…and Experience Comes from Bad Judgment

In Tuesday’s post, I gave full rein to my fears about the possible faults and flaws with current federal Medicare quality improvement demonstrations. While I stand by what I wrote, I felt the immediate guilt of being caught stones in hand in a pretty drafty glass house.

Over the last 15 years I have participated in or directed (from the funder side) more projects than I can recall, efforts to demonstrate and disseminate improved models of care. And while I will stack the Foundation’s record up to anyone’s, my contention that most things don’t work unfortunately also applies to us. Most of the demonstration efforts we have supported have failed to influence practice widely, therefore failing to meet OUR objective for them: to improve the health of older Americans.

During those 15 years we have learned more and more about what is needed to drive change in health care delivery, one painful lesson at a time. We have learned that good ideas are not enough. Even those ideas that have gone through the development and testing phase to successfully answer the question Does it work? still need to publicize their existence and set up technical assistance and tools for their adoption. They need conducive attitudinal, regulatory, and financial conditions under which they can grow and flourish. “Experiences” abound at every level. So, in the spirit of sharing lessons learned, here is a non-exhaustive list:

Read the rest of this entry »

© iStockphoto.com/shaunl

In case you hadn’t noticed the coincidence, Groundhog Day and the conclusion of the Centers for Medicare and Medicaid Innovation’s Innovation Challenge grant program are both coming very soon. While it might not be readily apparent, I think this is a sign.

For those of you who don’t favor light comedy, Groundhog Day is not only the day that Punxatawny Phil (or a similar groundhog) predicts the change of the seasons, but also the title of a Bill Murray/Andie MacDowell movie in which a misanthropic weather man is doomed to relive that very same day over and over again until he learns to get it (and life) right.

Read the rest of this entry »

Delirium is acute brain failure, characterized by disorientation and confusion. Occurring in approximately 25% of older hospitalized patients, up to 50% of older surgical patients, and up to 75% of older intensive care unit patients, delirium is all too common. When it occurs, delirium is bad for patients during the hospital stay and afterward. Patients who develop delirium have a death rate similar to heart attack, an increased hospital complication rate, and an increased rate of nursing home placement compared to patients who do not develop delirium.

An interdisciplinary group of healthcare professionals is trying to improve delirium for patients. With support from the John A. Hartford Foundation, in November 2011 they published “Advancing Delirium Science: Systems, Mechanisms, and Management” as a supplement to the Journal of the American Geriatrics Society. Co-editor Marianne Shaughnessy, PhD, CRNP, stated, “The supplement was a mechanism to pull together experts from many disciplines with a common goal–advancing delirium science.”

The supplement focuses on three key areas with forward-thinking pieces written by leading experts from many countries. For example, one of the systems articles highlights the Johns Hopkins Delirium Consortium, sharing their model of interdisciplinary and interdepartmental collaboration across two hospitals. In the mechanisms section, Dr. Barbar Khan reviews the available biomarkers for delirium. Drs. Joseph Flaherty and Milta Little describe the Delirium Room model of care in the management section.

Read the rest of this entry »

Consider this: a woman is hospitalized for pneumonia and her admission chest x-ray shows an “incidental pulmonary nodule,” or a growth in the lungs.  Should she receive serial follow-up imaging to determine the presence of cancer?

Of course! She may have cancer, and who wouldn’t want to know for sure and start treating it?

What if the woman is 85 years old with congestive heart failure, chronic kidney disease, chronic malnutrition, and needs help from others to bathe and dress?

What if, based on these characteristics, you knew her life expectancy and that she will most likely die before a definitive cancer diagnosis and treatment could offer any benefit to her?

Read the rest of this entry »

At least once a week for the last 10 years, I have probably said or written that our fragmented and myopic, episodically focused system of care doesn’t meet the needs of older adults with complex, chronic health problems. And if there is one growing aging issue that throws even more sand in the gears of what little systematic care we have, it’s dementia. In this week’s Journal of the American Medical Association, Elizabeth Phelan, a Beeson Scholar alumna, offers powerful evidence about the consequences of this misfit between the capacities of our primary care system and the needs of older adults with dementia, even in one of the best primary care systems in the country, Group Health Cooperative in Seattle, Washington.

Dr. Phelan, along with her colleagues and mentors at the University of Washington/Group Health Cooperative, used an epidemiological study of dementia incidence among senior members of Group Health in Seattle to assess rates of hospitalization for patients with and without dementia. Controlling for age, sex, and rates of co-morbid illness, she found that all-cause hospitalization was 41% higher for patients with dementia. The raw admission rates were 200 admissions per 1,000 patients per year for those without dementia versus 419 admissions per 1,000 patients per year after the onset of dementia.

To make matters worse, when you look at admissions for potentially preventable, ambulatory-care- sensitive conditions–things like urinary tract infections and congestive heart failure that should respond to careful outpatient management–the differential between non-demented and demented was even greater. Raw rates of admissions were 37 per 1,000 patients per year for the non-demented versus 106 per 1,000 patients per year for the demented. Fully adjusted for other, concurrent medical conditions, ambulatory-care-sensitive admissions were 78% higher among the demented than non-demented patients. Now, we don’t know how many of these admissions might actually be preventable, but some surely were. The size of difference is absolutely terrifying.

Read the rest of this entry »

From left: the author, her grandmother, and her brother, Nick

It is a pleasure to introduce myself as a new member of the John A. Hartford Foundation staff.  In the brief two months that I have been with the Foundation, I have felt overwhelmingly inspired by the dedication and passion of my colleagues and the tremendous amount of progress made by the Foundation’s grantees toward our shared mission of improving the health of older Americans.

As a California native, I came to New York City fresh out of undergraduate education at UC Santa Barbara and jumped into management consulting for nonprofit and philanthropic organizations.  This work introduced me to the importance of philanthropy as an agent for social change.  Prior to joining the Foundation, I worked with the New York City Department of Health and Mental Hygiene’s Primary Care Information Project (PCIP).  This Mayoral Initiative seeks to improve the quality of care in underserved communities through the use of health information technology (HIT) and helps NYC primary care providers achieve “Meaningful Use” as defined by the federal government.  My work with PCIP introduced me to the lack of and the need for patient-centeredness and care transitions, which are vital to improving health care delivery and reducing costs.  At PCIP, I began focusing my career on improving the quality of health care for all Americans.

Read the rest of this entry »

Shortly before the holidays, I had the privilege of speaking with geropsychiatrist and researcher Dr. Stephen Thielke, a recipient of the Paul B. Beeson Award, which is funded in part by the John A. Hartford Foundation.  I was excited to hear about the work that he and his colleagues are doing to dispel myths and stereotypes about pain and aging.  Among them are the notions that pain is a natural part of getting older, that pain inevitably gets worse once it is present, that people who tough it out become accustomed to pain, and that pain medications are highly addictive.  While it all sounds innocuous, this conventional wisdom limits the choice of treatment and the care that older adults receive and ultimately sets boundaries on their quality of life.  So it’s important to get the word out that the real evidence, in fact, encourages optimism.  More on that shortly. 

But first, a few words of introduction.  As I learned, there’s a nexus of connections at the heart of this work with links to the Hartford Foundation.  Indeed, a significant part of what we do at the Foundation is to bring thought leaders together.  As some of our readers may know, Dr. Thielke is an Assistant Professor in the University of Washington’s Department of Psychiatry and Behavioral Sciences, and he is also the Associate Director for Education at the GRECC of the Seattle Puget Sound Veteran’s Administration.  Early in his career, Dr. Thielke received a Hartford-funded professional development award for aspiring young scholars devoted to geriatric health outcomes research.  It was during this time that he met Dr. Cary Reid, a fellow Beeson alumnus and the Director of the Hartford Center of Excellence in Geriatrics at Weill Cornell.  Dr. Reid’s mentorship enabled him to develop a research program on the effects of chronic pain on quality of life among older adults.  Along with Dr. Joanna Sale, a researcher from the University of Toronto, they began to explore the stereotypes that older adults have about chronic pain and its treatments.  Together, they discovered that myths and misconceptions about pain are common, and that they influence how people live with and manage their pain.  (For queries, contact Dr. Thielke here.)  Identifying and addressing such stereotypes is one of the key unmet needs in pain management.

So what’s the real evidence, and how is it important to patients and providers?  While more research needs to be done around the factors that influence pain outcomes, initial research shows that pain doesn’t occur more often in older adults, that it is more transitory than we think, that toughing it out is not the best approach, and that the medications used to treat pain are not highly addictive in general.  These findings highlight the benefits of appropriate treatment.  The bottom line is that patients shouldn’t give up.  They should work with their providers to identify what works best for them, and that can mean physical activity in addition to pills.

Read the rest of this entry »

Happy New Year!

The New Year brings us to the 30th anniversary of the Foundation’s Aging and Health program and a transition to its future.  In 1982, the Foundation began a project, as a small part of its overall work in Health Care Cost and Quality, to recruit physician faculty from other fields into geriatrics.  The retraining of these physicians started our efforts to address the shortage of academic leaders in what was foreseen to be a vital discipline for the future aging population.  Fast-forward 30 years, and the Foundation has invested hundreds of millions of dollars in the development of faculty and geriatrics curricular models and tools in three key health care disciplines — medicine, nursing, and social work — while maintaining its long-standing commitment to developing and disseminating innovative models of care in which these professionals work.

And finally, after what seems like years of crying in the wilderness supporting programs that have received little notice outside of the small geriatrics community, it feels like our time has come.  The leading edge of the Baby Boom cohort started turning 65 in 2011.  Health reform passed in 2010 and, despite its focus on regulating commercial health insurance and expanding coverage for the uninsured, has significant provisions for reforming the delivery of care to the Medicare and Medicaid populations and even some attention to workforce issues.  The national conversation on health care clearly recognizes that we are on an unsustainable pathway and that the Medicare program must lead the way in delivering better care for lower costs.

We are tremendously proud of the accomplishments of our grantees in these efforts.  They have pioneered service delivery innovations that the Center for Medicare and Medicaid Innovation (CMMI) will expand.  They have developed educational programs that will provide future professionals with the skills they need to serve their future patients.  In every field, energized and exciting grantees and alumni are ready to share their expertise, improve the quality of care, discover new knowledge, and most importantly, get involved in leading change at all levels — institutional, professional, and policy.  These people, whose lives and careers we have been privileged to touch, are a national asset and an appreciating one — their influence and impact is still only beginning to be felt.

Read the rest of this entry »

Live it up in 2012!

Best wishes for a joyous and healthy New Year from Health AGEnda and the John A. Hartford Foundation

It seems like only yesterday that I met Dr. Pat Archbold, and it is not without a pang of sadness that I must here announce that as of December 31, 2011, she will be stepping down as the director of our Hartford Building Academic Geriatric Nursing Capacity  (BAGNC) Initiative housed at the American Academy of Nursing.

Six years ago I took a long walk down a dirt road with Pat Archbold and Patty Franklin, then BAGNC program manager, on the grounds of the Aspen Institute Wye River Conference Center.  It was during the NIA Summer Institute nursing preconference, which was organized by Dr. Taylor Harden.  I was a new program officer, Pat had recently taken over the leadership of the BAGNC Initiative, and we were brainstorming our first major effort together–a 2005 renewal of the Initiative. One couldn’t ask for a better setting for long walks and serious conversation. We were very far from our rooms when the summer sky gathered its clouds and burst. Without umbrellas or gear, without anywhere to take cover, we were drenched in an instant.

A pickup truck came rolling down the road, and Pat suggested we catch a ride. The driver kindly stopped, and we climbed into the bed of the truck.  I will forever cherish the memory of sitting in the bed of that pickup truck in the pouring rain with Pat Archbold.

Read the rest of this entry »