Article Archive
November/December 2014

Building From Within: 5 Strategies for Growing a Geriatrics Practice
By Donald J. Murphy, MD, FACP; L. Elane Shirar, MD; Shannon M. Tapia, MD; Genie H. Pritchett, MD; Debra Parsons, MD, FACP; and Christine McLemore, DO
Today's Geriatric Medicine
Vol. 7 No. 6 P. 10

Developing a thriving geriatrics practice that is both professionally and financially rewarding depends on calculated planning and specialized strategies.

Most older adults receive primary care from family practices, internal medicine practices, and specialists. Very few see a fellowship-trained geriatrician as a primary care provider. There's no reason to believe this trend will change. Further, we can expect more older adults to rely on nonphysician providers for their primary care. This is likely to be the case in most types of practices, including private practice, hospital-based clinics, and federally qualified health centers (FQHCs) as well as in nonhospital settings such as homes, assisted-living facilities, nursing homes, and in clinics.

This article will help practices develop a competent geriatric focus with the diverse primary care providers on your staff. A practice seeking to build geriatric services does not need a geriatrician. But it does need providers who like caring for older adults and their families. Developing a compensation plan that rewards, or at least does not penalize, providers who take the extra time to deliver good care to older adults and their families is the single most important element.

Starting Point
A practice needs at least one provider who expresses an interest in caring for older adults. The initials following the providers' names, such as MD, DO, NP, and PA matter little to most older patients. To build a geriatrics practice from within, you need a system that takes care of most needs of older patients, expecting that there will always be some who need more specialist engagement.

1. Allow Adequate Time
This is the most important aspect of creating effective geriatric care. Providers who express an interest in caring for older adults and allow adequate time to evaluate and treat will thrive. Patients and families appreciate the time and attention and will provide positive feedback. Practices that allow 15 to 20 minutes for a follow-up visit for elders with multiple comorbidities—the majority of patients in a geriatrics practice—often have frustrated providers. Patients, families, and providers all become dissatisfied when visits allow only enough time to skim the surface.

Practices that provide other services during a visit, such as pharmacy and social work consultation, allow patients and families to experience a team approach to important geriatric services. However, if providers rarely can spend extended time with complex patients, they are unlikely to embrace a growing panel of elders. As much as providers might want to focus on care of complex patients, they will likely feel like the proverbial mouse expected to run faster on the wheel. Without one or more providers who are enthusiastic about their work, a system cannot build geriatrics from within. Spending adequate time with patients, at least for some, is essential.

2. Devise Fair Compensation Strategies
The sweet spot for providers providing good geriatric care is 13 to 15 patient visits in an eight-hour day. This provides time for relatively straightforward visits, for extended visits (whether a new patient history/physical [H/P], or complicated follow-up visit), and for everything in between. Practices focusing on Medicare managed care may have additional resources to allow providers to see fewer elders per day, for example, 10 to 13. In any type of practice, whether traditional fee-for-service, Medicare managed care, or FQHC, a practice cannot expect a provider to render quality geriatric care if the sweet spot is set too high. If the geriatric champion is expected to see 20 patients per day, including many complex seniors, he or she is likely to burn out. The architect of the geriatric services will leave.

A fairly compensated geriatric champion who treats fewer yet more complex patients will likely thrive and succeed in building geriatric services. Before long, the practice grows beyond the walls of the clinic.

Three mechanisms allow for fair and attractive compensation for providers providing good geriatric care. The first is salary. A competitive salary allows a provider to focus on quality of care rather than simply on quantity of visits. The risk of offering an attractive salary is that a provider may not be as productive as he or she should be to build the practice. Incentives, with most based on volume, do matter. Successful practices find the right balance between salary and volume expectations. Further, successful practices prorate salaries so that providers can work part-time. Caring for the expanding population of older adults will require commitments from the growing pool of part-time providers.

The second mechanism is a relative value unit (RVU) plan. Practices can design RVUs that reflect the time needed for various visits. For example, a geriatric provider gets three RVUs for spending one hour with a complex patient and family. Her colleague who is seeing three follow-up visits in the same time period would get the same three RVUs. The geriatric provider is not being penalized for the time required to provide good geriatric care. Further, the geriatric provider can rotate from the lower volume (geriatric) segment of the practice to the higher volume (more traditional family practice and internal medicine) as desired and needed by the practice. An RVU plan makes compensation fair regardless of how much time a provider devotes to geriatric services. The real challenge of designing a fair RVU system lies in the accounting and human resource departments. It creates extra work for them. Clinicians can readily agree on a fair RVU plan. Practices that solve the accounting and payroll puzzles are the ones most likely to build geriatrics from within.

The third mechanism, though germane only for traditional fee-for-service, is compensating providers based on their thorough knowledge and implementation of evaluation and management (E/M) guidelines and time-based billing. Providers who know how to capture their work through good use of E/M and time-based billing will be compensated fairly for focusing on geriatric care (see website for MESA [Medicare Experts/Senior Access] at Although their compensation will not be as high as providers who are seeing 20 to 25 patients per day, the difference is not as great as many might believe. In short, the geriatric champion will not feel penalized for seeing only 14 patients per day. When she knows how to capture all of the work involved with caring for those 14 patients, she and her practice will feel fairly compensated for this geriatric service, and she will be incentivized to build the geriatric practice. An administrative bonus to recruit other providers to join the practice helps to extend the geriatric team from one to three or more providers. When a practice has three or more providers committed to geriatric care, it can extend beyond the walls of the clinic.

3. Expanding to Home Visits
Elders who have their primary care team follow them at home appreciate the full benefits of a primary care medical home. Home may be an apartment or a house, an independent living facility, a small group home, or an assisted-living facility (read further for nursing home care). Providers and patients know that home visits add different perspectives and offer comfort and convenience that might be difficult to match in a clinic visit.

Successful practices address the two key challenges of providing home visits. One involves logistics and overhead. Scheduling appointments, windshield time for providers, unexpected no-shows, and the like all cost time and money for the practice. The key to cost-effective delivery of home visits is geographic grouping. A practice providing home visits to patients in three assisted-living facilities near the clinic and some independent homes in the neighborhood can provide good service with relatively little overhead. In contrast, a practice providing home visits for four patients who live in different parts of a metropolitan area cannot do so cost effectively. A large practice or health care system may choose to subsidize the inefficiencies of starting a geriatric home visit program. This burden would be too great for a small practice.

The second challenge is fair compensation for the providers who perform the home visits. Again, this is the key strategy for building and sustaining successful geriatric practices. The providers have to be compensated for their travel time, whether via salary, stipend, RVU, or a combination.

Revenues from the Centers for Medicare and Medicaid Services are fair and attractive for home visits in a fee-for-service world. As long as providers know how to capture their work while providing home visits, the revenues cover the costs and can provide a thin margin. In a FQHC practice, the flat fee for any visit is not really sufficient to cover the costs of home visits. However, an FQHC may choose to subsidize home visits. Mission, satisfaction of patients and providers, reducing risk of inappropriate hospitalizations, and anticipation that payment changes will eventually cover costs for an FQHC are all compelling reasons to subsidize home visits.

Another compelling reason is competition. If a clinic-based practice or a large health care system operates in a market where other providers are providing home visits, the clinic-based providers can count on losing some of their patients to the providers offering home visits. When providers from a geriatrics practice show up and provide good services at an assisted-living facility, some of the other residents will likely shift to that geriatric practice, no matter how connected they may feel to their clinic-based primary care provider. It is much more convenient for patients, the families, and the facility's staff to establish care with a practice that provides home visits.

4. Expanding to Nursing Homes
Extending geriatric services from clinic and home-based visits to nursing home visits is more challenging in a large metropolitan area where patients may end up at various facilities for skilled and long-term care. Extending care to nursing homes is easier in a smaller community or in a large metropolitan area where patients associated with a large system tend to go to nearby nursing homes.

When the geographic grouping of visits is convenient, a provider can reach the volume goals—the sweet spot of 13 to 15 patients per day—with a good variety of visits. For example, a nonphysician provider might see 20 patients in the family practice clinic on Monday and see 13 on Tuesday, the day designated for geriatric services. He might see six elders in the clinic on Tuesday morning, six in the nearby nursing home (both skilled and long-term patients), and one at an assisted-living facility on his way home.

As in any other setting, the geriatric provider must know how to capture his work in the nursing home. He must know how to deliver and bill for a 10-minute visit, and he must know how to deliver and bill for a 70-minute visit.

Although providing services in nursing homes can be more financially rewarding for a practice, with the ease of seeing a higher patient volume within a smaller space and time than in providing home visits, it creates additional stresses for the practice. Three are worth noting, with the first being the volume of calls from nursing homes. The number of phone calls for 100 nursing home patients is significantly higher than the number of calls for 100 clinic and home-based patients. Someone has to take those calls in the middle of the night.

The second stress is the acuity of care provided in most subacute units, ie, the skilled beds in nursing homes. Many of the patients in subacute units in 2014 would have had longer hospital stays in 1994. Providers must feel comfortable with the acuity of care provided in most nursing homes.

The third stress involves the time pressure to see patients in nursing homes. This includes both the visits (H/P and follow-up) in subacute care and those (regulatory visits) in long term care. In most situations, the physician (not the nonphysician provider) is expected to complete the H/P within 72 hours of a patient's admission to a skilled unit. In some settings, the time window is shorter, for example, within 24 to 48 hours of admission. An example would be a nursing home in a large metropolitan area that accepts many Medicare managed care patients. In other settings, the time window is longer, for example, a nursing home in a small rural community. These time pressures are not as prevalent in a practice focusing only on clinic and/or home visits.

5. Building Geriatrics as a Recruiting and Retention Strategy
Many primary care providers have entered the field motivated to care for the whole patient, through the continuum of their patients' lives. Many of them desire to know their patients' medical and psychosocial problems on a deeper, more comprehensive level. Getting to know patients and their families by spending additional time with them, as well as visiting them in their homes, can lead to much greater professional satisfaction for many primary care providers. Over the last two decades, medicine has shifted toward a structure in which many providers often feel hurried and unable to dive into the deeper layers of patient care and human connection. By giving interested providers the additional time necessary to see geriatric patients, practices can open the door to greater provider satisfaction.

Practices should consider the financial and emotional costs of replacing unfulfilled providers, particularly those who can become disillusioned with the typical hectic office practice. Recruitment, provider training, waiting for provider efficiency to grow after starting, staff morale, and patient relationships are all expensive building blocks for any practice. Offering a reprieve from the typical time constraints in a primary care practice, if even for only one or two sessions per week, can improve provider satisfaction. This is often the best recruiting strategy.

Colorado Practice Example
Founded in 2007, Rocky Mountain Senior Care (RMSC) is a Colorado-based geriatrics practice. It grew out of four family practice clinics, the first of which opened in 1996. In 2007, RMSC had one provider dedicated to building geriatric services. It has now expanded to 54 providers focusing on geriatrics, with 30% of them working part-time. RMSC has the honor of providing primary care for patients in more than 400 facilities statewide. Compensation is based on salary plus a productivity-based bonus. Elane Shirar, MD, is the founder and owner of RMSC. Don Murphy, MD, and Shannon Tapia, MD, work as part-time geriatricians for RMSC.

Continuous Learning
As noted earlier, fellowship training is not necessary to build a successful geriatrics practice. A physician or nonphysician provider dedicated to older adults and continuous learning can build a successful geriatrics practice. Learning comes from experience and a disciplined review of the medical literature. Sources that are particularly useful in that respect include the following: The Geriatrics Review Syllabus from the American Geriatrics Society; articles and reviews from the major medical journals (eg, JAMA, Annals of Internal Medicine, New England Journal of Medicine); articles and reviews from specialty journals (eg, Journal of the American Geriatrics Society; local grand rounds, if available; local publications focused on care of elders (eg, MESA's Clinical Pearls and Protocols at; and continuing medical education courses devoted to geriatrics.

Providers cannot keep up on everything, but disciplined review of selected resources will give providers the knowledge and confidence to build a successful practice.

Collective Experience
Good geriatric care can often involve an approach that could be considered counter culture. A high-touch, low-tech approach might not sit well with some families, primary care providers, and specialists. Successful geriatric providers take the time to weigh the competing interests and find good compromises for their patients.

As in any other field of medicine, confidence is important. Confidence comes with experience, and experience takes time. A young provider may have the passion and tools (specifically, administrative support) to build a successful geriatric practice from within, but she will not have had the experience and confidence to impart to the patients, staff, and colleagues to build a thriving practice.

She need not wait 10 years to gather that individual experience. She can gather the collective experience of her medical colleagues, office and triage staff, and specialists. Team meetings, case studies, sidewalk chats (HIPAA compliant), and phone calls all contribute to building the collective experience and confidence.

Trends in America suggest that more care of older adults will fall upon non–fellowship-trained family practitioners, internists, and nonphysician providers. In the standard outpatient practice, this may seem like a daunting challenge given the expectations for patient turnaround and time constraints. Creative solutions exist for nonspecialist providers to have appropriate support and compensation for providing excellent geriatric care. If you build it, they will come, especially if few other practices in the community are building geriatric services.

— Donald J. Murphy, MD, FACP, a practicing geriatrician, is the medical director of Medicare services for Colorado Access in Denver.

— L. Elane Shirar, MD, is the founder and owner of Rocky Mountain Senior Care in Golden, Colorado.

— Shannon M. Tapia, MD, is a practicing geriatrician in Denver.

— Genie H. Pritchett, MD, a practicing internist-geriatrician, is vice president of medical service for Colorado Access.

— Debra Parsons, MD, FACP, an internist-geriatrician, is a senior medical director at Colorado Access and a clinical professor in the department of medicine at the University of Colorado School of Medicine.

— Christine McLemore, DO, a practicing family physician, is medical director for Metro Community Provider Network in Englewood, Colorado.