Health AGEnda

Treasure!

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.

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Advising the National Health Care Workforce Advisory Commission

Last month, after months of waiting and insider speculation, the Government Accountability Office announced  the members of the National Health Care Workforce Advisory Commission, in accordance with PPACA section 5101. Their challenge will be to make recommendations on the numbers, nature, and deployment of the health care workforce. These recommendations will  be essential to making a reality of the promises of expanded  access and coverage under health reform.  Their work will also be vital to the reform of the delivery system, which is essential to improving our mediocre health care performance while increasing efficiency so that we can stop health care’s so far inexorable devouring of federal and state budgets.

When you put it that way, I am glad that my nomination to the commission was not successful.  (There had been a suggestion in the law that in addition to representation of providers and consumers, having  representatives of “health care philanthropy” on the commission might be appropriate, so I threw in my hat.)

Nonetheless, I will offer some free advice to the commission (me and the entire health policy world, I’m sure):  carefully consider not just the size of the workforce in all its various components but also what it is trained to do and the systems of care into which it is deployed.  Given our fragmented, inefficient health care system, it would be a mistake just to scale up our current workforce in proportion to the need.  If we do, we should not be surprised to get the same mediocre quality of care at ever-increasing costs.

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“King” Solomon

David H. Solomon, MD

One of the great pleasures of working at a foundation is to be able to meet and support great leaders who make lives better for others.  One such leader in geriatric medicine is David H. Solomon, MD.  An illustrious educator and scientist, Dr. Solomon has earned so many awards and honors that now others are honored in his name.  Each year now the American Geriatrics Society bestows the David H. Solomon Award for physician leaders.  At his home institution, where he served as chair of medicine, there is an endowed chair named for him, the Albert F. Parlow and David H. Solomon Chair for UCLA Program on Aging.

However, I know David best for the leadership he has provided over many years for the Foundation-funded Geriatrics-for-Specialists Initiative.  The Foundation has come to believe, educated by David and many others, that all physicians need to be knowledgeable about the special considerations in caring for their older patients.  In fields that participate in the surgical care of older adults, stretching from emergency medicine at the front of the hospital, to anesthesia, to rehabilitation at the other end, there is a particular need for internalized expertise.  Older adults are major if not dominant users of many surgically related services and yet there is still limited appreciation for their special care needs pre and post operatively.

Just out this January is a paper in the Journal of the American Geriatrics Society based on remarks David made to the May 2009 annual meeting of the Section for Enhancing Geriatric Understanding and Expertise among Surgical and Medical Specialists (SEGUE), as it is now called, entitled Introduction to the Geriatrics-for-Specialists Initiative:  Geriatrics Specialty Care at the Tipping Point. In his comments David reviews this 16 year old effort, including such milestones as the development of the Jahnigen career development awards for junior faculty in the specialties, the research agenda development process highlighting important gaps in essential geriatric knowledge, and most of all, the development of a sound and respectful partnership among the specialty disciplines and geriatrics.

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SCAN, Health Affairs, and Long-Term Care: The Sequel

hacvrnewIn addition to the good news of Health Affairs focusing on long-term care coupled with the additional bad news on hospital readmissions from skilled nursing facilities, as I reported a few weeks ago, this special issue of Health Affairs had many other features of interest.  A non-exhaustive list includes:

Susan Reinhard, senior vice president of AARP’s Public Policy Institute and leader of a project to enhance nurse and social worker training in support of family caregivers, had a paper discussing promising strategies to help older adults move from nursing homes to less restrictive care—or avoid nursing homes altogether. Although effective, these initiatives are underutilized.

Diane Meier, leader of the Center to Advance Palliative Care at Mt. Sinai in New York, wrote a commentary on the need to implement palliative care in nursing homes.  With her co-authors, she argues that essentially anyone in institutional long-term care is at the point where they would benefit from the application of the person-centered principles that are core to palliative care.

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Better Geriatric Care = Easier Caregiving

When we talk about what we do at the Foundation, we often get asked, “What are you doing for caregivers?”

 This puzzles me in two different ways.  First, I need to figure out which of the many caregivers is meant: the family and friends who provide care to their loved ones, the direct care workers (aides and attendants) who provide the most hands-on, paid care, or the professionals (RNs, MDs, etc.) who, I hope, also see themselves as caregivers?  Second I’m not quite sure what to say.  The Foundation doesn’t have many projects specifically focused on informal/family caregivers, but I think that all of our work benefits them as well as the older adults they love.

Family Caregiver Alliance

Family Caregiver Alliance

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Team or Mob?

© iStockphoto.com/Mikedabell

© iStockphoto.com/Mikedabell

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.

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Recognizing the Need for Team Care

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.

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