Reflecting on The Gerontological Society of America’s (GSA) annual meeting, I am more confident than ever that teamwork and interprofessional collaboration are essential to improved care of older Americans. From the fabulous research work, to the clinical teams, to the interprofessional education efforts, I saw examples that made me sure that this is at the core of good care for older people and therefore an important direction for the Hartford Foundation.
I suppose that interprofessional collaboration was at the top of my mind because on my way from New York to the GSA meeting in San Diego, I had stopped for a site visit at the University of Minnesota to learn about the Health Resources and Services Administration’s (HRSA) newly funded $4 million National Center for Interprofessional Education and Colaborative Practice.
My colleagues and I visited the center as part of a consortium of funders interested in the issue who have been working with HRSA in designing and reviewing proposals for the center and who hope to add more even more support, building upon HRSA’s investment to advance this national agenda. I wouldn’t normally write about a grant in development for HealthAGEnda, at the very least for fear of bad luck, but in this case I think that our readers and stakeholders deserve to know what we are thinking and what is going on.
If you’re like me, at national meetings you cruise the display booths in the convention halls trying to keep a finger on the pulse of the field. I usually come away weighed down with reports, freebie journals, and fliers. When eventually I recycle the build-up, I’ve often only benefited from the physical activity entailed in carrying around the extra weight.
But sometimes you find something wonderful.
At the Gerontological Society of America meeting last November (yes, I am that far behind in my reading), I struck gold. On an abandoned table in the back of the hall I found a series of policy briefs from The Maxwell School of Citizenship and Public Affairs at Syracuse University. Evidently the Maxwell School’s Center for Policy Research also hosts the Syracuse University Gerontology Center and over the years has put out a series of policy briefs that include many aging and health issues drawn from presentations by some of the best in the field, including Beeson Scholars Sean Morrison, Tom Gill, and David Casarett; UCLA/RAND’s Neil Wenger; and former Kaiser CEO, David Lawrence.
As always, I read the new article by Atul Gawande in the New Yorker, The Hot Spotters, with great anticipation and high expectations. His topic was a perennial in geriatric care — targeting — the idea of finding those particular people who need and can benefit from an intervention and ensuring that they get it. Moreover, the main targeting strategy he talked about was finding those people with very high rates of utilization and expense and trying to figure out what they really need to stay healthy, stay out of trouble, and stay out of expensive hospitals. Good stuff. (Click here to see a prior post about Dr. Gawande and some video of him speaking.)
I was even more interested when in the first example he used, mapping patterns of health care use in Camden, NJ, he observed that the two “most expensive city blocks were in North Camden, one that had a large nursing home called Abigail House and one that had a low-income housing tower. . .” and that “a single building in central Camden sent more people to the hospital with serious falls—fifty-seven elderly in two years—than any other in the city. . .” This was going to be really good.
As usual Dr. Gawande captured the issues deftly, “our health-care system. . . was never designed for the kind of patients who incur the highest costs. [It] is vastly inadequate for people with complex problems: the forty-year-old with drug and alcohol addiction; the eighty-four-year-old with advanced Alzheimer’s disease and a pneumonia; the sixty-year-old with heart failure, obesity, gout, a bad memory for his eleven medications, and half a dozen specialists recommending different tests and procedures. It’s like arriving at a major construction project with nothing but a screwdriver and a crane.” (I think the screwdriver is the brief office visit — good for tightening a few screws, but not much else — and the crane is the hospital — powerful, but a bit much, if what you really need is a ladder.)
In the beginning of November, I spoke about nurse-led change at the American Academy of Nursing’s annual meeting. If we are going to reform the health care system, I said, nurses must be at the forefront of change. Nurses have the most contact with patients; they are the most highly respected profession in America, according to the Gallup Poll; and they are 2.3 million strong. They are in the trenches, making health care happen every day, one patient at a time.
In order to create change, nurses need to identify the deficiencies in our health care system, understand what strategies are available to fix them, and make possibly uncomfortable choices in favor of change. Here are a few inconvenient truths that nurses must confront:
- Health care reform = better care for older adults. Caring for older adults is nursing’s core business. Although older adults represent only 13 percent of the population, they are 46 percent of patients in critical care; 50 percent of hospital days; 70 percent of home health services; and 90 percent of residents in nursing facilities. Whether or not nurses are geriatric specialists, they still need to know how to provide appropriate care for older adults. Nursing education must address this issue.
- Hospital quality = nursing quality. No one has more impact on the quality of care that hospitals provide than nurses. Together with social workers, nurses play a critical role in patient and family education at discharge; in addition, the success or failure of the discharge process directly affects hospital readmission rates. Nursing procedures also directly impact the prevalence of “never” events such as pressure ulcers and hospital acquired infections.
- Team care = better care for older adults. Effective teams have a common purpose, specialization of function, defined roles, and processes for coordination in place. Unfortunately, creating them is difficult. Chris Langston, in an earlier post entitled “Team or Mob,” details the factors that work against teamwork in the health care system. Nurses—as well as physicians and social workers–need to put aside desires for autonomy in recognition that teamwork among health care professionals yields the best results for patients.
- Nursing must embrace all nurses. Fights over turf, the nursing competence of one degree holder over another, and entry requirements are counterproductive. Nurses need to unite behind change. In fact, nurses must be leaders for change, even if lacking in resources. They cannot wait for others—politicians, bureaucrats, or academic colleagues—to “allow” or “invite them” to join the debate. Nurses have the skills and knowledge we need now to revitalize and reshape the health care system to deliver better care to older adults.
Across many projects and partnerships, the Foundation has come to believe that high quality care for complex older adults MUST be team care. Not only is there far too much work for any one provider, but the nature of the work requires a team to implement successfully. Geriatric care is long-term care, not necessarily in the sense that everyone is in an institution, but in the sense that geriatric care is chronic care that needs to be delivered over years of time. Older adults and their family members always need to be on the team. However, teamwork over long periods of time with evolving goals and changing clinical issues is not only very hard and outside most clinicians’ skill set, it is also countercultural.
Even within the professions where the Foundation works to build competence and capacity for teamwork, there is a centrifugal force that tears at the team concept and leads to passionate re-creation of the wheel and destructive struggles for turf. Over the last several months, my colleagues and I have noted with dismay various projects that have been proposed to enable one profession to develop some competence that is already integral in another. Physicians have proposed to become experts in care coordination and discharging planning. Nurses have trained to “master” community care and psychosocial supports.
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,
At a meeting called by the Institute of Medicine to discuss its recent report, Retooling the Healthcare Workforce for an Aging America, we focused on the particular issue of using team care to meet those needs. Reflecting on the IOM process, I observed that in addition to considering workforce issues from the traditional viewpoint of counting heads, the group think about “weighing” heads as well-that is, considering what knowledge, skills, and attitudes need to be in the minds of the workforce.
Many health professionals feel a terrible ambivalence about caring for older adults, especially in cases that seem futile and hopeless. They ask themselves, why even bother to give medical attention if a cure isn’t likely? Even more commonly, professionals feel overwhelmed by the complex requirements of geriatric care, particularly when facing them alone. Most of us have probably heard a provider say, “I didn’t ask about that because I didn’t want to open Pandora’s box.”
Fortunately, many stakeholders have begun to recognize that with appropriate training and support, a team approach can bring together the skills and time needed to deliver high quality care. We now recognize that a team approach offers a way to open that box in a safe and effective way. Additionally, because health care remains a cottage industry, supporting many thousands of businesses, the team approach not only improves quality of care but actually widens the supply chain, and in human terms, helps put food on the table for many more families.