Implementation of a Multidisciplinary Team to Improve the Quality of Care for Older Surgical Patients at a Rural Academic Medical Center

Abstract

For the first time in history, people age older than 65 years make up >20% of the non-metro population, compared with 16% of the metro population. From 2010 to 2020 the nonmetro population age older than 65 years grew by 22%, while the working-age population declined by 4.9%, and the population aged under 18 years declined by 5.7%. 1,2 Multidisciplinary geriatric surgical programs are an increasingly recognized approach to the care of older surgical patients and preliminary data suggest they can reduce length of stay. Although rural areas have the greatest proportion of patients age older than 65 years, implementation of such programs faces special challenges in rural settings with limited resources. Dartmouth-Hitchcock Medical Center is one of the most rural academic centers in the United States. Challenges include a shortage of geriatric-trained providers, long distances to access primary care and subspecialists, and extremely limited postacute care options and skilled nursing facility beds. To address the unique needs of our provider and patient population we began with a development period where we conducted stakeholder interviews. Using these data, we mapped out a workflow and developed pilot projects to address different portions of the workflow, such as preoperative screening for frailty and cognitive impairment, interdisciplinary weekly case conferences, proactive case management, delirium and geriatric surgery postoperative pathway order sets, and a variety of tools for reorientation and delirium management. Herein we describe the process of development and pragmatic clinical implementation of geriatric-focused care for older surgical patients in our rural tertiary center, including some of the main challenges we faced and the strategies we undertook to overcome them, and some of our early patient centered and clinical outcomes. This information may assist other institutions as they design geriatric-focused surgical programs to address the growing population of older adults and the need for compliance with state legislation. The clinical program described is not a research study, and the outcome data we report is for the purpose of description, and should not be interpreted as a rigorous research investigation of the effect of our intervention.