Apr 292014

As much  as we tell ourselves and each other that 80 is the new 60, or 60 is the new 40, we are kidding ourselves, and setting up a future in which the needs of very frail elders are unseen, misunderstood, and unmet. Popular culture and its pressure to be forever young  ignores the reality of aging: That those of us lucky to survive chronic conditions, such as cancer and heart disease, will just grow very old. There are benefits to living—look how many of us prefer to do just that—but there are challenges to aging. We will change: physically, mentally, emotionally and spiritually. Our circumstances will change: independence may give way to dependence, our homes may give way to nursing homes, our working income may give way to financial uncertainty.  Very frail elders, like very young children, have unique and particular circumstances that require attention and care from family and friends, and from communities and government. To understand these needs,  it helps to first understand who frail elders are—or who we mean when we speak of them.

The last century heralded major changes in American health, and in public health. These, in turn, have led to longer lives;  the average US life expectancy for a child born in 2010 was 78.7 years, a thirty-year gain from 1900.  There are simply millions more of us! alive.  Since 1900 the number of Americans over 65 has increased from 3.1 to 41.4 million persons. The increase among the older population will accelerate as the Baby Boomer generation ages. In fact, the Baby Boomers are estimated to reach 80 million persons by 2040.

It is not just that people are aging, but that they are aging into very long lives.  In 2011, the 75-84 group (12.8 million) was 16 times larger and the over 85 group (5 million) was 40 times larger than their populations than at the turn of the 20th century. Those over 85 is projected to triple from 5.7 million in 2011 to 14.1 million in 2040. This is an unprecedented rate of growth for those over 65.

The very old face challenges of inhabiting such old bodies.  More than half of older adults have three or more chronic diseases. Alzheimer’s and related dementias also plays a role in increasing illness and disability. Over 5 million persons over the age of 65 report having Alzheimer’s or a related dementia disease.  By 2050, the number of people age 65 and older with Alzheimer’s disease will nearly triple to 16 million. Currently, nearly one in three deaths are attributable to Alzheimer’s or dementia-related diseases, and Alzheimer’s is the sixth leading cause of death.

People who are frail and have multiple chronic conditions experience problems in completing tasks of daily living, and almost one third of adults over 65 have problems with tasks such as eating, dressing or bathing.  Increasing age comes with increasing struggles;  almost half of those over 85 report difficulty walking and a quarter report difficulty bathing and showering.

We say that these people are frail, but what is frailty and why does it matter?  Geriatricians define frailty as “a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity.” (Fried et al, 2001). A person with none of the indicators is robust, a person with 1 or 2 indicators is pre-frail, and a person with 3 or more indicators is frail.

As we develop and test  MediCaring, it is important to have a standard way to identify frail elders, and to coordinate and deliver the array of services they need. Doing so is imperative: Millions of Americans will now experience an extended period of frailty. We have unprecedented change on the horizon—and an urgent need to respond to the challenges change brings.


LP Fried et al. J Gerontol A Biol Sci Med Sci(2001) 56 (3):M146-M157. doi:10.1093/gerona/ 56.3.M146

key words: MediCaring book, Joanne Lynn, Janice Lynch Schuster, aging, frailty

[1] Life expectancy at birth, at age 65, and at age 75, by sex, race, and Hispanic origin: United States, selected years 1900–2010. Centers for Disease Control and Prevention. http://www.cdc.gov/nchs/data/hus/hus12.pdf#018

Apr 282014

 For most of us, for most of our lives, healthcare involves doctor visits for routine and acute care, and sometimes visits to specialists when dealing with complex or advanced illness. To be sure, many of us also find health and healing beyond the walls of a clinic or the contents of a medicine cabinet—attention to diet, exercise, spirit and community can also strengthen us. For the very old, the very frail, managing health becomes less a process of preventing and treating illness, and more a concern of maintaining function and enjoying quality of life. To this end, very frail adults often shift focus as their needs and situations change. And while medicine remains part of the equation, other services become tantamount: long-term care, for instance, as well as good nutrition, access to affordable and safe housing, reliable transportation, and ways to remain connected with the larger community.

MediCaring Communities will work to meet these needs by helping to align the needs of frail elders and their families with the mix of health care and social services a community can provide. The MediCaring model would ensure that all members of a multidisciplinary team would know all enrolled individuals: these individuals and their families would be real to professional caregivers, who would understand their situation and priorities, in part, through the presence of a comprehensive care plan.

The MediCaring model includes all covered services under Medicare and Medicaid.  However, by working with elders and their families to understand the realities of what they face, the benefits and costs of treatments, and strategies to achieve goals and priorities, MediCaring elders may be less inclined to opt for very expensive and burdensome medical treatments and more likely to choose options that enhance quality of life, maintain comfort, and ensure dignity. The MediCaring model would not bar choices or limit access; rather, it would aim to ensure that elders and family members clearly understand the degree to which a treatment or procedure will offer any help, and the costs (i.e., physical, emotional, financial) of pursuing it. Elders would never find themselves barred from medical treatments that they want. Rather, they and their families would be part of an informed and thoughtful decision-making process and able to understand and decide which treatments and procedures to pursue, and which to avoid.

The following list highlights key characteristics of a prototypical MediCaring community.

Multidisciplinary Team. A multidisciplinary team whose sole focus is frail elders will coordinate person-centered care in the community. Teams would include clinicians and practitioners trained and skilled in diagnosis and treatment; medication management; rehabilitation; self-care; nursing care; mental health; caregiver assessment, training, and support; nutrition; community services; and housing.  Teams would include a physician, nurse, and social worker, as well as ongoing and reliable access to pharmacists, rehabilitation specialists, mental health experts, housing services staff, caregiver support personnel, and legal advisors. The team’s capabilities and functioning would be measured and certified as meeting standards that reflect well-coordinated care, rather than adherence to a requirement for certain disciplines doing certain tasks.

Care Plans. The MediCaring team will work with elders and their families, and with one another, in developing comprehensive care plans. The local authority charged with implementing MediCaring would ensure that adequate and appealing community resources were available to meet the many needs elders have, including the need for services such as hospice and palliative care. The scope of care planning must respect limits that the person or surrogate prefer, while also addressing any issues that arise in terms of particular services, e.g., housing, finances, caregiver support, medications, and various therapies.

Primary Care. MediCaring builds on and ensures primary care for elders who live with advanced, serious, and complex conditions. Primary care for frail elders is not primary care as usual–doctor who provides routine prevention, chronic disease self-care education, and coordination of services from specialists. Rather, this is primary care writ large, responsive and responsible in recognizing and meeting the array of physical, psychosocial, and spiritual needs elders and families encounter. Although MediCaring builds on geriatric principles and palliative care standards and approaches, it is not limited to simply medical aspects of care for frail elders.

Continuity of Round-the-Clock Services. MediCaring includes continuity of services across time, settings, and providers, with round-the-clock coverage and real-time availability to the elder and  his or her caregivers. A MediCaring team would be charged with providing medical and nursing advice and support. In the case of an urgent phone call (or text or email) with a pressing health concern, a team member with appropriate skills for the problem would respond within ten minutes. Ideally, the team member on call would know the elder and caregivers, and would always have immediate access to an up-to-date care plan.

Home Visits. Very frail elders and their caregivers can be taxed and stressed by the challenge of simply getting to a physician’s office. Whenever feasible, urgent home visits to assess emerging situations should occur within three hours of a call (or, in rural or remote areas, telemedicine should be used). The process of developing care plans for MediCaring elders should include honest and forthright understanding about when and if to call 911, or to go an emergency department. For frail, homebound elders, many technical and supportive services, built on a competent physical examination, can be safely done where the elderly person lives, including simple diagnostic x-rays and imaging tests, blood and urine tests, skin biopsies, electrocardiograms, and more. This spares frail elders the difficulties and sometimes trauma of being moved to another setting simply to receive good care, especially when that care can so effectively be delivered to them. Home visits are a wise, safe, and effective alternative to preventing or delaying hospitalizations and nursing home placements.

Comprehensive services. In some cases, urgent issues created by crises of housing, nutrition, transportation or family caregiving arise, and, unchecked, can have a significant effect on health. MediCaring will focus on preventing such crises by having a sort-of disaster preparedness approach to frail elders: direct care workers will be on standby to cover a caregiver crisis; safe housing will be readily available for emergency placement; short-term funding will be provided for heat or air conditioning needs; reliable and safe transportation will be available for necessary appointments and other responses for addressable issues. Addressing the social determinants of health ensures an approach that avoids the current challenges many frail elders and their families endure.

key words: MediCaring book, Janice Lynch Schuster, Joanne Lynn, eldercare

May 302013

by Anne Montgomery

There’s a reason why the nation has convened a White House Conference on Aging (WHCOA) once a decade, and it’s this:  Historically, these seminal events – which involve thousands of people feeding in ideas from communities across the country – have spurred creative consensus at a national level about how apparently intractable current challenges can be practically approached, even as strategies for making promising opportunities a reality over time are also mapped out.

The United States is now in Year 3 of its “Age Wave,” and it’s become clear to policymakers and stakeholders alike that much work remains to be done to build sufficient capacity for delivering the comprehensive array of services that our aging society demands, in the form of policy frameworks that align financial incentives and position a broad array of mostly non-coordinated providers to be accountable for delivery of consistently good-quality services.  So how can we get from where we are today to meeting these goals? What policies and strategies will get us there?

This is where the WHCOA comes in.

The first Conference was held in January 1961 at the directive of Congress, which established it in legislation that was enacted in 1958 (Public Law 85-908).  In addition, in 1959, a Senate Subcommittee on Problems of the Aged and Aging was established, and three years later, this panel was elevated to become the Special Committee on Aging.  In the words of then-Aging Committee chair Sen. Pat McNamara, the convening Conference was dedicated to “bringing to national attention the problems, potentials – and challenges – of an aging population.”

For perspective on what McNamara and other framers had in mind for the WHCOA, here is how the aspirations of an aging society were framed in the Aging Committee’s foreword, which accompanied the first Conference’s final report:

“Today the life expectancy is around 70 years.  In 1900, it was less than 50 years.  In the lifetime of today’s younger generation, without any further progress in medical science, an average life expectancy of 80-85 will be typical….Our traditional approaches to the ‘aged’ require reappraisal in the light of hard facts. For one thing, past approaches were characterized by a tendency to look at the problem involved – if indeed, problems were recognized – in a fragmented way.  A systematic, coordinated outlook and action policy [emphasis added] are increasingly called for as we become more and more conscious of the impact of the aging trend in our society upon the lives of the total population and even upon the policies relating to matters not otherwise considered as directly affected by the emergence of the ‘problems of the aged.’”

More than 50 years later, these prognostications have turned out to be remarkably accurate. According to the Social Security Administration, a man reaching the age of 65 today can expect to live, on average, until 83. A woman turning 65 today can expect to live on, average, until the age of 85.  Equally or perhaps more important, one out of four 65-year olds will live to be 90 years of age or older, and one out of 10 will live beyond age 95.

The WHCOA framers could not know which, if any, of the many ideas and recommendations that were suggested and debated in 1959, 1960 and 1961 – the first Conference was held after 2 ½ years of public meetings and deliberations–would be adopted.  Many focused on health care and income. Today, looking back with the benefit of hindsight, we know that in 1965, Congress enacted legislation establishing Medicare, Medicaid and the Older Americans Act.  These statutes and programs have grown in scope and importance over the years, and they are widely acknowledged to be essential for meeting the challenges of our nation’s quickly accelerating “age wave.”  The issues being debated at present are whether these and other public programs, along with private-sector options, have adapted sufficiently to meet the challenges of the 21st century. Many are arguing that further reforms are warranted.

Yet looking ahead, the policy picture is far from clear. The current state of discussion about Medicare and Medicaid is vigorous – but divided.  No firm consensus has emerged on the specific nature of what changes are essential.  Moreover, the Older Americans Act, which is overdue for reauthorization, has been overshadowed by a range of other issues that are deemed to be more pressing.  At the same time, the number of Americans turning 65 each day grows by about 10,000.

This situation suggests that a national conversation in the form of a WHCOA, to be held in 2015, and accompanied by a process of meetings and conversations – both in-person and online – to solicit input and ideas from thousands of citizens across the country would be a sound civic investment – just as it was more than five decades ago.

All WHCOAs have resulted in subsequent adoption of signature initiatives.  For example, the 1971 WHCOA is given credit for creation of the Supplemental Social Insurance program and establishing the National Institute on Aging within the federal government’s biomedical research establishment, the National Institutes of Health.  In 1995, the WHCOA called for establishing a program to recognize and assist the nation’s millions of family caregivers – which led to enactment of the National Family Caregiver Support Program. This WHCOA also highlighted a pressing need to develop strategies for detecting, addressing and preventing elder abuse, along with improved opportunities for retraining and assisting older workers.  Notably, it rejected the notion of pitting programs for older adults against those that serve cohorts of younger adults, adolescents and children.

Most recently, the 2005 Conference provided momentum for reauthorizing the Older Americans Act in 2006, which strengthened the role of Aging Disability Resource Centers (ADRCs).  Discussions of elder abuse generated widespread attention and interest, and were transformed into a discussion on elder justice, which in turn helped to prompt Congress to enact the Elder Justice Act in 2010.  Significantly, the 2005 Conference flagged the issue of coverage and support for long-term care as a critical and emerging issue—one that is awaiting further action.

To forecast what the next WHCOA might be able to help develop in one key area, it is useful to review some of what the delegates considered when they assembled more than 2,500 delegates in Washington, D.C. in 1961.  The four-day meeting resulted in a report that covered 20 areas of emphasis. Among these was a section titled “Local Community Organization,” which declared, in part:

“To put total emphasis on the care of the aged, as opposed to developing a community in which one can age with dignity and independence, would poorly serve the coming generations of Americans. We must not create the continual crisis of ‘problems.’ A total program of local community awareness and individual responsibility can develop the great opportunity which we presently have in the lengthened lifespan of Americans….To create this activity in the local community, where the individual must live and function, it is recommended that local communities immediately create a Committee on Aging through which planning may be done for the good life that can be achieved by and for its elder citizens.”

With the subsequent establishment of 50 State Units on Aging as part of the Older Americans Act, and more than 600 local Area Agencies on Aging and their close cousins, ADRCs – which aim to be potential portals for long-term care services and supports – the concept of building stronger networks of cohesive, locally-rooted initiatives that can support frail elders and individuals with disabilities in their own communities is one that has the potential to create a series of lively and productive discussions at the next WHCOA.

In this and many other areas, there is a lot left to do – so if you or your organization would like to lend support to the idea of convening a WHCOA in 2015, please take a moment to read the “Letter to the President” (supported by more than 40 organizations including AARP and the National Council on Aging) and then send in your own request.

[Update: The White House Conference on Aging was held in 2015. Read the “Final Report of the 2015 White House Conference on Aging”.]

Anne Montgomery is a Visiting Scholar at the National Academy of Social Insurance and a Senior Policy Analyst at the Altarum Institute. She worked for the Senate Special Committee on Aging from 2007 until early 2013. This article originally ran on the NASI website (www.nasi.org) on May 13, and is reprinted here with Anne’s persmission.



Key words:  White House Conference on Aging, National Academy of Social Insurance, Anne Montgomery, age wave, aging, elder care, frail elders

Jan 232013

By Dr. Joanne Lynn

The latest issue of JAMA features our paper describing   an exciting and successful initiative from the Centers for Medicare and Medicaid Services (CMS) and fourteen of its quality improvement organizations (QIOs).  Grounded in quality improvement methodology—plan-do-study-act–this unusual project offers many insights for those aiming to reduce avoidable readmissions.  And its raises a number of important question about how we measure progress in reducing readmissions. (For more on that topic, see our earlier MediCaring blog, https://medicaring.org/2013/01/07/readmissions-count-should-cms-revise-its-calculations/ )

A Medicare patient’s ability to receive successful treatment during care transitions from one setting to another has a crucial effect on the overall cost and efficiency of the Medicare system. Errors in information transfer, care planning or community support can cause hospitalizations, rehospitalizations and unnecessary costs to the Medicare program.

This project involved a three-year, community-based effort to improve the care transition process for fee-for-service Medicare beneficiaries. Participating QIOs facilitated cooperation among providers, health care facilities, and social services programs, such as Area Agencies on Aging. They centered their efforts around each community’s unique needs.   QIOs worked with communities to understand their own particular causes of readmissions, and to implement appropriate, evidence-based models to address them.  Communities analyzed results of the intervention along the way, and changed course to stick with interventions most likely to work.

The results, when compared to 50 comparison communities, showed significant reductions in hospitalizations and rehospitalizations, both by an almost 6% average, saving Medicare $3 million in hospitalization costs per average community per year.

This correlation has already led to new national efforts such as Partnership for Patients and the Community-based Care Transitions Program. In addition, in the 10th Scope of Work, all 53 QIOs are leading community projects nationwide (so far, in more than 400 communities).

This paper may be the first time one of America’s leading medical journals has published a report based on QI methods. Doing so represents a profound change in the openness of American medicine to learn not only what works for a patient, but works for the delivery system, too.

key words: quality improvement, care transitions, CMS, CFMC, Joanne Lynn, readmissions, community coalitions, JAMA

Jul 232012

By Dr. Kyle Allen and Susan Hazelett

The Summa Health System/Area Agency on Aging, 10B/Geriatric Evaluation Project(SAGE) is a collaboration between an integrated health system and the local Area Agency on Aging which was begun in 1995. SAGE  provided the organizational structure to develop the resources and processes needed to effectively integrate geriatric medical services and community-based long-term care services. Such integration is essential to bridging gaps between acute medical care and community-based care, enabling medical and social services providers to reach frail older adults living in the community with multiple chronic conditions, and to improve their quality of life. The SAGE project, which operates in the Akron, Ohio, metropolitan area, has managed to do just that. Results of the 17-year collaborative indicate that consumers, health care systems, health care providers, and payers have all benefited from the focus on integrating service delivery.

In the early 1990s, Summa Health System (SHS), an integrated not-for-profit health delivery system, had launched several projects aimed at improving care for frail elders. Summa comprises six community teaching hospitals with more than 2000 beds, as well as its own health plan, skilled home care, hospice, and a foundation. Summa’s insurance plan has 150,000 covered lives, including a Medicare Advantage Plan of 23,000.One of the projects being tested at Summa was the ACE (Acute Care for Elders) model, a model of hospital care delivery aimed at improving the functional status and clinical outcomes for hospitalized older adults. Recognizing that this model did not have the necessary patient connection in the outpatient setting, Summa realized it would need to expand its reach to elderly patients across the continuum of care. To this end, it created the Center for Senior Health (CSH), an outpatient consultative service that supports primary care providers by offering an interdisciplinary, comprehensive geriatric assessment; high-risk assessment; a geriatrics resource center; a clinical teaching center; inpatient geriatric consultation and outpatient consultation followup. The CSH attempts to treat and reach the whole patient by addressing acute and chronic medical needs, psychosocial needs, and family concerns. Despite the range of services provided, the CSH continued to be limited in its scope because it did not have access to patients in their homes, nor could it provide long-term case management. As a result, it began to rely increasingly on community-based long-term care agencies for this kind of information and management.

At about the same time, the Area Agency on Aging 10B, Inc. (AAA) found itself managing a growing number of consumers with functional decline, geriatric syndromes, and multiple chronic illnesses. The AAA, which serves more than 20,000 elders in Northeast Ohio, recognized that it needed to be better integrated with the acute medical sector if it were to achieve its goal of delaying and preventing nursing home admissions.

Leaders from Summa Health and the AAA recognized the challenges and deficits each one faced in providing continuity of care to patients/consumers, and began meeting to discuss how they could build a new, integrated model of care. They realized that they shared a common goal and vision to improve care for frail elders, and launched SAGE, which provided the organizational structure needed to effectively integrate their services. SAGE had no grants or funding, just a spirit of collaboration and cooperation, and a common desire to do more than just business as usual.

A SAGE task force was created comprised of staff from both organizations, including physicians, nurses, and social workers, as well as senior leaders, to promote communication, provide feedback, and create initiatives that linked the two. The group met monthly for two years, and now meets quarterly. Among its early objectives were the development of protocols to screen and identify at-risk older adults, to establish mechanisms for information sharing and resources, to identify gaps and duplication in service delivery, to locate a AAA case manager at the CSH, to educate staff from both organizations, to collect data and information, and to identify and address barriers to implementation.

Eventually SAGE created an RN care manager assessor program, in which placed an AAA assessor in the acute care hospital. The assessor works closely with the ACE team to identify hospitalized patients who can benefit from community-based programs, as well as patients who are eligible for PASSPORT, the state’s Medicaid waiver program. This was a new initiative for the AAA, which had traditionally conducted these assessments post-discharge, in the patient’s home. That assessment now occurs before the patient is even discharged from the hospital, thus helping to determine needs for  community based services and facilitating the process for eligibility  and approval for Medicaid long term care benefits.  This is beneficial because patients will typically receive Medicare covered services for skilled needs but long term care needs are not addressed as well and the Medicare skilled benefits are provided for only a limited time usually < 30 days.   Without the other supports this vulnerable population is at risk for poor health care access, emergency department visits and  hospital readmission. The AAA then assumes case management for the consumer, and offers periodic geriatric follow-up.

This program has facilitated improved capacity management for complex patients in the acute care hospital. It improved AAA communication with primary care and hospital staff, reducing repeat hospitalizations, ED visits, and nursing home placements. It improved outcomes for complex patients, and decreased discharges from PASSPORT to nursing homes. During the pilot period,  referrals to and enrollments in the PASSPORT program doubled.   The AAA was also successful in replicating this model at other hospital systems in the Northeastern Ohio AAA service area.  A more recent positive outcome  related to this collaboration work was the awarding for AAA 10b Inc. one of the first seven  Community Based Care Transitions projects from CMS/CMMI as part of the The Community-based Care Transitions Program (CCTP), created by Section 3026 of the Patient Protection and  Affordable Care Act

In developing SAGE, several barriers had to be overcome, primarily those affecting leadership of the program, development of an effective multidisciplinary workgroup, and resources (in terms of staff time). The program can be adapted by other communities around the country, offering their acute medical system and community-based programs a way to align their services and collaborate in ways that better address the needs of frail older adults.

Key words: community collaboration, SAGE Project, ACE Units, CCTP, 3026, pilot programs

Jul 202012

by Phil Burgess

There are two views of aging in America.

In one, a 70 year-old woman drives another to the doctor.  Across town, a later-life adult takes an even older neighbor to do her grocery shopping and then helps her bring the groceries into the house and makes sure they are properly stored.  When arthritis keeps a home-owner from installing his new storm windows, two volunteers go out to get the job done.  This is the view from the ground, where people are “aging in place,” where real people live, work and play.

There is another view.  That of the hand-wringing analysts and “big thinkers” who tell us that boomers are retiring at the rate of 10,000 a day for the next 18 years; that the number of Americans 65 years or older is about to double – from 35 million in 2000 to more than 70 million in 2030; that Social Security is headed for bankruptcy and Medicare has unfunded liabilities measured in trillions.  To some extent, they are right because our elected leaders are unwilling to address entitlement reforms and new approaches to taxes and spending that are required to get us on the right track.

But at the community level, enterprising Americans are problem solvers, not analysts and finger pointers.  They figure out who needs what and then set out to make it happen.  Somewhere along the way they invariably form a non-profit association to bring people together to get the job done.  Indeed, the American “do-it-yourself” tradition of forming local, voluntary associations to solve problems has deep roots in our culture.

The British statesman and political philosopher Edmund Burke called these voluntary associations the “little platoons” of society and argued that society’s little platoons will out-perform and out-innovate the big battalions of government on most days on most issues – especially human services.

I was privileged last week to see a pioneering and highly-effective little platoon up close.  Founded in 1993 and called Partners in Care – known as PIC – it is headquartered in Pasadena on Ritchie Highway.  Driven by feisty professional women, starting with CEO and co-founder Barbara Huston, and a steadfast, high-energy staff, PIC is dedicated to changing the experience of aging by enabling aging adults to remain in their own home, townhouse or apartment throughout their bonus years.

Last year, for example, PIC member-volunteers, most of whom are themselves seniors, contributed tens of thousands of hours to helping other seniors – including more than  9,000 rides for more than 160,000 miles of “door-through-door” and “arm-in-arm” transportation services.  Most transportation is for medical services – doctors’ appointments and the like – followed by grocery shopping and running errands such as banking and the post office.

PIC member-volunteers also provide home maintenance and handyman services that include fixing leaky faucets, changing light bulbs, painting, cutting the grass and installing home safety equipment – such as grab bars, railings, shower seats, and toilet risers.

PIC’s “lifeline” service provides a personal emergency response – e.g., “I’ve fallen and I can’t get up” – to help older adults live safely at home, providing a sense of security to those living alone and to their families, who may live down the street or hundreds or even thousands of miles away. And PIC provides advocacy services to help elders resolve issues with others in the community such as utilities and landlords.

Here’s how this little platoon works.  When PIC members provide a service, such as transportation, their time is “banked” in the PIC “time-exchange” – like a savings account.  “Though no one who needs a service is denied,” according to Huston, “the PIC exchange is based on the premise that everyone has time or talent to contribute – even if it’s to read a book to an elder with impaired eyesight.  When a member volunteer performs a task or service for another member, he or she earns credit hours that are banked for a later date or donated to another person.  By sharing skills among a large network of people, a community is created, the activities of daily living are accomplished, and people receiving help feel better because they earned it.  The result: Seniors are able to live at home, independently, well into later-life.”

The fact is most Americans in their bonus years are eager to use their gifts of time, talent, and treasure (including experience, not just money) to help others or repair that part of the world they can affect.  Part of PIC’s mission is to provide a way to channel that desire in the service of others.

PIC’s “virtual retirement community” is managed by a small staff.  Compared to assisted living, which can cost as much as $8,000 a month, aging-in-place seniors, who require fewer services, are served by PIC for less than $60 a month .  That is an advantage of a little platoon, “virtual community” approach to the growing national problem of longevity, an approach invented here in Anne Arundel County,.

Still, that $60 has to come from someplace.  The biggest single slice is earned income from The Boutique, located at 6 South Ritchie Highway, where people donate upscale used clothing, jewelry, furniture, glassware and other household items.  All donations and revenues from sales are used to support PIC programs that help older adults remain independent, living in their own homes.  The rest comes from competition for government grants (less than 10 percent), foundation grants, fundraisers and, most importantly, individual donations from community supporters and stakeholders.

Partners in Care is a community treasure.  Not just because it allows people to live out their bonus years at home.  Not just because it provides opportunities for older adults to use their gifts of time, talent and treasure to give back.  And not just because individuals aging in place dramatically reduce demand for taxpayer-funded medical and social services.  Partners in Care is a community treasure because it gives the rapidly-aging population of Anne Arundel and surrounding counties opportunities for giving back in the form of in-kind work and social engagement which, together, are the best predictors of successful aging.  As Marie Beynon Ray put it, “The only [later-life] choice that can’t be justified is retiring to a life of do-nothingness.”

Writer Phil Burgess, a columnist for the Annapolis Capital Gazette, is the author of Reboot: What to Do When Your Career is Over But Your Life Isn’t.  This post originally appeared in the Capital Lifestyle section on July 15, 2012. He is the president of the Annapolis Institute, and is interested in hearing from others about their post-career experience. You can email him at [email protected].

Key words: caregiving, community organizing, volunteer bank, aging in place, Partners In Care,

Jul 102012

Older residents (with fee-for-service Medicare) of a four-county region around Rochester, New York, are likely to benefit from the innovative programs being launched by a community-based care transitions project (CCTP) in that region. The “Community-wide Care Transitions Intervention” is anchored by Lifespan of Greater Rochester, a non-profit organization funded mostly by the Administration on Aging. The collaborative effort includes four acute care hospitals , two home health care agencies, and the regional independent health planning organization.

Of particular interest to MediCaring readers may be the involvement of the hospital pharmacist in this endeavor, which seems to be a key development to addressing the common problems of medication mismanagement. MediCaring talked to pharmacist Andrew Smith of Strong Memorial Hospital, and Brenda Bartock, RN, MPA, director of program development for Visiting Nurse Service of  Rochester and Monroe Co., Inc.

Smith explained that he receives a daily list of hospital admissions from which he selects the best candidates for the pharmacist intervention. The “best” candidates include those with what the program characterizes as an active Preventable Quality Indicator (PQI) diagnosis, or characteristics that put them at risk for re-hospitalization, such as comorbidities, polypharmacy, previous hospital admissions in the last year, or other risk factors such as living alone, absent social supports, or no transportation.  Smith then follows these patients during their hospitalization, meeting with them as soon as possible to discuss the enhanced hospitalization program and his availability to help them with medication. He will meet with them again near discharge, when he reviews medications with each patient (and family), focusing on what’s changed during the admission and what’s new, and letting them know that he is available to answer their questions. Using software called the Medication Action Plan, Smith gives patients an easy-to-read yet comprehensive medication list that they review together. He makes sure that prescriptions match insurers’ formularies and that schedules are workable for patients and family caregivers. Five days after discharge, he calls patients to follow up, making sure that they have not run into problems obtaining or using prescribed medications.

This is quite different from the usual process, in which there is no formal discharge planning with the pharmacist. Ordinarily, hospital pharmacists review what a patient has been prescribed during the stay, and not what was being used before the hospitalization. And although the pharmacist might occasionally see patients, that is not the norm.

Smith told MediCaring that, just three weeks into the program, he has seen some changes  being made. He offers services that the medical team often simply does not have time to address, such as helping patients to understand the need for a new medication and  helping them to reconcile pre-hospitalization medication routines with post-hospitalization routines.

Because the program was just launched in June, Smith says there has not really been an opportunity to see its effect on patients. He is not yet sure that the five-day follow-up call is the best timing. Smith also notes that the process enables him  to work more closely with physicians to develop medication management plans, providing doctors with information they welcome because it helps them to ensure that patients have workable routines.

According to Bartock, the pharmacy intervention helps to strengthen the program, and the case management it provides.  She says patients coming into the transitions program who have received the pharmacy intervention tend to be “in better shape than those who don’t have it.” In general, patients who are offered the intervention agree to participate in it. In just under three weeks, Smith says, he had seen approximately 20 patients.

Those interested in learning more about the Lifespan work can contact Mary Rose McBride at  585-244-8400, ext. 112 or  585-787-8376.

Key words: CCTP, care transitions, pharmacist, polypharmacy, frail elders, discharge planning

May 242012

Your 80-year-old mother, who can’t recognize you due to severe Alzheimer’s dementia, has developed pneumonia after being hospitalized with a broken hip. Her doctor has told you that she might pull through and that the medical team needs your input on how and where she will live after this episode: at home, or at a nursing home, and with what help—family, home care agency, and/or hospice. You realize that you don’t know what her wishes are—and that she can no longer express them. You also don’t know how you, as her sole family caregiver, will be able to take care of her or afford professional help in doing so. Meanwhile, the doctor is asking what measures should be taken, and for how long, to keep her alive. You don’t have the answers to those questions either. Suddenly, you feel very much alone, bewildered and overwhelmed.

In one sense, you’re not alone, as five prominent women writers recently explained during a roundtable discussion that Altarum Institute’s Center for Elder Care and Advanced Illness held on April 13. During the roundtable discussion, “The Last Word: Influential Women Discuss What Matters When Loved Ones Face Aging,” (watch it online on YouTube) the presenters—three of them geriatricians, and all of them influential social commentators and family caregivers—discussed their experiences in caring for aging loved ones and patients. The writers warned that the number of aging Americans who are struggling with these issues, along with their families and friends, is already substantial and growing rapidly.

Pulitzer Prize winning columnist Ellen Goodman introduced the panel with an overview of the state of aging in America, noting that the first members of the huge baby boomer generation will turn age 85 in 2031. This demographic “cannonball” is already hurtling toward us: each day, 10,000 baby boomers are turning 65. Goodman described her own experiences as a caregiver to her mother and related the constant and seemingly impossible decisions she had to make on her mother’s behalf. She noted that her experience has led her to develop a soon-to-be-launched program, The Conversation Project, aimed at encouraging people to think and talk about their preferences and priorities for the end of life.


Indeed, many of us haven’t given any thought to how we want to live out our final months; nor what role loved ones are likely to play during this final phase of life. Without such planning, the last months, when they come, are likely to be disorienting, frightening and overwhelming.

Geriatrician and family caregiver Cheryl Woodson, M.D., speaking from a decade of experience caring for a sick and aging parent, urged caregivers not to feel that they are not doing enough. Many have unrealistic expectations about what they can and should do, and failing to live up to these expectations can leave many feeling guilty and alone.

In fact, Dr. Woodson said, caregivers need to recognize and understand that we are facing social, cultural and demographic times unlike any in our history. We are facing a future with millions more “old old” people who will be more disabled and frail for longer than any previous generation. Caring for these aged loved ones, Woodson said, means “This is not your mama’s caregiving.” Indeed, it is a whole new world.

Dr. Muriel Gillick, a Harvard professor and geriatrician, addressed other unrealistic expectations many hold: The notion that if we simply eat well, exercise plenty and live right, we will live to a ripe old age and die in our sleep. That scenario is not likely to play out for the majority of us, who will, in fact, grow old and sick and die after many years of living with a serious chronic condition.

Author Susan Jacoby echoed this sentiment, pointed to the ways in which we deny the realities of aging and instead rely on the images we see in Viagra ads: That we will all be paragliding in our old age, living out fantasies and walking into the sunset hand-in-hand with our equally spry spouse. Instead, Jacoby suggested, we must pay attention to what we really face and acknowledge the hard realities of that future and find ways in which we can cope with frailty, illness and death.

Journalist Francine Russo gave a slightly different take on the world of caregiving during the roundtable, describing the dynamics of sibling relationships in the context of caring for aging parents. She noted that many of us will revert to roles we played as children, and that those old roles will not serve us well in our efforts to serve our parents—indeed, they can tear families apart.

Finally, geriatrician Joanne Lynn described her experiences as a physician and a family caregiver, noting that in the years when she herself cared for a very sick child and a very frail in-law, she could always find people willing to support her in the former work, but very rare to offer help in the latter. She spoke of the need for neighborliness in the future, for finding ways that communities and individuals can come together to share the common work of caring for the aged. She suggested that reforms must come at the local level and that communities need to set priorities for elder care and advanced illness and determine the shape and course of their own programs and services for frail elders.

The panelists agreed on various steps proposed—ranging from policy changes to discussions families can and should conduct—to plan for the provision of supportive services that preserve the comfort and dignity of frail elders. Such steps should also take into account both the elder’s and their caregivers’ emotional wellbeing and financial solvency from the onset of aging-related disability through death.

Mar 272012

From Dr. Joanne Lynn, Director, Center for Elder Care and Advanced Illness, Altarum Institute 

“Nothing about me without me!”  That’s the cry of the disability community and the AIDS community and so many others affected by health care dysfunctions.  But for the elderly, thus far, it has been acceptable for everyone else to shape the care system – the doctors, the drug companies, the Congress, the managed care companies, the care coordinators, and on and on. But where are the voices of the elderly?  When do we hear from the folks providing support and love for disabled elderly persons? 

We desperately need that voice.  Without it, we are prone to make decisions in the interests of the status quo or to prioritize myths and provider interests that don’t match what elderly people and their families most need.  The frail and ill elderly are only sometimes able to voice their own needs – but they mostly have family who love and support them, and those family caregivers can become the key to building an efficient and reliable set of supports and services.

Most of us are now or will be family caregivers – and now, most family caregivers are overwhelmed, unorganized, and voiceless.  We need to change that.  Family caregivers need to speak up on behalf of their elderly loved ones, and themselves, and push back on commonplace presumptions as to what matters most at this time of life.  But those of us who are not right now overwhelmed with care needs need to make it easier for family caregivers to have a voice!

That’s the point of our “Agitator’s Guide” (https://medicaring.org/action-guides/agitators-guide/). We’ve drafted up some specific things anyone can do—RIGHT NOW—to improve the lives of frail elders in your community.   We are looking for your advice.  Tell us what possibilities strike you as worthy.  Try one or two out, and let us know how it goes.  All of us aging persons need to weigh in on this and hit upon some acts that change the power of inertia – that is, “keeping doing what we’ve been doing” – which gets us nowhere. 

The time for speaking out is now – we risk being overwhelmed with the costs and challenges of elder care as the numbers double. We must make services appropriate, reliable, and efficient.  Let’s try out some avenues and see what works!

key words: eldercare, advocacy, quality improvement, patient engagement