This past weekend I sat with some of the top leaders in geriatrics and heard them rail against usual care for older adults by specialists and non-geriatrically trained generalists. They complained bitterly about oncologists who wildly overtreat the frail and yet undertreat the vigorous, cardiac procedures done without patient benefit, and silo mentalities that predictably put complexly ill people on trajectories of misadventure, hospital readmission, and decline.
However, in public, I know that most professionals will not break the white-coat wall of silence and denounce their colleagues for inappropriate care. And so, the fact that non-geriatrically informed care doesn’t have to be our usual care escapes most people. Unless you’ve been very lucky and seen someone receive geriatrically skilled, compassionate, and patient-centered care, you don’t know what you’re missing. And it is very hard to create demand for things that no one knows.
As I thought about this problem, I realized that I had also heard many of those same railing voices talk about how to deliver good care to older adults—not in a conference room or a big meeting, but all by myself while running on the treadmill at my local Y. Not an hypoxia-induced hallucination, but really real.
Over the weekend I was at a meeting where Bruce Vladeck, former Centers for Medicare and Medicaid Services administrator (back when the agency was known as The Health Care Financing Administration), said something that really resonated with me. Commenting on the “disconnect” between the potential of geriatrics as a field and the urgent needs of older adults, he said that efforts to “geriatricize” medical education will be insufficient. “Young physicians will know more geriatrics than ever, but it will be drowned out in all the other ‘noise’ surrounding their practice. You can’t bridge the disconnect by reinventing doctors. You have to change systems.”
I couldn’t agree more and our new strategic plan focuses on bridging just this disconnect by bringing geriatric expertise to bear on critical leverage points in health care. So, I am very proud to announce the first cohort of the Practice Change Leaders, our newest effort to drive systems change by building on the capabilities of geriatrics experts and alumni of Foundation programs. The list of scholars and their projects is at the bottom of this post.
The Practice Change Leaders for Aging and Health program grows out of the success of the Practice Change Fellows (PCF) program which has offered advanced leadership and systems change training to 40 geriatric health care professionals since its inception in 2007. In this next generation program, the leadership (Eric A. Coleman, MD, and Nancy Whitelaw, PhD) and mentors from the PCF will work with alumni of the federal Innovation Advisors Program, a special leadership program sponsored by the Center for Medicare and Medicaid Innovation to help advance delivery system reform to meet the needs of older adults.
Change doesn’t just happen. It requires bold leadership, innovative thinking, resourcefulness, and an unwavering determination to swim against the tide when necessary.
So where will we find the leaders we so desperately need to bring change to our unwieldy and dysfunctional health care system? Practice Change Leaders for Aging and Health, a new national program co-funded by the John A. Hartford Foundation and The Atlantic Philanthropies, represents a significant step toward answering that question.
Starting on Jan. 1, 2013, the Practice Change Leaders Program will choose 10 health care leaders per year for three years through a rigorous, competitive application process. Those selected will receive one year of funding to complete innovative projects and expand their effectiveness as organizational leaders.
Medicare has become a central issue during this heated election season, but the debates are loud, confusing, and often play off fear, intergenerational conflict, and ideological differences about the role of government. Unfortunately, what gets lost in the raucous debate is the opportunity we all have at this particular moment to preserve Medicare, lower its costs, and at the same time improve people’s health.
How can we do this? By working together—no matter our political persuasion—to transform the way care is delivered in Medicare and throughout the U.S. health care system.
I had the opportunity last week to see a federal program that is doing just that. It was the last meeting of this year’s Innovation Advisors, participants in an initiative sponsored by the Center for Medicare and Medicaid Innovation, created under the Affordable Care Act. My colleague, Amy Berman, introduced readers to the Innovation Advisors back in February, and has been involved in their training and development since. The goal of the program is to support individuals who can test and refine new models to drive delivery system reform—models that result in better care, better health, and lower costs.
The Center for Medicare and Medicaid Services and its Center for Medicare and Medicaid Innovation has just announced its new Innovation Advisors fellowship program. This fast track program (applications due November 15, 2011) will offer:
An opportunity to become an integral part of CMMI’s efforts to transform health care nationwide
National and regional networking opportunities with other leading health care innovators
A caricature of how philanthropy stimulated social change in “the good old days,” derisively called Philanthropy 1.0, describes the process this way: first, private funding helped successfully develop an innovation; the innovation then gained recognition; and finally the government rushed in to adopt it and take it to scale. (If you build a better mouse-trap, the world will beat a path to your door.) In the cynical modern perspective, this process of adoption, if it ever really happened, stopped with the Great Society programs of the Johnson administration.
Today, in the supposedly more complicated age of Philanthropy 2.0, program sustainability is thought to derive from complex business plans (e.g., combining government support with earned revenue and public fundraising) or from political advocacy processes, including stakeholder capacity development, lobbying, and ultimately, legislative action.
But the world is wide, and every once in a while, if you do build a better mousetrap, work hard to polish it, connect it to stakeholders, and remain patient—the world will come to your door. This week we are celebrating a new partnership with the National Institute on Aging, our third, to sustain the Jahnigen and the Williams career development awards, two programs pioneered by the Hartford Foundation over the last 10 years through a new R03 award mechanism entitled GEMSSTAR—Grants for Early Medical/Surgical Subspecialists’ Transition to Aging Research.
On the Martin Luther King Holiday, I think it is only right to think about ageism, which, along with racism and sexism, is a fundamental barrier to achieving the more just and equitable society that we desire. Coincidentally, over the weekend, I had an opportunity to hear from Bill Thomas, MD, the developer of the Eden Alternative and The Greenhouse model of long-term care. (And author of the Changing Aging Blog featured on our blog roll.)
Dr. Thomas had come to address our leadership retreat of directors of academic geriatric programs, where each year we bring someone who has shown unusual leadership in aging to stimulate attendees to think about their own unique contributions (in the terms of our recent annual report–to think about how they will “answer the call to leadership”). As a provocative speaker he did not disappoint.
He argued that our society is suffering from malignant, metastatic adulthood. He posited that both children and older adults are inappropriately pressured to conform to the highly agentic, doing-oriented model of adulthood valued by our society, rather than the more “being-oriented” state truly appropriate for their life stages. He argued that older adults find themselves valued (and value themselves) to the extent that they “STILL” can do all the things of earlier adulthood–leading to the ludicrously one-sided portrayals of older people busier than ever barefoot water-skiing and globetrotting–and foreclosing the existence of an authentic “elderhood.”
As part of its theory of change, the Foundation has made big bets on the specialty of geriatric medicine. (Click here for a nice summary of what geriatricians do.) Unfortunately, we are losing the numbers game. Geriatric medicine is the only specialty in which a physician takes a pay cut in return for additional advanced training. Why? Because almost all older adults are covered by Medicare, and Medicare pays relatively poorly for the core services of geriatric medicine: office-based evaluation and management services (diagnosing, adjusting medicines, referring to specialties, coordinating care, educating patients and family members). Therefore, geriatricians make about 10 percent less than generalists who treat older adults, but not exclusively older adults, and of course much, much less than specialists in the procedural areas such as dermatology, radiology, or gastroenterology.
It gets worse. To provide real geriatric care, the physician needs to work with a team of professionals: social workers, nurses, physical and occupational therapists, nutritionists, and others. Many of these services cannot be billed directly to Medicare and need to be covered out of (already meager) practice revenues. Finally, to add insult to injury,
There are those who view leadership as an innate set of qualities that catapult individuals into positions of influence; they hold a belief that leaders are born into the role. Here at the John A. Hartford Foundation, we believe that leadership, while certainly requiring some level of natural talent, can and must be nurtured. Our 2008 Annual Report details personal accounts of achievement and suggests that formal training has been a critical factor in fostering national leaders in the field of geriatrics. Formal training is one of the four key pillars of any leadership program; the other three are mentoring, peer networking, and answering the call.
Having served as Nursing Education Initiatives Director of the Hartford Institute for Geriatric Nursing at New York University, the Hartford Foundation’s first investment in nursing, I saw and experienced the impact of the Foundation’s formal training initiatives. In addition to the initiatives highlighted in the annual report, NYU ran a Hartford-funded Geriatric Nursing Research Summer Scholars Program, a boot camp of sorts to strengthen proposal submissions and careers of young researchers. The leadership training component of the program strengthened participants’ professional networks, presentation skills, and career planning. This formal training has had a remarkable impact on the field.
Hot off the press is our 2008 Annual Report, A Call for Leadership in Aging. Unlike Hartford reports of years past that have showcased a single discipline or initiative, this report focuses on the need for leaders in aging from all facets of health care. As it stands, our health care system is broken and unprepared for the impending age wave. Change cannot happen without leaders. Our 2008 Annual Report acknowledges that leaders do not spontaneously emerge from within the ranks; leaders are grown. And the need to grow leaders in the field of aging has never been more urgent.
This charge is made very explicit in the 2008 Institute of Medicine report, Retooling for an Aging America, which confirms we will not be able to grow enough gero-specialists to care for our rapidly aging society. Therefore, we must ensure that all health care professionals are armed with the skills to care for older Americans. We must also create and test service delivery models that will improve the care of older adults. To address both mandates, we must support programs that attract leaders to the field of aging and place them at the helm of education, research, practice, and policy initiatives.