Family Caregiver Assessment in Primary Care: How to Strengthen the HealthCare Triad?

Family members have long been important yet underrecognized participants in medical encounters between older adults and their physicians. The recognition of family caregivers as “hidden patients” in geriatric care encounters first arose in the published literature about 30 years ago, which led to the emergence of the concept of the “healthcare triad” in gerontology and geriatrics to describe encounters and interactions among older patients, family caregivers, and physicians, including in the context of dementia care. In the early 1990s, the American Medical Association (AMA) officially recognized the pivotal role primary care physicians could play in helping to alleviate the adverse effects of family caregiving. The AMA called for healthcare partnerships between family caregivers and primary care physicians and recommended medical education and healthcare reimbursement initiatives to encourage physicians to use the partnership model. More recent studies have reaffirmed the critical role of family caregivers as participants in medical visits with older adults generally and for persons living with dementia in particular. Older adults report being more satisfied with outpatient medical visits when they are accompanied by family members or other companions than when they are not. Older adults also report that physicians engage in more communication about their conditions when they are accompanied to medical visits, and these trends are the strongest for older adults in the poorest health, including those with cognitive impairment. According to a recent study, the vast majority of primary care practitioners recognizes the value of family caregivers as participants in older patients’ outpatient visits. Given this enduring theme of involving family caregivers in medical encounters with older adults, it is tempting to conclude that, in the year 2020, primary care physicians, including geriatricians, routinely determine the needs of family caregivers when caregivers accompany older adults to office visits. In this issue of the Journal, Riffin and colleagues report results from a recent national survey of primary care physicians, the majority of whom were in private practice, suggesting that positive strides have been made but that considerable improvement is needed in how physicians support family caregivers of their older patients. Although the response rate in this study was disappointingly low (22%), and the sample size in this study was quite modest (62 geriatricians and 44 general internists), the authors made the most of the data they gathered and cast their findings and recommendations nicely within current practice and policy trends regarding ongoing barriers and facilitators to assessing the needs of family members of older patients. Their study revealed that physicians most often engaged in unstructured discussions with caregivers about their needs and concerns, lack of time was by far the most common barrier to assessing caregiver needs, and access to easier and better referral mechanisms to community resources were the most sought after facilitators to help caregivers. It would be useful to know how respondents from private practice settings compared to those practicing in academic and community health center settings as those in the former settings are less likely to have clinical or administrative support staff available to provide patient or family education regarding community support services. A particularly surprising study finding was few differences between geriatricians and general internists in their responses to survey questions. Because geriatricians treat older adults exclusively, this unexpected study finding prompts the question of why geriatricians perform no better than internists in their caregiver-related practice behaviors. The incorporation of caregivers into the longitudinal clinical experience of care for older patients is embodied in geriatric fellowship curricular milestones. Training expectations include managing psychosocial aspects of care, including interpersonal and family relationships (Milestone 23), and assessing and incorporating caregiver needs and limitations, including caregiver stress, into care management plans (Milestone 24). Clinical practice guidelines that embody these training expectations, both for trainees and practicing geriatricians, could lead to protocols for incorporating more structured discussions with family caregivers into office visits. Assessment of caregiver needs and referral practices in primary care have received the most attention in the dementia care literature, but frailty, more broadly, and multiple chronic conditions among older patients in the absence of dementia bring caregivers to physician encounters; much less is known about caregiver involvement in these medical DOI: 10.1111/jgs.16994