Health Care Disciplines and the Older Adult Dentists Physicians - - PDF document

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Gregg Warshaw, M.D. Professor of Family and Community Medicine Semmons Professor of Geriatric Medicine University of Cincinnati College of Medicine

Health Care Disciplines and the Older Adult

 Dentists  Health Educators  Nurses  Occupational

Therapists

 Physicians  Physician Assistants  Physical Therapists  Speech Therapists  Social Workers  Pharmacists  Other

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Primary Care

 Family Medicine

Family Medicine

 General Internal Medicine  Geriatric Medicine  Advanced Practice Nurses (clinical nurse specialists,

nurse practitioners)

 Physician assistants

Physician assistants

Some practitioners derive much of their fee schedule payments from primary care services

P titi d i lt P t f h f Practitioner and specialty Percent of charges from primary care services

Nurse practitioner 65.4% Geriatric medicine 65.0 Family medicine 62.5 Internal medicine 44.4 Physician assistant 34.8 All other 13.4

.

Source: MedPAC analysis of 2006 claims data for 100 percent of Medicare beneficiaries.

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Summary

 Considerable progress achieved over past 30 years to

p g p 3 y prepare health care providers to provide optimal care to

• lder adults

 Facilitated by: geriatrics clinical research, development of

geriatrics and palliative care specialties, accreditation and certifying bodies, professional societies, foundations, and dedicated clinician educators

 Barriers: Reimbursement, care system, and ageism

, y , g  Pace of change needs to accelerate in the training of health

professionals, care system innovation, and reimbursement reform to ensure quality care and control health care expenditures

Case: Susan and Her Father

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Four Simultaneous Initiatives

I i h kf f PCP d h

 Increasing the workforce of PCP and other

health team providers

 Preparing PCPs and other health team providers

to provide expert geriatrics chronic care

 Paying adequately for quality chronic care  Cost‐effective models of chronic care

Health Affairs 29, 811‐818, 2010

Questions

 Why are well trained primary care and health team

providers essential to addressing the medical care needs of older adults?

 How well are we doing preparing current and

future practitioners to care for a rapidly growing

• lder population?
• lder population?

 What more can be done to improve the capabilities

• f current and future providers to care for older

adults?

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AGING OF THE US POPULATION

82 90

 Number of people 65 yr, in millions

36.8 3 1 20 30 40 50 60 70 80

Slide 9



3.1 10 1900 2005 2050

LIFE EXPECTANCY IN 2004 (Mean)

All R All Races All Male Female At birth 77.8 75.2 80.4 Age 65 18.7 17.1 20.0 A 85 6 8 6 1 7 2

Slide 10

Age 85 6.8 6.1 7.2

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Projected Total Number of People With Chronic Conditions

180

(in millions)

118 125 133 141 149 157 164 171 120 140 160 118 100 120 1995 2000 2005 2010 2015 2020 2025 2030

Sources: Partnership for Solutions. “Multiple Chronic Conditions: Complications in Care and Treatment”; RAND Corporation, 2000.

Medicare Spending on Beneficiaries with Chronic Conditions

4 Chronic Conditions 12% 12% 5+ Chronic Conditions 68% 3 Chronic Conditions 10% 2 Chronic Conditions 6% 1 Chronic Condition 3% 0 Chronic Conditions 1% 6%

Source: G. Anderson, “Hospitals and Chronic Care”, PowerPoint Presentation to the American Hospital Association. Partnership for Solutions. 16 June 2004.

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Annual Prescriptions by Number of Chronic Conditions

50

33 3 49.2

10 20 30 40

Average Annual Prescriptions* 3.7 10.4 17.9 24.1 33.3

1 2 3 4 5

Number of Chronic Conditions

*Includes Refills Sources: Partnership for Solutions, “Multiple Chronic Conditions: Complications in Care and Treatment,” May 2002; MEPS, 1996.

Hospitalizations for Ambulatory Care Sensitive Conditions

261 300 261 236 219 95 62 36 18 169 131 50 100 150 200 250

• spitalizations per 1000

Medicare Beneficiaries 18 7 50 1 2 3 4 5 6 7 8 9 10+ Number of Chronic Conditions Ho M

Sources: Partnership for Solutions. “Multiple Chronic Conditions: Complications in Care and Treatment,” May 2002; Medicare Standard Analytic File, 1999.

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Ambulatory Care Visits to Primary Care and Specialist Physicians, United States, Patients Age 65 and over 1980 1990 2006

Specialist

Primary Care

Specialist

Primary Care

Specialist

Primary Care

38% 62% 47% 53% 59% 41% 38% 62% 47% 53% 59% 41%

Source: CDC, NCHS, National Ambulatory Medical Care Survey

Utilization of Physician Services by Number of Chronic Conditions

37.1

Unique Physicians

1 3 4.0 5.2 6.5 8.1 13.8 2.0 7.8 11.3 14.9 19.5

Physician Visits

1.3 1 2 3 4 5+

Number of Chronic Conditions

Sources: R. Berenson and J. Horvath, “The Clinical Characteristics of Medicare Beneficiaries and Implications for Medicare Reform,” prepared for the Partnership for Solutions, March, 2002; Medicare SAF 1999.

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Questions

 Why are well trained primary care and health team

providers essential to addressing the medical care needs of older adults?

 How well are we doing preparing current and future

practitionerss to care for a rapidly growing older population?

 What more can be done to improve the capabilities of

current and future to care for older adults?

Quality of Care Provided to Vulnerable Community‐Dwelling Older Patients (I)

 Assessed quality in two managed care organizations

Assessed quality in two managed care organizations (1998‐99)

 Observational cohort study of care processes of 22

conditions; 420 vulnerable older adults

 General medical: CHF, pneumonia, etc.  Geriatrics: Dementia, incontinence, etc.  Chart reviews and patient interviews  Mean age: 80.6 years; 64% female

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Quality of Care Provided to Vulnerable Community‐Dwelling Older Patients (II)

 Overall quality indicators passed

Overall quality indicators passed

 General medical

52%

 Geriatric

47%  Chronic care quality indicators passed

 General medical

51%

 Geriatric

29% 9  Least well managed: falls and mobility, urinary

incontinence, cognitive impairment, end‐of‐life care

Quality of Care Provided to Vulnerable Community‐Dwelling Older Patients (III)

 Possible reasons why geriatric conditions may receive

y g y inadequate attention in primary care

 Skills not well taught during training  Skills may not be maintained if conditions seen

infrequently

 Assessment tasks may be perceived as too time

consuming

 Conditions may not be recognized  Little feedback from third parties  Inadeqaute team‐care

Ann Intern Med. 2003;139:740‐747

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Medical student geriatrics curriculum (2008)

23% of medical schools require a geriatric

23% of medical schools require a geriatric clerkship

56% of medical schools integrated geriatrics

into a required clinical rotation

Schools could report more than one type of experience

Geriatrics Workforce Policy Studies Center Surveys of Geriatric Academic Leaders in US Medical Schools 2005 & 2008.

Geriatric Physician Workforce Pipeline

9,666 MDs graduated from FM & GIM 9 g residency programs in 2008 Only 3% entered a Geriatric Medicine fellowship program in 2009

Source: AMA and AAMC data from the National Survey of GME Programs 2008/2009 & 2009/2010.

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Required Time devoted to clinical instruction in Geriatric Medicine

D i I t l M di i d F il During 3 year Internal Medicine and Family Medicine Residency program

 20 days (Median) Internal Medicine  12 days (Median) Family Medicine

Geriatrics Workforce Policy Studies Center. Surveys of Program Directors in Internal Medicine (2008), Family Medicine Residency Programs (2008)

Geriatric Medicine Training in FM and IM Residency Programs as rated by Program Directors as rated by Program Directors

Geriatrics rated second most important curriculum area by IM and FM

• ICU/CCU first for IM
• Ambulatory Adult Medicine first for FM

Curriculum conflicts #1 obstacle to implementing GM curriculum

Geriatrics Workforce Policy Studies Center. Surveys of Program Directors in Internal Medicine (2008), Family Medicine Residency Programs (2008) .

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Other Disciplines Training in Geriatrics

PHARMACISTS

• There are 1,219 certified geriatric pharmacists and

269,900 staffed pharmacy positions.

• Less than half of all pharmacy schools have a full‐time

geriatric pharmacy specialist.

Elizabeth Bragg, Jennie Chin Hansen. A Revelation of Numbers: Will America’s Eldercare Workforce be Ready to Care for an Aging America? Generations ; 2011; 34(4):11‐19

SOCIAL WORKERS

• In 2006, 12 percent of licensed social workers (38,400)

identified their practice areas as “aging”.

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Other Disciplines Training in Geriatrics

PSYCHOLOGISTS

• 70% of practicing psychologists provide some services to
• 70% of practicing psychologists provide some services to
• lder adults.
• A sample of the American Psychological Association

found that most respondents lacked formal training in geropsychology and perceived themselves as needing additional training. PHYSICAL THERAPISTS PHYSICAL THERAPISTS

• From 1992 through 2010, 1,109 physical therapists have

been certified in geriatrics by the American Physical Therapy Association (nearly 200,000 PT positions).

Elizabeth Bragg, Jennie Chin Hansen. A Revelation of Numbers: Will America’s Eldercare Workforce be Ready to Care for an Aging America? Generations ; 2011; 34(4):11‐19

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Nursing

 43% of nursing schools have full‐time geriatrics faculty

43% of nursing schools have full time geriatrics faculty

 92% of B.S. nursing programs integrate geriatrics into

the curriculum

 In 2008, 1.9% (4,963) of advanced practice nurses were

certified in gerontology

 In 2009, 3% of nurse practitioners are certified in

9 3 p gerontology; 13% have long‐term care privileges

 In 2009, 28 nursing schools offered master’s level

gerontological clinical nurse specialist degrees, down from 36 in 2007.

228 193 182 197 184 196 200 250

Number of GNP and G‐CNS Newly Certified 2005‐2010 (2.7 million RNs in US)

37 31 26 25 50 100 150

Numbers

13 21 25

2005 2006 2007 2008 2009 2010 Year

Gerontological NP Gerontological CNS

Source: American Nurses Credentialing Center. Data compiled by GWPS Center

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571 710 6 700 800

Number of Newly Certified Gerontological Nurses 2005 ‐ 2010

244 231 333 319 571 100 200 300 400 500 600 Numbers 100 2005 2006 2007 2008 2009 2010 Year Gerontological Nurses

Source: American Nurses Credentialing Center. Data compiled by GWPS Center

Settings of Care

 Home Care

Home Care

 Adult Day Care  Program of All‐Inclusive Care for the Elderly (PACE)  Group Homes, Adult Foster Care, Sheltered Housing  Assisted Living  Nursing Homes Chronic Care  Nursing Homes – Chronic Care  Nursing Homes – Sub Acute Care  Continuing Care Retirement Communities

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PCP Resident Training in LTC Settings

 Most family medicine residency programs provide

Most family medicine residency programs provide training experiences in nursing home and home care settings

 In 2005, IM residency program directors reported:

 65% nursing home experience  33% home care experience  33% home care experience

Nursing Homes As a Site of Care

 Large need for geriatrics care

 15,850 homes  1.7 million beds  2.5 million discharges  1.3 million residents

 Diverse population Sub acute care

 Sub‐acute care  Chronic care of patients with dementia and multiple

chronic illnesses

 Hospice and palliative care

Slide 38

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HOME CARE OF THE FUTURE

Community‐based care to play a pivotal role in Community based care to play a pivotal role in health care system reform

 Increased integration into accountable care

• rganizations

 Helping to avoid hospitalization and

d i i readmissions

 Bundling of payment for episodes of care with

hospitals and nursing homes

Slide 39

Questions

 Why are well trained primary care providers essential

to addressing the medical care needs of older adults?

 How well are we doing preparing current and future

PCPs to care for a rapidly growing older population?

 What more can be done to improve the capabilities of

p p current and future providers to care for older adults?

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NIA Funding for Models of Care N=69 (1999‐2008)

 Interdisciplinary team care  Care Management  Chronic‐disease self management  Medication management  Preventive home visits  Proactive rehabilitation  Transitional care

J Am Geriatr Soc 58:2345‐2349, 2010

Geriatrics in Primary Care: Enhanced Primary Care

 GRACE Model (Geriatric Resources for Assessment

and Care of Elders)

 Guided Care  ACOVE (Ambulatory Care of the Vulnerable Elderly)

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Geriatric Resources for Assessment and Care of Elders (GRACE) Model (I)

• NP and social worker (employed by the PCP) provide

h b d d l home‐based CGA and long‐term care management

• Interdisciplinary team led by a geriatrician
• Individualized care planning during weekly team

meetings is guided by 12 protocols for common geriatric conditions

• NP and social worker continuously implement the care
• NP and social worker continuously implement the care

plan in collaboration with the PCP

• The NP and social worker coordinate care among all

providers and sites of care (electronic medical record and Web‐based tracking system )

Slide 43

Geriatric Resources for Assessment and Care of Elders (GRACE) Model (II)

• Low‐income seniors enrolled in a trial of the GRACE

inter ention compared ith usual care intervention, compared with usual care:

• Better quality of care for the geriatric conditions and

general health processes targeted

• Improvements in health‐related quality‐of‐life

measures

• Fewer emergency department visits over 2 years
• Hospital admissions were significantly reduced in the

second year among high risk patients

JAMA 2007;298:2623‐2633

Slide 44

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Guided Care (I)

 Guided Care Nurse works in partnership with PCPs

Guided Care Nurse works in partnership with PCPs

 Nurse is based in PCPs office; EHR  Supports the ongoing care of 50 – 60 patients with

multiple chronic illnesses

 Provides intensive transitional care  Expands on care management; disease management

Expands on care management; disease management

 Promotes self‐management; family support

J Gen Intern Med 2010; 25: 235‐42

Guided Care (II)

At 8 months Guided Care patients had: At 8 months Guided Care patients had:

24% fewer hospitals days, 37% fewer skilled nursing facility days 15% fewer emergency department visits 29% fewer home health care episodes 29% fewer home health care episodes 9% more specialist visits

Arch Intern Med 2011 (in press)

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ACOVE Intervention Trial

 Two community‐based medical groups

y g p

 Controlled trial  644 patients, age 75 years or older, with falls,

incontinence, or cognitive impairment

 Intervention: Case finding, physician and staff training

to assess and treat conditions

 Outcomes:  Outcomes:

 Screening tripled condition identification  Intervention group patients received better care for falls

and incontinence; not dementia

J Am Geriatr Soc 57:547‐555, 2009

PCP Competencies Specific to Practicing in Interdisciplinary Geriatrics Models of Care

 Geriatric medicine clinical skills

Geriatric medicine clinical skills

 Motivational interviewing  Team care  Care coordination  Information technology  Continuous quality improvement  Continuous quality improvement

Health Affairs 29, 2010: 811‐818

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Patient Centered Medical Home

 Access to Care and Information

Access to Care and Information

 Practice‐based services  Care management  Care coordination  Practice‐based team care  Quality and Safety  Quality and Safety  Health Information Technology  Practice management

Recommended Geriatrics Competencies for IM and FM Residents (I)

 Twenty‐six competencies in 7 domains

Twenty six competencies in 7 domains

 Medication management  Cognitive, Affective, Behavioral Health  Complex chronic illnesses in older adults  Palliative and end‐of‐life care  Hospital patient safety  Transitions of care  Ambulatory care of older adults

J of Grad Med Ed 373‐382 September 2010

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Recommended Geriatrics Competencies for IM and FM Residents (II)

Example competencies p p

 Review and re‐evaluate patient medications  Administer and interpret screening tools for dementia,

delirium, depression, etc.

 Plan of care incorporate the patient’s and family’s goals

• f care, preserves function, and relieves symptoms

 Detect evaluate and initiate management of bowel  Detect, evaluate, and initiate management of bowel

and bladder dysfunction

 Identify older adults at high safety risk (driving,

abuse/neglect) and assess or refer

Partnership for Health in Aging

A collaboration of multiple health profession organizations A collaboration of multiple health profession organizations under the leadership of the American Geriatrics Society

Published in 2010

Multidisciplinary Competencies in the Care of Older Adults at the Completion of the Care of Older Adults at the Completion of the Entry‐Level Health Professional Degree

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Multidisciplinary Competencies in the Care of Older Adults at the Completion of the Entry‐Level Health Professional Degree  Intentionally broad

Intentionally broad

 Each discipline may individually implement  Each competency should be considered in the context

• f the unique needs of older adults

 The competencies should be implemented taking

account of the individual preferences and ethnic p backgrounds of the older adult

Multidisciplinary Competencies in the Care of Older Adults at the Completion of the Entry‐Level Health Professional Degree  Six Domains/23 Competencies

Six Domains/23 Competencies

 Health Promotion and Safety  Evaluation and Assessment  Care Planning and Coordination  Interdisciplinary and Team Care  Caregiver support  Healthcare Systems and Insurance Benefits

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Multidisciplinary Competencies in the Care of Older Adults at the Completion of the Entry‐Level Health Professional Degree

Examples; Examples;

 Advocate to older adults and their caregivers

interventions and behaviors that promote physical and mental health, nutrition, safety, social interactions, independence, and quality of life.

 Choose, administer, and interpret a validated and

reliable tool/instrument appropriate for use with a given older adults to assess: a) cognition, b) mood, c) physical function, d) nutrition, and e) pain.

Elements of Successful Geriatrics Training Experiences

 Modeling excellent care for older adults in the

hospital, office, and community‐based settings

 Caring for patients across sites and through transitions  Experiences with interprofessional teams in all

settings g

 Longitudinal experiences

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IoM 2008 Geriatrics Workforce Report

Selected Recommendations: Selected Recommendations:

 Training in all settings where older adults receive care  Incorporate competence in the care of the older adult into

licensure, certification, and maintenance of certification

 Payers should include a specific enhancement of

reimbursement for clinical services delivered to older adults by practitioners with a certification of special expertise in y p p p geriatrics

Institute of Medicine. Retooling for an Aging America. Building the Health Care

• Workforce. Washington DC: The National Academies Press, 2008.

Case: Susan and Her Father

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Conclusions

 Considerable progress achieved over past 30 years to

p g p 3 y prepare health care providers to provide optimal care to

• lder adults

 Facilitated by: geriatrics clinical research, development of

geriatrics and palliative care specialties, accreditation and certifying bodies, professional societies, foundations, and dedicated clinician educators

 Barriers: Reimbursement, care system, and ageism

, y , g  Pace of change needs to accelerate in the training of health

professionals, care system innovation, and reimbursement reform to ensure quality care and control health care expenditures