This study advances knowledge regarding the dynamics of older adults’ accompaniment to routine physician visits by providing the first empirical evidence as to its co-occurrence with receipt of ADL or IADL task assistance and its persistence over time.. We found nearly one-third of community-dwelling older adults were accompanied by a family companion during routine physician visits, of whom less than half received ADL or IADL assistance. Family companions who also provided ADL or IADL task assistance were more regularly present and actively engaged in routine physician visit processes. Persistent accompaniment of older adults to routine physician visits was found to be the norm rather than the exception. Three-fourths (76.3%) of older adults who were accompanied to physician visits in 2005 continued to be accompanied in 2006, almost always (87.1%) by the same family companion.
Although family is acknowledged as important for the health care workforce for an aging America,1
productive chronic care interactions, 3, 4
and the patient-centered medical home,5
surprisingly little is known about family involvement in health care delivery processes. A small evidence base finds nearly 4 in 10 disproportionately old, sick, and less educated patients are accompanied during routine physician visits,2
and family companion presence to be influential to valued patient endpoints.2, 7, 8
Our study extends this literature in documenting that accompaniment most often persists longitudinally, that more than half of accompanied older adults are functionally independent, and that family companions are more verbally active when accompanying functionally disabled patients who receive ADL or IADL task assistance. Several national quality initiatives argue for more effective integration and partnership between health care professionals and patients’ families and friends,4, 5, 19
highlighting a need to advance “best practice” professional educational competencies and provider practice infrastructure to facilitate effective patient-family-provider partnerships. 11, 20
We are unable to comment on activities or processes beyond those specified in the MCBS, but it is reasonable to speculate that accompanying helpers who are consistently present and involved in physician visit communication may be better prepared to facilitate health care management activities at home and in the community.21
For example, the MCBS does not field questions regarding medication management, but it is plausible that some number of accompanying family companions assist patients with medications. To the extent that physicians discuss medication names, treatment effects, and intended outcomes during physician visits, we surmise that the presence and engagement of family members during physician visits might benefit desired outcomes such as medication adherence, safety, and information exchange between physicians.
There is a growing awareness that families commonly help coordinate care across a fragmented health system.1, 13, 22
The range of activities they assume, in what settings, and under what circumstances requires further investigation. The fact that 41% of accompanied older adults receiving task assistance were hospitalized during the calendar year confirms the relevance of family to transitional care efforts. Identifying strategies and resources that prepare family companions for the roles they assume in physician visits and in chronic disease self management also merits consideration. For example, decision aid interventions have been found to benefit patients’ knowledge and participation in treatment decisions.23
The extent to which families already assume relevant “coach” functions,24
and the potential to further develop family companions’ skills to motivate patient engagement in treatment decisions and self management has to our knowledge been unstudied.
This study establishes that older adults are commonly accompanied during physician visits by the same family companion, and that such arrangements most often persist over time. Results substantiate the importance of health care workforce initiatives that advance the patient-family-physician partnership.10–12
Most health care professionals receive limited formal training to prepare them for interactions with an accompanied patient-family companion dyad.11
Guidelines and competencies for optimizing professional health care workers’ interactions with patients and their “family caregivers” have been recently advanced by, or on behalf of, several physician, nurse, and social work professional societies.12, 20
Results from this study confirm the practical importance of these initiatives, and the potential benefit of educational innovations that prepare physicians and other health care professionals to interact with accompanied patients and the broad range of family companions involved in their care.
We found variability in the scope of assistance received by accompanied older adults, the behaviors assumed by family companions during physician visits, and the temporal stability of the patient-family companion dyad. Indicators of accompanied older adults’ vulnerability, including age, education, and numbers of chronic conditions were associated with receipt of task assistance as well as persistence of accompaniment at one-year follow-up. Although spouses were most consistently involved in the capacity of family companion during physician visits, older adults accompanied by an adult child were most likely to be persistently accompanied at one year. That family companions exist within a broad and dynamic social network, with greater fluidity in adult child involvement is consistent with what has been reported in regard to ADL and IADL assistance provision.25
Collectively, findings suggest merit to developing effective strategies that build the capacity of patients within the context of their existing support systems13, 26
and that improve information transfer and care coordination across both professional and lay caregivers.5, 22, 27
The role of family companions who accompany older adults to physician visits without providing ADL or IADL task assistance has been less recognized to date. Our results indicate that more than half of family companions, most often spouses, fit this description. Although these family companions were less active during physician visits, it is not clear that implications of their presence is less influential in regard to patient-provider communication or outcomes of care. A complex set of issues preclude broad generalizations in regard to patient-family provider communication dynamics, including the nature, severity, and sensitivity of conditions being managed, patient concerns regarding confidentiality, variability in family dynamics, and the roles and behaviors assumed by family companions outside the physician office.26
In light of the high prevalence of older adults’ accompaniment to physician visits, there is a striking lack of knowledge regarding optimal approaches and supportive infrastructure to facilitate productive patient-family-provider partnerships that are responsive to patients’ needs and preferences. For example, systematic elicitation and documentation of patients’ authorization for information access (preferably in an electronic health record) would benefit family companions seeking medical information for the purposes of coordinating patients’ health care or adjudicating insurance documentation, and for patients or health care professionals concerned about ensuring patient privacy.28
Several limitations of this study merit comment. Although the MCBS provides a wealth of information from a nationally representative sample, information regarding helpers and helping arrangements was sparse. We were unable to examine hours of care, attitudes toward provision of care, whether helpers were paid, or their gender, education, age, or employment. Because we could not differentiate between proxy respondents who were also family companions, we were unable to ascertain the extent to which proxy reporting introduced measurement error or bias to study findings. Questions regarding receipt of assistance are fielded annually; therefore analyses regarding the extent to which helping arrangements persist were necessarily one-year in duration. We were unable to empirically examine family companion involvement in conjunction with recovery from health event, (e.g. discharge from the acute hospital), or their exchanges with physicians or physician practices by phone or email. Articulating the evolution and trajectory of helping arrangements was beyond the scope of this study.
Our study is particularly important in the context of recent efforts to establish the patient-centered medical home. Although the patient-centered medical home conceptually encompasses family, and places the “patient and his or her family at the center of care”5, 6, 27
the extent to which the medical home infrastructure extends to patients’ families has not been well articulated. In establishing that older adults’ accompaniment to routine physician visits typically persists over time in the presence of actively engaged and consistently involved family companions, findings support recent effort by the Centers for Medicare and Medicaid Services to improve care for individuals with multiple chronic conditions4
and to better equip families with information and resources (e.g., www.Medicare.gov/caregivers
). Efforts to advance the “patient and family-centered” medical home5
make now an opportune time to expand the evidence base around how
physicians, physician practices, and other health care providers might partner with older adults’ existing family supports – who are already present, actively engaged, and consistently involved in care provision.