Table 2 Key findings with example quotes. The participant number is followed by a letter, which indicates the participant type (P = patient, C = caregiver, G = geriatrician, R = referring physician, and M = health manager). 

Theme 1: Challenges in navigating the healthcare system for older adults

System navigation and wait times

“No obstacles [in getting a CGA], but just in terms of getting… you know, an appointment took a long time… The whole process of getting [wife’s name] diagnosed it took maybe two years… all together two years.” – 13P

Shortage of geriatricians

“I think that’s a massive problem… I think that geriatricians are the best doctors for the patient population that we have now, and that we’ll have for the next 30 years. I really do feel like we’re the only ones who have the training to put together these comprehensive plans for older adults… I’m a big believer in the value of geriatricians in the next 20 to 30 years as… gatekeepers to health resources… I think that that is very bad and terrifying that the match rate is so low.” – 04M

Demoralization of health care providers

“So you know, specialists are demoralized, because they realize they cannot see their patients in a timely way. Like, you know, our waitlist in geriatric medicine is ridiculous. Like we realize it’s foolhardy. You know, someone who’s, you know, [got] an eight month waiting list or whatever it is, you realize that you’re not seeing them, they may not live eight months. So it’s ridiculous, but we do it because we don’t have a way to solve it right now. So like I said, that’s why I think we need real disruptive change. And I’m hopeful that it will happen. It won’t happen from politicians, it’ll happen from us.” – 19M

Big G little g

“I think one of the ways is when all physicians are getting training, whether it’s in hospitalist medicine or internal medicine or surgery, they should all go through a robust geriatric rotation. Because once they are on a consulting geriatric rotation, and they see what our benefits of our services, what we can do, and how we see things from our lens, then those, when they become clinicians in the future, they will remember their training, how geriatrics was very helpful.” – 02G

Cost as the common denominator in hospital decision making

“How do you motivate hospitals? Like it all comes down to money, right? It’s actually not about like patient care. It’s really about money.” – 04 M

“If there’s donations targeted to seniors’ care, that would certainly incentivize the hospital more. I think ultimately just the general public expressing more of an interest in seniors’ care, which is unfortunately, I think something that again is not a very shiny area for people to focus on. So, you know, you do see a lot of interest in, for example, fundraising or donations for paediatric care, but seniors’ care tends to be a little bit in the shadows.” – 09M

Outcomes that hospital managers want to see

“And a lot of our system is focused on, you know, again, reaction as opposed to prevention. Partly because preventative medicine, obviously there’s a long time for us to actually see the impact. So it’s like you invest now and you see the benefit in 10 or 15 years, which for governments and institutions might be too long a frame for leaders and executives.” – 20M

Older adults as a priority for hospitals

“There’s a lack of appreciation for what we can offer the geriatric patients that our hospital serves. I think a lot of lip service is paid to being geriatric/senior friendly, that kind of thing. But when I start asking things like, hey, I’d really like to run another clinic on Thursday afternoons, I can hire a new geriatrician, but I would need nursing support, I need a room, I need a room potentially for a resident, a learner with them. Suddenly, it falls on deaf ears. So I guess that has been an ongoing frustration the whole time I’ve been division head, that we’re just not resourced appropriately.” – 06M

“It’s just the noise, the hustle, the bustle and everything rather than just going and sitting in a waiting room in a doctor’s office. And it’s a friendlier atmosphere rather than feeling like you’re being passed by. You don’t know why you’re at the hospital.” – 18C

“You don’t want it to be ducked away at the way the last floor of the building… like I’m going to send you into a funeral parlour. It should look like the rest of the of the hospital, it should not be a downgrade.” – 22P

Countering ageism in society at large

“I mean, at one time, elders were honoured. They were important. Society, a lot of societies, they were very important. Now, they just become old and useless.” – 21P

Theme 2: Varied perceptions of the impact of a CGA

Benefits of a CGA

“The benefits of seeing everybody with frailty in the hospital… I honestly think hospital stay would be decreased tenfold. I think you’d see bounce back rates to go down by at least 20 to 30% for these patients. I think patients would have incredible medical literacy, at least as they left hospital in terms of how to… really take hold of their own health and wellbeing. It would enable us to properly provide safer doses of chemotherapy… I also think it would be a blessing for family physicians that often get the brunt of discharge summaries that are often lackluster from surgical services.” – 10R

“[The geriatrician’s] bedside manner and the way she talked to me and she could tell that I might not be understanding what she’s saying and she would say, ‘okay, let me take a minute and explain that to you’… I think she did more than listen. I think she listened with her body if that makes any sense to you…. I’d also add to that that I think it’s important that everybody experiences what I experienced with that [geriatrician].” – 16P

Perceived consequences of a CGA

“I see geriatric notes that are five and six and seven pages, and I’m astounded… I think the geriatricians know my patients better than anyone, right? But I would have to ask my geriatrician colleague, do they ever get a sense that perfection is the enemy of the good? I’m sensitive to the importance of probabilistic thinking or Bayesian reasoning in our practice of medicine, right? We approach certainty asymptotically, right? Never to arrive, right? But we don’t ever get there. But each step closer and closer towards diagnostic certainty, right, comes with greater expense, greater time, and oftentimes greater risk, right? And I think individuals probably have a different comfort level for how much uncertainty they’re

willing to live with in the practice of medicine.” – 03R

“From a surgeon perspective, um, not all surgeons want all of their patients to be seen by med consults or geriatrics, for example… cause I think they probably worry that it lengthens their hospital stay. I’m just being honest.” – 12R

Awareness of evidence for a CGA

“The benefits of the CGA are probably not very widely known. So, from a political point of view, for sure it’s not well known. But even in the medical community, probably honestly, if we really put it, including myself, probably even among geriatricians who provide CGAs, we probably like… if I was to sit down and I had to list out the benefits or if you gave me a list of like 50 potential benefits that are evidence-based and maybe 20 of them are true. I probably wouldn’t be a 100% correct. I don’t even know myself… I know a lot of family docs don’t even refer to geriatrics because they don’t really know what the point is because, you know, the opinion is sometimes, well, you can’t treat it.” – 07 M

“Well, I mean, you could do it through, I mean, you know, telling regular doctors that this is a service. I mean, does everybody, every GP know this service exists?” – 23P

Out of pocket payments

“$75 for a workbook… [Learning] the ropes memory book. And…transportation, you know TTC [public transit in Toronto] that’s it.” – 13P

“I’m driving down, paying for parking, driving my dad back. So really the cost of it for him, he takes the taxi or the TTC [public transit in Toronto], um, and then transportation. And for me, it would be just like my time, which, you know, time off work.” – 15C

Theme 3: Divergent views on healthcare setting for CGA

Acute care as priority

“To me it would be quite clear that it should be absolutely in the hospital so acute care. Outpatient clinics, I think the other roles from my impression could be completed by somebody else who gets extra training like a family doctor or maybe a nurse practitioner. But in the hospital, there is a degree of complexity that requires a geriatrician for sure.” – 05R

“I think I like inpatient work more than outpatient, which has come and gone throughout my career, but I’m kind of like more of an inpatient phase right now. And I’ve had arguments with my colleagues about this because some of them feel very strongly we should just be an outpatient-based specialty. But I don’t know, my gut instinct is I think we can do the most. I really do think we can do the most as an inpatient consultation service.” – 06M

“From my perspective, inpatient… because as a surgeon, that’s where I see most of my patients. Very little is done of impact in the outpatient setting that doesn’t also centre around an inpatient admission. So I think for me, that’s very important to have that support to really get patients in and out as safely and quickly as possible through their surgical admissions.” – 08R

Community clinic as priority

“I think maybe the outpatient setting to be honest. I think if I look at the work I do in acute care a lot of it is just good internal medicine and an understanding of geriatric syndromes, which I think those that have an affinity for care of older adults can probably do a pretty decent job in collaboration let’s say with a clinical nurse specialist who has additional training in older adult care and services that are available around the city. I think often in the acute care setting the comprehensiveness of our consultation notes are probably not as good as those in the outpatient setting where we have dedicated time to speak with family members, the patient themselves when they’re well and is able to communicate to us kind of their value goals and symptoms.” – 11G

“I actually think that the greatest value in terms of geriatric specialty knowledge and comprehensive geriatric assessment is probably in a setting that’s community-based and ambulatory, where you’re actually working on more preventative medicine.” – 20M

Rehabilitation as an option

“But I would say that at least in our environment here, there’s a huge need to support the community and older adults living at home. And so, when you work in a rehab hospital like ours, where you’re supporting things like a falls clinic or outpatient program, which supports family doctors, and then our inpatient setting, which also supports transition back to the community. And we also admit patients directly from the community. You’re also supporting older adults to live at home. And I think that’s a huge need at this time, where we don’t have enough long-term care beds, we don’t have enough often home care support. So, helping the community and older adults stay out of hospital, I think, is a really important part of a geriatrician’s role. Not to say you’re not needed in acute care, but if we can keep older adults out of hospital, then you won’t have to see them in acute care.” – 14M

“It’s just because we have a pretty supportive system already. You know, I love having the geriatricians, and they add a lot. But if I had to, if I were sitting as king of the healthcare system, I would direct them to other places instead. My selfish interest is to have them in rehab for my patients. But if I, you know, if I take that away, then I think they have a really big impact in these other locations. Right. So, a greater impact if they’re not provided at those other two settings.” – 26M

Work exposure to all settings

“I do [like to work in all of the settings]. And that’s always been a personal preference, because I feel like we can’t be out of touch with what happens. Right? Like, you know, the reason why they don’t know what happens, like internists have, I’m not trying to like, you know, you know, like bash my internal medicine colleagues, but basically, because, you know, they haven’t done a lot of the outpatient stuff. And they don’t know really what happens. They don’t step foot in a rehab facility, they don’t know what is available there. Right. And so I think that people need to work through the whole system. Like, that’s how we kind of know what actually works and what doesn’t. And, we need better collaboration instead of being siloed, right between our institutions and our specialties.” – 25G

Facilitators to implementing the CGA

“An efficient EMR [electronic medical record] has definitely helped me. I’ve used different ones. Having someone who would do parts of it like. Say if an OT [occupational therapist] like on the ACE [acute care of the elderly] team already did the cognitive assessment, then that saves me time. If you have a nurse who can help you with figuring out their medications, gathering history, social history, baseline functioning, I think those things would help.” – 01G

“I think strong advocates on the units, whether they are charge nurses, whether they are allied health providers, whether we have some very strong-headed social workers, sometimes physio and occupational therapist, like from allied health, they’ll say, ‘Hey, listen, this person has Parkinson’s. Can you please get the geriatrician to come and assess this patient?’” – 02G

“So at our hospital, the one thing that facilitates it is we have something called a delirium team. So a delirium team is, it’s essentially like an occupational therapist at each site. We have standard CAM [confusion assessment method] scores that are done on every patient by the nursing staff, not always accurate, but they’re done. And then if a patient has two consecutive positive CAM scores, the delirium team gets flagged. And their role is to, number one, like see the patient, assess for delirium, educate the staff on how to prevent and manage delirium from a non-pharmacologic perspective. But they also act as flags when they see a patient, given their experience with geriatrics, to say, this person should see a geriatrician.” – 04M

“I think hiring more geriatricians, having more residents and fellows, um, on the service, having, um, a nurse practitioner as well, I think is probably also incredibly helpful.” – 12R

“If we didn’t have such a health care shortage in general, like if I was thinking like what would be the ideal, I think this is what it should be. [Once] you get to a certain age, you get a referral [and] you keep your main physician, and… they are part of your team. I think that’s probably the best practice… like [a] best in class… model.” – 24C

Barriers to implementing the CGA

“Yes, I think I appreciate that geriatricians right now, we have a more consultative model, in that we do a great CGA, it’s detailed, it’s comprehensive, but we tend to leave the recommendations with the hopes that there’s other community partners who can help implement that. But I think the reality is we have to recognize that in the limitations of our system, you can’t expect that there will be someone there to implement those recommendations.” – 09M

“I do wish that the outpatient clinic was a bit more willing to follow some patients more longitudinally over a year or two, for example. I find that like many other clinics, it tends to be a single consultation and then return to family doc, which may be appropriate, but, um, you know, I, when I see the patients for followup, often most of the recommendations have not really been carried out.” – 17R

“[Without a team, ] I think you’ll have a lot of turnover [of healthcare providers], and I think you won’t have as much interest from people. New [geriatrician] grads don’t want to work at a place where they’re totally isolated. Gone are those days. I don’t even want to work in a place that I don’t have any other team support or other geriatricians as a new grad, right?” – 27M