Geriatric Medicine and Long-Term Care Best Practices

01Purpose and scope

This manual supports the course Geriatric Medicine and Long-Term Care. It describes how clinicians, nurses, therapists, social workers, and care staff work together to evaluate and manage older adults who have multiple chronic conditions, declining function, or ongoing needs for support at home, in assisted living, or in skilled nursing settings.
The manual covers the routine work of geriatric assessment, care planning, medication oversight, transitions between settings, documentation, and quality monitoring. It does not cover acute emergency care, end-of-life legal documents in detail, or pediatric and adult specialty care, although those topics overlap with daily practice. Clinical decisions for an individual patient always rest with the licensed clinician responsible for that patient.
Practice differs considerably between a primary care clinic, a memory care unit, a home health agency, and a large skilled nursing facility. Staffing ratios, reimbursement rules, licensing requirements, and reporting duties vary by jurisdiction, so readers should confirm current requirements with their state or national regulator, their employer, and the authoritative source named in their own organization's policies.

02Core principles

Geriatric practice starts from function rather than diagnosis alone. Two people with the same heart failure diagnosis may need very different plans depending on whether they can climb stairs, manage their own medications, recognize early symptoms, and get to appointments. Assessment therefore looks at mobility, cognition, mood, continence, nutrition, sensory function, social support, and the goals the person actually values.
Older adults often present atypically. Infection may appear as confusion or a fall rather than fever, and pain may show up as agitation or reduced eating. Practitioners learn to treat sudden change in behavior or function as a finding worth investigating, and to compare the person with their own recent baseline instead of with a textbook norm.
Polypharmacy and deprescribing are central concerns. Many older adults take five or more medications, and each addition carries interaction, falls, and kidney clearance risks. The American Geriatrics Society Beers Criteria is a widely used reference for potentially inappropriate medications in older adults, but it is a screening tool, not a substitute for the prescriber's judgment about a specific patient.
Shared decision making and goals of care guide the plan. A care plan that the resident or family cannot follow, or that conflicts with what the person considers acceptable, usually fails regardless of its clinical logic.

03Planning and preparation

Before a first visit or admission review, gather the available records: the problem list, recent hospital discharge summaries, the current medication list with the dispensing history, prior functional assessments, advance directives, and contact information for the health care proxy or designated decision maker. In facilities, this also means reviewing the admission packet, the resident's prior living situation, and any incident reports from the preceding weeks.
Decide early who will attend. A useful planning conversation includes the clinician, a nurse or care coordinator, and the person receiving care whenever possible. Family members, a pharmacist, a rehabilitation therapist, or a social worker may be added depending on the questions. Confirm the person's preferred language, hearing and vision needs, and whether they need an interpreter or large print materials.
Plan the environment as well as the visit. Schedule longer appointments, allow for rest breaks, and arrange transport or mobility aids in advance. For cognitive screening, choose a quiet room with adequate lighting and make sure glasses and hearing aids are in use. Tools chosen for convenience, such as a short questionnaire completed by a family member without the patient present, have limits and should be labeled as proxy information.

04Recommended workflow

1
: Confirm the reason for the encounter and the person's own priorities. Ask what matters most to them in daily life, such as remaining at home, sleeping through the night, or attending a grandchild's event, and record their words rather than a summary.
2
: Complete a structured geriatric assessment. Typically this includes a review of systems, medication reconciliation, cognitive screening with a validated tool, depression screening, a falls risk review, activities of daily living, instrumental activities of daily living such as managing finances and using a telephone, nutrition and weight trend, continence, pain, and hearing and vision. Each domain should lead to a documented finding, even if the finding is that no problem exists.
3
: Perform a focused physical examination and relevant tests. Check orthostatic blood pressure when dizziness or falls are reported, examine feet and skin for pressure injury risk, and review recent laboratory values such as kidney function and sodium. Order tests only when the answer would change management.
4
: Reconcile medications line by line. Compare what the person says they take, what the bottles show, what the pharmacy dispensed, and what the chart lists. Identify duplicates, high-risk agents, anticholinergic burden, sedatives, and drugs started for a problem that may have resolved. Record a decision for each medication: continue, change, taper, or stop, with a reason.
5
: Set goals and write the care plan. Each goal should name a function or condition, a measurable target, a responsible person, and a review date. For example, a goal might be to walk to the dining room with a rolling walker twice daily with no more than one standby assist within four weeks. Avoid goals that are vague or cannot be observed.
6
: Communicate the plan. Give the person and their caregiver a written summary in plain language, including what changed, what to watch for, and whom to call. Send the plan to the pharmacy, home health agency, or facility nursing staff so that instructions match.
7
: Schedule follow-up and define escalation. Specify which changes need a call within a day, such as new confusion, fever, a fall with head strike, or reduced urine output, and which can wait for the next visit. Confirm that the person knows the after-hours number.

05Quality checks, risk controls and compliance

Quality work in geriatric care relies on a small number of recurring checks. Medication reconciliation should be repeated at every transition, including admission, discharge, and any change in prescriber. Fall risk screening should be repeated after a fall, a new medication, or a change in mobility. Pressure injury risk and nutrition status should be reviewed on a schedule set by the facility or agency policy.
Risk controls include restraint minimization, fall prevention plans, hypoglycemia precautions for people on insulin or sulfonylureas, delirium prevention bundles, and careful management of anticoagulants. Restraint use is tightly regulated in many settings, and most jurisdictions require documented clinical justification, monitoring, and periodic reassessment. Confirm current rules with the relevant state survey agency or national health authority.
In the United States, certified nursing facilities complete the Minimum Data Set assessment and follow the Resident Assessment Instrument process, and home health agencies use their own assessment framework. Other countries and provinces use different tools and reporting obligations. Staff should know which instruments apply to their setting and who signs off on them.
Privacy and consent rules apply to every record. Share information with family only as permitted by the person's consent, the proxy document, or applicable law. This guidance does not replace qualified professional judgment, approved facility procedures, or any required authorization for a specific patient or setting.

06Collaboration and documentation

Geriatric care is team work. The clinician sets the medical plan, the nurse monitors symptoms and medication administration, the pharmacist reviews interactions and dosing, the therapist designs mobility and self-care programs, the social worker addresses finances, housing, and caregiver strain, and the aide carries out daily care and reports changes. Each role should know the others' concerns and the threshold for calling them.
Documentation should be specific enough that a covering clinician at night can act on it. Replace phrases such as doing well with observable findings such as ate about half of lunch, walked to the hallway with one standby assist, and slept four hours with two awakenings. Record the source of information, especially when a family member or aide reports something the resident did not confirm.
Handoffs deserve a standard format. Many teams use a structured tool such as SBAR, which covers situation, background, assessment, and recommendation. Use the same format at shift change, during transfers, and when calling a physician after hours. Keep the handoff short and include the time, the person's goals of care, and any code status or treatment limits.

07Measures and continuous improvement

Useful indicators include the rate of falls with injury, unplanned rehospitalization within a defined window, the number of residents on high-risk medications, the proportion of medication reviews with a documented decision for each drug, pressure injury prevalence, and the share of care plans with measurable goals. Track these on a run chart or control chart so that a team can see trends rather than reacting to single events. Define each measure precisely before collecting data, including numerator, denominator, and time period.
Continuous improvement works best with small tests. A unit might introduce a pharmacist-led medication review on admission for two months, compare the number of medication changes and adverse events with the prior period, and then decide whether to continue. Be cautious about small sample sizes, changes in case mix, and seasonal patterns, which can make results look better or worse than they really are.
Limits matter. Some outcomes, such as functional recovery or quality of life, are slow to change and hard to attribute to a single intervention. Some measures can be gamed, for example by reducing documented falls without reducing actual falls. Pair outcome measures with process measures and direct observation, and review results with frontline staff who can explain what is happening on the floor.

08Common mistakes and how to prevent them

A frequent error is treating every new symptom as a new disease. An older adult with a sudden drop in appetite may have a medication side effect, constipation, depression, dental pain, or early infection. Build a habit of checking the medication list, bowel pattern, mood, and recent changes before ordering tests or adding a drug.
Another error is stopping medications abruptly without a plan. Some drugs, including beta blockers, benzodiazepines, and certain antidepressants, can cause withdrawal or rebound symptoms. Deprescribing should be gradual where needed, with a written schedule and monitoring for the symptoms that prompted the drug originally.
Teams also lose information at transitions. A discharge summary that lists a new diuretic without a weight monitoring instruction, or a facility that does not receive the updated anticoagulant dose, creates predictable harm. Use a checklist at each transition, confirm the receiving team has the list, and ask the person to repeat back the key changes.
Finally, care plans get copied forward without review. Goals written at admission may no longer fit a person whose function has improved or declined. Schedule reviews, and treat a plan that has not changed in months as a prompt to ask whether it still matches the person's goals.

09Practical checklist

Confirm the person's priorities and goals in their own words before making changes.
Gather prior records, the current medication list, and the names of any proxy or decision maker.
Complete a structured geriatric assessment covering cognition, mood, function, falls, nutrition, continence, pain, hearing, and vision.
Reconcile every medication against bottles, pharmacy records, and the chart, and record a decision for each one.
Screen for delirium, orthostatic hypotension, and recent infection when behavior or function has changed.
Write goals that are measurable, assigned to a named person, and scheduled for review.
Give the person and caregiver a plain language summary with clear warning signs and contact numbers.
Send the updated plan and medication list to every team member and outside pharmacy or agency involved.
Check restraint, fall prevention, and anticoagulant plans against current facility policy and applicable regulations.
Review quality indicators regularly and discuss results with frontline staff before drawing conclusions.

★Learning sources

Micro Degree: Geriatric Medicine and Long-Term Care
Micro Degree: Healthcare Administration Practice
Micro Degree: Physiotherapy Assistant Operations
Micro Degree: Cardiac Care Support

?Frequently asked questions

How often should medications be reviewed for older adults in long-term care?

Medication reconciliation should happen at admission, at every transfer between settings, after any hospital discharge, and whenever a new prescriber takes over. Many facilities add a scheduled pharmacist review on a fixed interval set by policy. The exact frequency and documentation requirements depend on the jurisdiction and the setting, so confirm them with the facility's medical director or the relevant regulator.

What should I do if a family member disagrees with a proposed deprescribing change?

Start by asking what the family member is worried about and what they have observed at home. Explain the reason for the change, the expected benefit, and the warning signs to watch for, then offer a trial with a set review date. If the person has decision-making capacity, their wishes take priority, and if not, follow the documented proxy or legal decision maker and the facility's ethics or escalation process.

Are screening tools like cognitive tests enough to diagnose dementia?

Screening tools identify people who may need a fuller evaluation but do not establish a diagnosis on their own. A diagnosis usually requires history from a reliable informant, functional assessment, exclusion of reversible causes such as medication effects, thyroid disease, and depression, and clinical judgment by a qualified clinician. Results can also be affected by hearing, vision, language, education, and acute illness, so interpret scores in context.

How do I decide between home care and facility-based long-term care?

Begin with the person's goals, the level of help needed for daily activities, the safety of the home environment, and the availability of caregivers. Compare the cost, staffing, and clinical services of each option, and check which services are covered under the local payment system. This decision is shaped by local rules and available resources, so consult the relevant social services agency and a qualified clinician before recommending a placement.