Angry Yet? Sequestration Hits Meals on Wheels!

 Posted by on April 30, 2013  No Responses »  Tagged with: , , ,
Apr 302013
 

After a week of reading about the effects of sequestration on air travelers—the inconvenience, the waits—we were struck by today’s [April 30, 2013] Huffington Post article on how sequestration is playing out on the lives of a more vulnerable group of people: America’s elders. When last we checked (around 3 pm, ET), more than 10,000 people had commented on the article, “Meals on Wheels Sequestration Cuts Taking Effect,” http://www.huffingtonpost.com/2013/04/29/meals-on-wheels-sequestration_n_3165256.html?view=screen

To be sure, disruptions in air travel disrupt people’s lives and, in some ways, impinge on their safety. But as the sequestration begins to take its toll on social services programs around the country, we all will start seeing its devastating effects on the lives, safety, and well-being of other groups: People less likely or able to speak up, speak out, and demand congressional responses.

As Huffington Post reports today, sequestration means that millions of Meals on Wheels meals will not be prepared or delivered—anywhere from 4 to 19 million, depending on who is making the estimate—nationwide. The article describes how one Meals on Wheels recipient, William McCormick, a resident of Roanoke, Virginia, is responding to news of cuts to the program on which he has relied since 2005: He has decided he can, somehow, get by on his own. Despite the fact that he lives with multiple chronic conditions, has no car, and lives on his own, he is convinced that he can somehow make do—which is more, he thinks, than others in his situation can manage. McCormick harkens to his own boyhood, when neighbors looked out for and helped neighbors who were down on their luck.

In years to come, we are likely to face this kind of dilemma more and more often. Our failure or inability to confront problems created by an aging society and a fragmented health care system mean that millions of us face a future in which we will rely on the kindness of our communities to keep us housed, clothed, and fed—and we have to be worried that neighborliness and charity will simply be insufficient.

We face so many problems—as individuals, and as a society. For the short-term (or short-sighted), it can sometimes just seem easier to focus on things that affect us directly: Don’t make ME late by delaying MY plane!  We really need to find ways to take a longer view—and one that is based on conscience and compassion. We cannot be a decent society and let frail older people go without food (or young children go without school, or any of the other social programs that are falling by the wayside).  Where are our priorities—and when will Congress hear them?

key words: sequestration, Meals on Wheels, Huffington Post, frail elders

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Keeping Track of Dementia Patients: Would a Universal Identifier Help?

 Posted by on November 19, 2012  No Responses »  Tagged with: , , , ,
Nov 192012
 

By Maryann Ingram

I am caregiver to my live-in sister-in-law who has Korsakoffs and vascular dementia, with the onset at age 59. She lived in a nursing home for six years and then came to live with me last October under the “older adult living at home” waiver program.

I take her to all of her doctor appointments, and carry in hand my own “cheat sheet “ that contains important information, such as her medication list, her immunization history, code status, religion, list of all her doctors, and her medical history with dementia written across it in bold capital letters. I also include a copy of my power of attorney.

Recently, I escorted her to a local hospital for a cardiac procedure. While we were there, I told everyone we came in contact with that she had dementia. This list of people included the registration person, the admitting nurse, the nurse practitioner taking her history, the technician starting the IV, and the procedure nurse.

I informed them all that she had dementia and to be aware her answers to their questions would mostly be unreliable. I was amazed when the doctor completed the procedure and came out to speak to me:  He told me that the procedure had gone well, there no changes from her last study, and there was no need to do a stent. Still, he said, he remained puzzled by her symptoms.

“What symptoms?” I asked.

He replied that she had told him she was very short of breath and, for the past several weeks, had been unable to take her daily three-mile walk.

I had to laugh, just to keep my frustrations from being expose—then I told him about her dementia, and that she had never walked three miles daily. Last spring, I mentioned, we had taken an occasional walk in the park.

His jaw almost dropped. “Oh!” was all he could say. I informed him that I had told absolutely every person with whom we had come into contact that she had dementia, and that I had asked each one to label her chart, DEMENTIA.

I really wondered why he had not been told , but he treaded lightly and quickly changed the subject .

I decided to speak to the hospital patient advocate and simply told her the situation and then I said: “You put a bright red armband on FALL RISK patients. You clearly identify those who have drug allergies, don’t you?” She said that they did.

I suggested then that perhaps the hospital could do something similar to identify dementia patients, perhaps to giving them a purple wristband that would identify them, and note that they presented safety risks, unreliable information, and so on.

Has anyone ever considered such a universal identification system for patients living with dementia? It seems to be a real safety issue for them, and for their caregivers. I’m curious to know whether other MediCaring readers have had similar experiences, and what they make of my suggestion.

You can contact Maryann Ingram in care of medicaring at [email protected] Ms. Ingram, an LPN with 20 years of experience in long-term care, is serving her second term as an appointed member of the Maryland Board of Nursing.

key words: dementia, Alzheimer’s disease, long-term care

 

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Reaching Rural Residents: Improving Care Transitions in Western New York State

 Posted by on August 23, 2012  No Responses »  Tagged with: , , , , , , ,
Aug 232012
 

The P2 Collaborative of Western New York [name was changed to Population Health Collaborative in 2017] represents a different spin on the Community-based Care Transitions Program (CCTP) model. It is unique in its focus on a very rural area of Western New York, and is unusual in that it is one of a few  community-based organizations in CCTP that is NOT an Area Agency on Aging. P2 is a non-profit regional health improvement collaborative, with origins as a Robert Wood Johnson-funded Aligning Forces for Quality community project. Through that work, it has engaged in various activities within eight counties in Western New York.

As Megan Havey, Manager of Care Transitions, explains, “P2 doesn’t provide direct services, but acts as a facilitator to members of the collaborative.” The scope of the project really called for coordination by a regionally based group, one that could work with and understand the diversity of partners, and that could offer the sort of infrastructure support that such a collaborative would require.

The collaborative is one of the largest in the CMS CCTP portfolio. It includes eight local community-based organizations (CBOs) and ten hospitals, and works with other community agencies, organizations, and foundations including the Health Foundation for Western & Central New York, IPRO (the QIO), the Alzheimer’s Association, local  hospice organizations, and county health departments.  The work sprawls across seven counties, with programs that aim to serve more than 2,600 patients annually. The diversity of participating organizations is remarkable, ranging from a 5-bed to a 150-plus-bed hospital.

Over the last six years, many of the participating organizations had participated in pilot programs to improve care transitions. Other groups had little experience, but, Havey says, “…were in a great position to be mentored by groups that had experience.” In building the application, IPRO helped with many tasks, such as creating templates to conduct the required root-cause analysis, analyzing admissions data, and convening partner organizations. Havey says that although IPRO has now “stepped back” from the project, P2 continues to solicit IPRO for technical assistance and support.

The application process was instructive, Havey says, in helping the partners to appreciate just how flexible the project would need to be. “Each county had a very different target population and model,” she says. “It was important  to be able to engage partners and obtain their buy in, but also to be realistic about what we could achieve in each county. We could not create a cookie cutter model.” All of the local CBOs and hospitals are using the Coleman model, the Care Transitions Intervention™, and are targeting Medicare Fee-For-Service patients.

Havey says that developing a web-based data platform that all partners could use has been an essential step. The platform had to accommodate the range of reporting capacity partners bring to the project. To that end, P2 worked with a software company to invest in and develop a platform all hospitals could use to enter data about eligible patients. The system operates within the context of the Care Transitions Intervention, and allows care managers to document data about home and hospital visits, as well as follow-up calls and evaluation information.

Havey notes special challenges in serving a rural population, particularly in terms of accessing care. There are not enough providers, she says, and transportation to get to them can be difficult. “Rural counties have very poor health outcomes, with many medically underserved areas and populations. Our goal is to reduce readmission rates with an intervention that leads to better health outcomes and improves quality of life.”

Key words: care transitions, CCTP, Section 3026, rural residents, readmissions

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SAGE: Bridging the Divide between Acute Medical Care and Social Services in Northeast Ohio

 Posted by on July 23, 2012  No Responses »  Tagged with: , , , , , , , , ,
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

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Aging in place with in-kind work

 Posted by on July 20, 2012  No Responses »  Tagged with: , , , , , ,
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,

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Hospital Pharmacist Plays a Role in New-York Based CCTP Program

 Posted by on July 10, 2012  No Responses »  Tagged with: , , , , , , ,
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

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PEACE: Effective Collaboration Between Medical Services and Social Services

 Posted by on June 19, 2012  No Responses »  Tagged with: , , ,
Jun 192012
 

Since 1995,  Ohio-based Summa Health System and its partners have led a collaborative, the SAGE Project (Summa Health System/Area Agency on Aging, 10B/Geriatric Evaluation Project), which has worked to improve care for the state’s most vulnerable elders by integrating the aging network, and its social services, with health and medical care. The project aims to integrate a comprehensive hospital-based clinical program with the community aging network to improve the health and functional status of older adults, and prevent institutionalization for those at risk for nursing home placement.

More recently, members from the SAGE project have been working on the PEACE Trial (Promoting Effective Advanced Care for Elders), an initiative funded by the National Palliative Care Research Center and the Summa Foundation. In addition to Summa and the AAA, the project involves the University of Akron, Kent State University, and the Northeastern Ohio Universities Colleges of Medicine and Pharmacy. The randomized controlled pilot study features a geri-palliative care case management intervention for Ohio consumers who are participants in the state’s long-term care Medicaid waiver program, PASSPORT. The intervention involves collaborative care between a hospital-based interdisciplinary care team, the AAA, and the consumer’s own primary care provider.

Like other older adults throughout the nation, Ohio’s community-dwelling patients who had poor symptom control and coordination of care often experienced exacerbations that led to hospitalizations. Frequently, these elders  have not documented their advance care preferences, and so arrive in the hospital, where family members are left to make critical decisions for which they are unprepared.

The PEACE Trial seeks to change this dynamic by focusing on health coaching and patient activation for self management,  while promoting advance care planning discussions with primary care providers. The target population includes new PASSPORT enrollees over the age of 60 who are living with one of 9 life-limiting conditions. Nurse assesssors—care managers—from the AAA screen patients at the time of their initial PASSPORT assessment; patients are then randomized to the control or intervention group.

AAA nurse or social worker care managers engage with consumers in a variety of activities. Care managers make two home visits, for example, centered on symptom assessment and advance care planning. They review findings with an interdisciplinary team, which makes appropriate recommendations for the patient and the primary care provider. The care manager next accompanies the consumer to one visit with the primary care provider to discuss advance care goals. Following this, the care manager and the palliative care nurse supervisor make an additional home visit to begin to implement the care plan. The consumer then receives up to one year of monthly follow-up visits from the care manager.

Researchers are tracking outcomes, measured at 3-, 6-, 9- and 12- month intervals. Outcomes include symptom management, quality of life/death, relationships, patient activiation and decision making, and depression and anxiety.

An initial challenge was in getting buy-in from care managers, and in changing the culture of the AAA. However, all care managers eventually expressed their appreciation of the value of the project for improving consumer outcomes. The project is working to get more “top-down” support from the AAA so that participating care managers receive the support they need to work with consumers, including education and skills to engage them.   The researchers and case managers also realized they needed more formal curriculum to teach effective methods and skills for advanced care planning discussions and goal settings. A second project was developed to create an online learning curriculum through the support of the First Merit Foundation and led by the University of Akron College of Nursing.  A key challenge has been to avoid “medicalizing” the care plans, making sure that they attend to human/emotional factors as well as health and medical status.

The program’s strength lies in the strong working relationship among all the partners, particularly in the commitment of the AAA to improve care for frail elders. Partners report that they are “becoming bilingual”, that culture sensitivity and knowledge sharing between the aging network and acute care providers has grown.

For more information, see Results of the promoting effective advance care planning for elders (PEACE) randomized pilot study (2014) by Dr. Skip Radwany et al.

Key words: PEACE trial, palliative care, geriatrics, AAA, collaboration

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Baby Boomers and the Demographic “Cannonball”

 Posted by on May 24, 2012  No Responses »  Tagged with: , ,
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.

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Quality of Life Investments for Frail and Disabled Elders

 Posted by on May 22, 2012  No Responses »  Tagged with: , , ,
May 222012
 

By Joanne Lynn, M.D.

Readers of this blog are familiar with—and mostly supportive of—these two claims: (1) that social and environmental factors are stronger than health care services in shaping the population’s health, but (2) those factors are weaker than health care services in securing funding and public attention. Most of us are convinced that sending more funds and public support toward healthy food and exercise would do more to improve health than sending those funds toward high-cost medications or surgeries.

My question here is whether we can usefully apply the same perspective to the care needed for frail and disabled elders. Some will want to stop and contend that prevention of disability would still be the priority, and that argument has merit, of course. But “prevention” of disability associated with aging is really mostly delay, and most of us will have a period of serious disability before dying, no matter how well we eat and exercise.

As we age and accumulate illnesses and disabilities, we ordinarily need more and more support to get through the day, and we become less and less able to travel to get what we need. Furthermore, what we most need has to be local—no one travels to a referral medical center for spoon feeding or bed baths! So, we come to be tied to our communities, and to the housing, transportation, service supply and service coordination that our local system offers.

A community that has encouraged substantial new building with universal design and substantial retro-fitting of old buildings will have more elders able to stay at home longer, in comparison with one that is inattentive to making its housing stock elder-friendly. Some communities provide substantial non-medical services such as counseling for personal and financial planning, in-home nutrition and caregiver support, and keeping caregivers and elders in relationship with others. Those communities will have less reliance on nursing homes and hospitals, which is generally what aging persons strongly prefer. Senior-friendly housing and transportation are absolutely essential to the well-being of frail elders.

These claims appear to me to parallel the arguments for attention to social and environmental determinants of health generally. Indeed, the call for an “integrator” function to set priorities and manage systems to achieve population health locally seems also to be the right direction for elder care. If anything, elder care even more urgently needs integration across social services, housing, long-term-care services and health care services. A great deal of public and private funding goes into the uncoordinated cacophony of programs that aim to provide support and health care to frail elders, using probably about half of our lifetime expenditures on illness and disability and yielding remarkable waste, gaps, inefficiency and frustration. We need that integrator—and the integrator needs tools and authority.

In some other countries, care of the disabled and elderly is part of the public health system, alongside maternal-infant health and infectious disease. In the United States, however, services for the disabled and elderly have been outside of the scope of public health practitioners, who generally seem to lose interest when primary prevention fails (as it must). Indeed, at least for the elderly, the U.S. has mostly split the medical services into a quite separate category from the social supports. We fund health care with an open checkbook and we measure quality mostly as if each person faced at most one health challenge. In contrast, we primarily fund social services as poverty programs and rarely measure their quality at all.

From my perspective, engendering a way to manage the local system for elder care across medical and social issues is key to achieving “Triple Aim” goals. Can those advocating for attention to social and environmental determinants of health come to include frail elders and disabled persons in their scope? Well-being while living with serious and even fatal disabling conditions counts. Most of us will live for multiple years in this state—and some of us for much longer. Can’t we come to count improved well-being while ill as part of population health, and employ the tools, perspectives and personnel that now advocate for healthy built environments?

About this post:

This week (May 2012),  Joanne Lynn, M.D., Director for the Altarum Center for Eldercare and Advanced Illness, blogs on Improving Population Health. A few months ago (February 2012), David Kindig asked readers, “Where Would You Put the Money?” Dr. Lynn responded with a provocative comment, which she expands on here. This is reposted with permission of IPH, and is cross-posted on Altarum Institute’s blog, Health Policy Forum).

Key words: population health, frail elders, local integrator function, public health

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“The Last Word” Author Roundtable Video

 Posted by on April 27, 2012  No Responses »  Tagged with: , , , ,
Apr 272012
 

On April 13, 2012, Altarum Institute and the Center for Elder Care and Advanced Illness, cosponsored a special event: The Last Word: Influential Women Discuss What Matters When Loved Ones Face Aging.” Moderated by Pulitzer-Prize winning columnist Ellen Goodman, the program featured panelists Cheryl Woodson, Muriel Gillick, Susan Jacoby, Francine Russo, and Joanne Lynn. The group discussed experiences as family caregivers, interactions with patients and families, and myths about what it means to grow old in America. Their conversation sparked lots of enthusiasm and interest.

To watch the entire program, follow this link:

http://www.youtube.com/watch?v=wMDO1RE1vbY&feature=youtu.be

Key words:  Ellen Goodman, Susan Jacoby, Francine Russo, Cheryl Woodson, Muriel Gillick, Joanne Lynn, Janice Lynch Schuster, Altarum Institute, end of life, public policy, aging, caregiving

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