The complexity of multimorbidity and polypharmacy.

The participants, especially the physicians, referred to older patients’ health status mainly as complex and limited and, consequently, challenging. In particular, they described multimorbidity and polypharmacy, causing more intensive care and time effort, limitations of mobility and care options, special attention regarding adverse events, and also the perception that older people themselves feel overstrained or helpless because of their medical complexity. It was further described that most disease-specific guidelines did not consider complex conditions such as multimorbidity or frailty and, therefore, were not useful in these situations. These circumstances were described as particularly challenging because it was often difficult to determine “a reasonable scope of diagnostics and therapy” (S-516, §5).

Physical and cognitive restraints influencing treatment and communication.

Older adults’ physical and cognitive limitations, often influencing interactions and treatments, were also frequently noted in both groups. Cognitive restrictions such as limited sensory perceptions (hearing, seeing), slowness and forgetfulness were explained as challenging for communication. In general, a dominant description was how communication with older patients was more demanding. This was explained by the limited capacity to understand and remember complex information and more questions, and a need for information: “Difficulties in communication–patients absorb less information and cannot express themselves that well anymore” (D-189, §17). Moreover, it was mentioned that communication also needed to cover psychosocial needs more strongly compared to younger age groups. Therefore, more time and adapted communication styles (e.g., reducing complexity, speaking clearly) were required. Additional time was also needed because of more complex treatment planning as well as to exchange information with other disciplines and stakeholders, according to both groups. Many of the participants believed they did not have the time to implement these approaches.

Physical limitations such as impaired mobility or declined motor skills were also described as demanding alternative concepts of treatment, e.g., including more breaks during the consultation or treatment. This was particularly reported by dentists, who could often not tilt older patients in the dental chair during treatment because of cardiovascular diseases, stiffness, and dizziness.

In contrast, six participants stated that older patients appeared to be heterogeneous, with some still being fit and self-determined and not causing any additional effort.

Unclear or conflictual care planning.

In both groups, the participants described that some older people accepted their health status as normal due to their age and that they held the view or were unsure whether treatment would still be worth it. Conversely, some physicians stated that older people held unrealistic views of their health status and the possibilities of diagnostics and treatment. Concomitantly, conflicting views on older people’s compliance were outlined. On the one hand, especially GPs had the perception that older people were more paternalistic-oriented and more compliant. On the other hand, a lack of compliance and resistance to advice were also described, sometimes characterized as “stubbornness” (S-217, §10). Regardless of the cause, it was described that non-compliance increased physicians’ and dentists’ expenses.

Older patients’ care goals and non-medical concerns were perceived as challenging; this was most dominantly described by GPs. The first challenge on this matter was that reasonable treatment was not always clear, nor were patients’ individual goals, which could differ from the physician’s or dentist’s views. Moreover, psychosocial concerns such as loneliness, lack of familial or social support, financial problems and the organisation of support were described as additional demands on healthcare. The participants found themselves confronted with these demands, which could be of relevance in providing a good care plan, but likewise, several did not perceive it as their area of competence or could not provide the resources necessary for fulfilling them, e.g., due to limited time.

Organisational challenges.

As a result of the more complex care situation, treatment concepts were described as being more individualized and frequently incorporating “the solution of daily problems and organisational regards” (GP-253, §5). Sometimes, the organisation of social or specialist services was considered a part of the treatment concept. The dentists also highlighted how they focused their treatment concepts on reduced therapy, uncomplicated handling and, particularly, on the absence of pain.

Moreover, participants in both groups described that for older patients, more effort regarding the organization of (social) support and transport had to be made. One of the most important challenges was that necessary ambulatory and local support structures decreased and were more cumbersome to obtain. Specialists and dentists also complained about a lack of information and the necessary equipment to adequately treat older patients. The lack of information was further explained by missing medical reports and information from other disciplines. Moreover, care at home was perceived to be difficult to ensure due to bureaucratic and financial hurdles, especially when “the financial means of the older person are depleted” (GP-525, §8). Dentists also pointed out that providing dental care was difficult because staff and equipment needed to be transported and cooperation with the nursing home staff was sometimes bad.

Relationships with patients and further stakeholders.

Some participants stated that caring for older adults often means building relationships over many years, resulting in deep trust. This was also mentioned as a demand of the older patient group, which was described to be “happy to receive personal attention, a conversation away from the condition” (GP-198, §3) and sometimes needed special sensitivity.

In both groups, it was noted that the entire care situation changes when relatives or caregivers accompany the older patient. This could be perceived as helpful, but they were also stakeholders with their ideas and demands, resulting in additional expenditure of time. This was explained by sometimes differing own interests and goals of these people, as well as “utopian demands” (D-374, §3). It was also found that consultations with relatives and formal caregivers could be complicated and bureaucratic, e.g., regarding cost coverage of necessary treatments such as dentures.

Treating a person, not a case: Individual, patient-centred care.

Providing an individual, patient-centred view and treatment was a dominant feature of good healthcare in older age for both groups and considered very important when addressing older patients’ core motives. This was described as ensuring “individually adjusted therapy concepts, less guideline medicine” (S-232, §4) and adapting the care plan to the patients’ individual wishes, circumstances, functionalities, and treatment goals. The most important goal explained in this regard was maintaining independence and autonomy as best as possible, including mobility and functions such as chewing. Moreover, maintaining quality of life, guaranteeing freedom from pain, and providing prevention and control-oriented care were also found to be important. Balancing risks and benefits-oriented towards patients’ functionalities and feasibility were described, as was the necessary courage to provide less treatment and medication. Moreover, focusing on mental health and well-being as well as inquiring about the patient and listening well (“narrative medicine”) were mentioned.

Motivating patients to maintain activities and preventive measures, and to use early interventions if functions were declining were highlighted to support their maintenance of control and independence, as well as encouraging them to accept support, to engage in improving functions and recommending supportive measures without paternalism. Pointing out different treatment options and providing good counselling to them and, therefore, enabling the scope for decision-making were reported to strengthen patients’ self-esteem and autonomy.

Interacting empathetically without time pressure.

For a range of cases in both groups, communication was important in providing good healthcare. This was primarily described as listening patiently, paying attention, and addressing questions and concerns comprehensively to provide good counselling and comprehensible explanations. Therefore, “granting sufficient time” (D-454, §12) and acting empathetic, appreciative, respectful, and friendly were considered necessary. In both groups, taking sufficient time for the interaction was particularly considered to make the patients feel safe and meaningful. Good communication, counselling and conversations were also among the most important aspects to address all three older patients’ core motives and build trustful relationships, incorporating interactions on an equal level and respect for the older patients’ life’s work.

In contrast, three GPs and two dentists also mentioned that the interaction and therefore, healthcare, is good when patients are compliant and have realistic expectations.

Providing low-threshold, proactive care.

A very important feature in both groups, but disproportionally often described by dentists, was proactive care. Proactive care was described as providing reliable and continuous examinations and check-ups, strongly connected with broader offers of prevention (e.g., regarding mobility and dental prophylaxis) and dental hygiene (possibly with help) to maintain independence. Moreover, involving relevant people such as relatives or caregivers in planning care was considered proactive care. Some dentists additionally referred to enabling manageable care as well as long-lasting prostheses.

Access and infrastructure were also a feature of good healthcare in both groups, but especially dominant among the specialists. This aspect included medical and dental care located nearby or, alternatively, the availability of low-threshold opportunities for transport to reach a practice. Moreover, access and provision of further offers such as “social assistance, networks, ambulatory support” (S-470, §4) were described regarding this. Especially, physicians referred to ensuring these structures to address older patients’ motives to maintain control and independence, including the accessibility of information and optimisation of living and care facilities. Furthermore, ensuring support regarding medication intake, the involvement of relatives, and enabling the use of aids and restorative measures, were suggested to help address older patients’ core motives.

Another important aspect was low-threshold access to necessary therapies and diagnostics, as well as preventive examinations, without bureaucratic or financial barriers (e.g., cost coverage by insurances): “The semi-annual check-up is important because motor skills decline and the oral hygiene is not ensured sufficiently anymore” (D-439, §6). Additionally, timeliness and continuity of care, sufficient (specialist) physicians and accessibility were mentioned.

Networks of qualified healthcare providers.

Another aspect discussed under good healthcare was the availability of sufficient well-trained staff. Participants referred to broadly trained professionals, who are aware of the necessary aspects of caring for older patients. They also explained that healthcare providers’ perceived competence would make the patients feel safe. Moreover, the “close cooperation of all professional actors” (S-516, §4), such as medical professionals, nurses, caregivers, and social services, was proposed to enable holistic care and comprehensive, individually shaped support for patients. Three dentists also mentioned cooperation with nursing homes to provide good oral healthcare and hygiene.

Patients’ (health) status and skills.

Older patients having bad overall (health) was described as a barrier to providing care as desired, predominantly by dentists. It was held that physical limitations, namely decreased resilience, bone loss and limited motoric skills, made the desired treatments difficult to impossible. Moreover, multimorbidity and polypharmacy leading to medical complexity and an unstable overall health status hampered the desired treatments. Concomitantly, good overall health and functionality in the patients were described as facilitators by some participants.

A lack of skills and functionalities necessary to master daily life, as well as private or social barriers regarding support or financial resources, were also discussed as ultimately negatively influencing patients’ health status and, therefore, medical or dental treatment. Additionally, bad cognitive functioning and dementia were mentioned by some participants as barriers to cooperation. Consequently, a stronger prevention orientation was described as necessary: “make provisions at a young age, to need medical help as little as possible in old age” (S-499, §13). While physicians focused on cultivating a health-promotive lifestyle early in life, dentists rather focused on offers and coverage of dental prophylaxis and preventive routine examinations.

Patients’ environments and further stakeholders.

Patients’ environments, including further stakeholders such as relatives, were also mentioned as possible barriers to providing the desired care, especially by GPs. A lack of acceptance of patients’ wishes, lack of support or discernment by relatives and formal caregivers, as well as “a too high and counterproductive sense of entitlement” (GP-245, §7) were described as impediments to good care. However, the involvement and support of relatives and caregivers were mentioned as a possible facilitator as well. This could be achieved by meaningful exchanges with them and additional support to make good decisions for the patient.

Interactions with patients.

In both groups, but most dominantly by GPs, meaningful interactions with the older patients were mentioned as facilitators. “Intensive conversations” (GP-202, §19) and patients’ gratitude were perceived as being supportive. Moreover, the patients’ cooperation and their stable social environments were also described as supportive. Consequently, focusing more on the patients as individuals and granting them dignified and respectful care were described as necessary measures to improve healthcare. On this matter, narrative medicine was highlighted as a principle that should be supported by the organisation and reimbursement of the healthcare system.

However, a lack of patient compliance was described as hindering the desired care, especially by GPs. Physicians explained this factor as patients lacking discernment in the necessity of treatments, stubbornness and not adhering to treatment plans. Some dentists described that there might be discrepancies between the patients’ wishes and their perception of adequate treatment and, therefore, the latter would not be provided.

Reimbursement and time.

A lack of time to care for and interact with older patients as desired was mentioned in both groups, more dominantly by physicians, and especially against the background of greater demand on time, as already described. Consequently, the most important measure suggested was the reorganization of reimbursement: namely, providing higher renumeration for health services in general or, in particular, for older patients. In general, it was described that it would be desirable to receive more renumeration for greater efforts regarding time spent and to enable narrative medicine, which would otherwise be hardly or not possible at all. Moreover, cost coverage for further or necessary therapies and treatments such as prophylaxis, oral hygiene, physiotherapy or occupational therapy were found necessary. Especially dentists described how desired care depended on the “patients’ [limited] financial resources” (D-399, §8).

Information exchange and cooperation.

Specialists noted that one reason for not providing the desired care was “a lack of information and cooperation” (S-516, §7) and the absence of complete medical records to adequately treat their patients. Moreover, the specialists and dentists explained that cooperation with other disciplines and actors was needed to provide comprehensive and good care, but that their availability was often limited, communication was lacking, and that they also perceived a lack of willingness to cooperate. In particular, the specialists valued the exchange with colleagues and cooperation with other disciplines involved in the care of the older patient as a facilitator, as well as having a professional network. In both groups, better interdisciplinary cooperation and networking among all care providers were explicitly requested.

Motivated, well-trained, and sufficient healthcare providers.

One of the most important facilitators described in both groups was the attitude and motivation of medical professionals. To provide good care despite the described obstacles, it was explained that idealism and engagement, as well as empathy and a strong moral claim to supporting older patients and guaranteeing them the healthcare they deserve were facilitating. It was also mentioned that the participants thought of their own future as being old or “my older parents” (GP-198, §10) and the care they would like to receive. Moreover, the motivation, the attitude towards older patients and “routinely well-organized team[s]” (D-384, §8) were mentioned as important facilitators, as well as their professional experience in providing health or dental care for such patients. On-going qualification and training regarding the specialties of caring for older patients was additionally described as being supportive in providing good care. However, in both groups, the participants mentioned a lack of qualified staff as a barrier, and several suggested the recruitment and education of further qualified staff.

Strengthening the relevance of oral health.

Several dentists highlighted the necessity to raise awareness of the relevance of oral health in older adults among relatives, physicians and further actors. This included the integration of oral health matters and provision or support of oral hygiene, especially in care-dependent older adults, in education and training of medical staff, nurses and relatives. Moreover, broader possibilities and the cost coverage of prophylaxis in old age and support for visiting dental care were demanded. It was stated that “the dental care in nursing homes has been structurally secured in the past years–the ambulatory care still is a broad field” (D-451, §25–26). Finally, dedicated dental care rooms for visiting dentists in nursing homes were suggested.

Infrastructure of healthcare and further support.

In both groups, the design of healthcare structures was discussed as an important factor in providing the desired care. This concerned a lack of cost coverage by insurance schemes, lacking therapy places, and “age-appropriate transportation systems” (S-175, §8). Moreover, a lack of possibilities to provide home and nursing home visits was mentioned. Improvement of access was described as necessary, especially regarding cost coverage and the simplification of application for treatment and therapies, home visits and preventive appointments.

Moreover, low-threshold opportunities for support structures such as ambulatory services, “patient guides that take organisational tasks” (GP-158, §16) or welfare centres were suggested. Provision of barrier-free information, help in mobility and transport, daycare centres and visiting or mobile health and dental care were said to be necessary. Therefore, a good local infrastructure of social services and ambulatory care services were said to be facilitators of good healthcare. Support structures, such as local networks guaranteeing social integration and participation in cultural activities to prevent loneliness, were also required to serve older patients’ psychosocial well-being.