reprinted from Issue 18, Spring 2014 of Frontiers of Medicine (PDF)
$proxy_page= "/news/fom.html"; ?>
About 10,000 Baby Boomers turn 65 every day, and the number of seniors is expected to top 70 million by 2030. To help meet the needs of an aging population, the UCSF Division of Geriatrics is pioneering ways to provide better care to older adults, discover better therapies, and educate the next generation of medical professionals, caregivers and community members. "We are passionate about caring for older persons across the full spectrum of aging, and are proud to lead improvements in clinical care and public policy that enhance quality of life for older adults – ranging from the healthiest to the frailest seniors and their caregivers," says Louise C. Walter, MD, chief of the Division of Geriatrics.
Managing the Continuum of Care Takes a Team
One of geriatricians’ most powerful tools for providing coordinated care in a fragmented health system is a team approach that integrates the complementary expertise of nurses, physical therapists, nutritionists, social workers and many others.
"What we’ve learned in geriatrics is that often a problem is not a result of one issue, but five or six," says Christine Ritchie, MD, MSPH, the Harris Fishbon Distinguished Professor in Clinical Translational Research and Aging and director of the UCSF Program for the Aging Century. "When you address these multiple issues all at the same time, you’re much more likely to improve someone’s outcome than if you only address one. With a patient who falls, if you adjust their medications, engage them in strengthening exercises from a physical therapist and address home safety issues, that’s going to be much more effective than if one person says, ‘Do X.’"
While the challenges are immense, this is a time of unprecedented opportunity. Many groundbreaking geriatrics programs started at the San Francisco Veterans Affairs Medical Center (SFVAMC), which has been closely affiliated with the UCSF School of Medicine for more than 35 years. Because the SFVAMC is responsible for patients whether they are hospital- ized, in a nursing home or living at home, it has developed many programs to keep them as healthy as possible across every care setting.
Similarly, under health care reform, the country is moving to more inte- grated models of care, and the Centers for Medicare and Medicaid Services is beginning to hold institutions financially accountable for patients’ outcomes.
"As organizations become responsible for the continuum of care, geriatrics can serve as a national model for how to best provide this Innovations in Geriatrics Continued from front page Caring for an Aging Population care," says Ritchie. For example, UCSF is piloting programs that send a team of doctors, nurses and other health care professionals to the frailest patients’ homes, providing care before conditions become urgent. "Our analysis shows that hospitalization rates decline substantially when patients are enrolled in our Housecalls program, generating substantial cost savings and providing better care," says Ritchie. "Patients are happier, they actually do better, and they need less of some of the things that are the most costly. It’s the right care at the right place, at the right time."
The UCSF Division of Geriatrics and the Program for the Aging Century are developing many novel pilots to improve patient care, increase the evidence in support of the care provided and better educate health care providers to care for our aging society.
Clinical Innovation: ‘50% Medical, 50% Everything Else’
"I often tell our trainees that geriatric care is 50 percent medical and 50 percent everything else," says Helen Kao, MD, medical director of UCSF Geriatrics Clinical Programs. Those other factors can include family support, mental health and socio-economic status. "A medicine- predominant practice will only get you so far," she says. "Having strong relationships with the community is a direction for the future." Some of these partnerships include:
- UCSF Center for Geriatric Care:
In 2013, the UCSF Lakeside Senior Medical Center relocated to the new Institute on Aging (IOA) facility in the Richmond District of San Francisco, renaming it the Center for Geriatric Care. "We were very excited about combining the best of geriatric medicine at UCSF with the Institute on Aging’s incredibly strong reputation in community-based social services," says Kao.
She and two other physicians provide primary care to elders; the facility’s shared location with IOA makes it easier to connect patients with an array of support services. For example, Kao treated an elderly couple with dementia that was socially isolated. "They could literally walk around the corner from the clinic and down the hall to look at the adult day health center and meet the staff," says Kao. In addition to UCSF’s own onsite geriatric nurse practitioner and social worker, she connects patients with IOA’s mental health professionals and case managers, as well as services like the Friendship Line, a telephone-based crisis intervention center that also provides medication reminders and check-in calls.
Places like Google have people in communal settings where they can share ideas," says Kao. "Frankly, the same thing has to happen in health care. Being able to brainstorm with a psychologist on the stairwell has been fabulous."
- UCSF-UC Hastings Medical Legal
Partnership for Seniors:
Many seniors need help drafting an advance care directive or a will, but can’t afford to hire an attorney. Kao and Carolyn Welty, MD, co-founded a program in 2011 with UC Hastings faculty that brings law students into the clinic and on home visits. Trainees learn about medical and legal issues facing elders, and provide legal service. "There is a medical definition of cognitive impairment, and then there’s a legal definition," says Kao. "That is eye-opening for law students." With training, law students then help patients draft legal documents.
Kao hopes to expand the program to other learners from UCSF’s health professions schools. "There are so many legal determinants of health that medical trainees often don’t think about when they’re seeing the patient in clinic," she says. "We have one of the few medical-legal partnerships for seniors in the country, and hopefully it’s something we can grow."
- UC Care at Home: Kao and her
team run several programs for
homebound older adults. "We go to
great lengths to keep patients safe and
provide all of their care in the home,"
says Kao. "We ultimately want all our
clinical programs to be a seamless
panel of services that help patients
wherever they land."
The UCSF Housecalls program recently expanded from 100 to 160 patients, although many more remain on the waitlist. Many patients cannot walk or even get out of bed; others are housebound due to psychiatric or cognitive impairment. Kao and her colleagues Rebecca Conant, MD, Josette Rivera, MD, Carla Perissinotto, MD, MHS and Courtney Gordon, DNP, perform physical exams, adjust medications, draw blood for labs, and manage acute and chronic illness. "Our Housecall patients have one-third the average Medicare hospitalization rate," says Kao. "That is remarkable, if you think about their level of frailty." The need for these services far exceeds current capacity.
Geriatricians often function as detectives, interpreting nonverbal clues to address underlying problems. "Many patients with dementia can’t tell us that this hurts, or that itches," says Kao. "The immense advantage of seeing a patient in their home environ- ment is witnessing what is happening."
For example, a patient who throws his food may have difficulty chewing; meals that are easier to eat could resolve the issue. A patient who yells may be less agitated if people approach her from the front rather than from behind. "Oftentimes, the reflex is to give antipsychotics or calming medications," says Kao. "We try very hard to identify what might be triggering a patient’s behavior, and come up with creative solutions to keep patients calmer and safer."
Bridges, a geriatric transitional care program which was piloted with heart failure patients, now supports other complex patients through home visits designed to prevent unnecessary hospitalizations and maximize quality of life. Under the leadership of Brook Calton, MD, the Division of Geriatrics is also building a home-based palliative care service within Bridges to support seriously ill patients who are too sick to come to clinic, yet need symptom management and psychosocial support.
The Division of Geriatrics is partnering with many others to pilot the UCSF Care Support Program, bringing together a team of nurse practitioners, social workers, a psychologist, geriatrician and pharmacist to provide intensive case management in patients’ homes for those struggling to manage chronic illness. "There is a lot of face time, phone time, care coordination, and interaction with primary care doctors, specialists and patients," says Kao.
"These are time- and labor- intensive types of care," says Kao. "But for a subset of patients who are chronically ill, or so frail that sending them to the clinic requires a whole army of people, we may be able to provide better and more cost-efficient care – and make the patient and family happier. We hope to expand what we are able to offer."
- GeriConsults: To provide extra support for the many older patients at San Francisco General Hospital (SFGH), Edgar Pierluissi, MD, and geriatrics fellow Anna Chodos, MD, established a computer-based consultation service allowing primary care physicians to receive guidance from geriatricians. For more complex issues, SFGH recently established a geriatrics clinic open on Saturdays.
Research: Improving Function of Older Adults
"The United States spends more money than any country in the world on health care, yet that health care is disjointed," says Kenneth Covinsky, MD, MPH, the Edmund G. Brown Distinguished Professor in Geriatrics. "For US seniors with Medicare, we can spend an almost unlimited amount of money on medical tests and procedures that sometimes help, but often do more harm than good. But we are not able to provide the supportive medical and social services that patients and caregivers really need, even though these services would cost far less. Further, we know surprisingly little about how to best care for seniors, who are often excluded from clinical trials because they have more than one illness, cognitive impairment or other barriers to recruitment."
Most research focuses on specific diseases, contributing to a piecemeal approach when caring for elders with multiple conditions. "A whole-person geriatric approach can help us provide both better and more cost-effective care," says Covinsky. "Often what’s missing from medical research is the focus on functioning – is somebody having trouble walking? Can they care for themselves? We want to find out how we can treat them so they thrive in spite of the impairments of old age. Sometimes we can improve quality of life more by providing simple things like transportation so they can continue to go to church every Sunday, as opposed to getting an MRI scan."
In 2013, UCSF became one of only 13 sites nationally to be designated as a Claude D. Pepper Older American Independence Center, funded by the National Institute on Aging. Directed by Covinsky, the Center supports research about preventing and managing disability in older people, particularly those who are medically or socially vulnerable, and bolsters the Division’s already robust research program.A few examples of the Division’s research projects include:
- Advance care planning: Rebecca Sudore, MD, created a website (prepareforyourcare.org) that walks users through the process of creating advance care directives using clear, simple language and videos with trained actors.
- Quality of life: Alexander Smith, MD, MPH, has shown that good quality of life is possible in older subjects, even with severe disability that requires caregiving assistance. Respecting elders’ dignity and helping them maintain social connections are crucial.
- Diabetic seniors: Sei Lee, MD, MAS, has shown that a "less is more" approach is effective for elders with diabetes and multiple other conditions. Rather the focusing on perfect blood sugar control, such patients benefit more from a combination of reasonable control and increased focus on quality of life.
- Seniors and law enforcement: Brie Williams, MD, studies the intersection of geriatrics and the legal system. She is developing methods to screen for functional and cognitive problems in prison inmates, and training police officers and 911 dispatchers to identify age-related conditions, such as dementia and hearing loss, which can affect older adults’ safety.
Collaborating with Other Specialists
"Geriatricians can’t do it all alone," says Covinsky. "We also have a big interest in supporting people in other disciplines who are improving care and outcomes of older people." A few examples include:
- Surgical outcomes: Colorectal surgeon Emily Finlayson, MD, MS, is investigating how to improve surgical outcomes among frail elders.
- Preventing rehospitalizations: Hospitalist Ryan Greysen, MD, found that functional and cognitive impair- ment and social vulnerabilities contri- bute to rehospitalization of discharged seniors. He is developing ways to use mobile devices and social media to improve transitions of care.