond to me before July 20,1994. Thank you for your assistance.
VAFORM - 1 n c
MAR 1989 2105 9 g
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APPENDIX C
ADMISSION CRITERIA FOR
GERIATRIC EVALUATION AND MANAGEMENT UNIT
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Criteria for Admission (Revised, August 1994)
G eriatric Evaluation and M anagement Unit (GEMU), VAMC WLA
Acting Associate Clinical Director: Shawkat Dhanani, MD
Outpatient Coordinator Diane Dalton, RN, MSN
Exclusionary
1. Intensive monitoring
2. Terminal disease (< 6 months)
3. Well-documented, irreversible Dementia
4. Combative/Disruptive
5. Nursing home placement is 1° problem
6. Total nursing care (KATZ score 0)
7. Lack o f rehabilitation potential
Ihclusionarv
1 . > 65 years
2. Viable social support
3. Multiple medical and psychosocial problems
4. Loss o f independence 2° to acute illness
5. Geriatric problems
* Acute confusion vs. Unrecognized Dementia
* Undiagnosed urinary incontinence
* Failure to thrive / weight loss
* Polypharmacy, falls or disequilibrium
* Difficulty regaining functional status after acute event 2° to poor vision or hearing,
parkinson’s disease, malnutrition, etc., and if there is a potential for rehabilitation
6. Patient motivated
* Referrals to the program or further information can be made and obtained by
contacting: GRECC Fellow on 2EBC. Exten 4498
100
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Asset Metadata

Creator Li, Ying-Chun (author)

Core Title Service evaluation and quality improvement of a geriatric evaluation and management program

Degree Master of Science in Gerontology/ Master of Health Administration

Degree Program Gerontology,Health Administration

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Gerontology,health sciences, health care management,OAI-PMH Harvest,Political Science, public administration

Language English

Contributor Digitized by ProQuest (provenance)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-5316

Unique identifier UC11337622

Identifier 1381594.pdf (filename),usctheses-c16-5316 (legacy record id)

Legacy Identifier 1381594.pdf

Dmrecord 5316

Document Type Thesis

Rights Li, Ying-Chun

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA