Ana Tuya Fulton, MD, FACP, AGSF
Just about 25 years ago, I learned about the field of geriatric medicine and became exposed to what would become my career, and the most rewarding work I could have imagined. As a pre-med student, I was searching for summer internship opportunities. I reached out to the Department of Geriatrics at George Washington University, and they responded with a pleasant invitation to shadow their geriatricians, nurse practitioners and researchers for the summer to give me a taste of what careers in medicine might be like. As cliché as it may sound, I had no idea as I walked in on the first day of that three-month internship that the experience would alter my path forever. I left not only convinced that I would be a physician, but that I would be a geriatrician. I am excited to be part of the evolution of older adult care; the changes that have already taken place, and the continued prospects to bring improved awareness, quality of care and support to older adults.
The emergence of value-based models of care has brought increased attention to improving coordination and quality while reducing unnecessary procedures and increasing attention to quality of life and patient-centered, individualized care. This atmosphere of change is well suited to advancing models of care that are designed for older adults’ specialized needs, since those needs naturally fit these new priorities. As an example of how systems have evolved to provide this care, I’d like to share developments at Care New England health system (CNE) in Rhode Island, the second largest system in the state. In 2014, CNE embraced population health by forming a large accountable care organization (ACO), Integra Community Care Network, LLC (Integra).
As the culture in the health system became increasingly focused on improving quality of care for populations, particularly those ill and frail patients in the system, and improving care coordination and services, many needs for clinical programming were identified. One clear need was for a system-wide, comprehensive and interdisciplinary program in geriatrics. Needs assessments done with hospital-based teams, primary care teams and patients of the Integra ACO demonstrated that frail older adults were not getting the care they needed within the traditional models of care. Older adults needed more care and support at home and more care coordination resources. At the same time, primary care teams needed resources on – and help with addressing – goals of care, assessing older adults for cognitive and functional decline, and earlier identification of those patients at risk of increased utilization. Also, inpatient teams needed help managing older adults with complex needs, particularly those that developed complications such as delirium during inpatient hospital stays.
Since 2014, the CNE comprehensive program for older adults has developed and grown to have four geriatricians, one geriatric and palliative care nurse practitioner and one social worker. The programming varies across the hospitals and operating units in the health system, and targets needs based on the patients and providers served by each respective location. These programs include an inpatient consultation service that serves patients at Kent Hospital and at Butler Hospital (an inpatient psychiatric hospital with a senior specialty unit), and an outpatient consultation practice that helps primary care teams by providing consultations for dementia evaluation and treatment and geriatric assessment for screening and treatment of geriatric syndromes. As of February 2019, Kent Hospital also has a focused, 10-bed ACE (Acute care for Elders) unit, providing interdisciplinary care aligned with the Age-Friendly Health Systems four M’s model. Those four M’s focus on the key issues and needs of older adults – mentation, what matters, mobility and medications. This unit has already shown improved patient and family satisfaction, better identification of underlying cognitive impairment, prevention of delirium and improved coordination of care.
A specialty outpatient consultation practice exists to serve older women in the gynecology oncology practice at Women & Infants Hospital. This practice works to help the primary gyn-oncologist stratify risk using geriatric assessment results to support shared decision-making with patients. Finally, geriatrics is closely involved in the programming of the Integra ACO. Clinical support is provided to the primary care teams and the numerous nurse care managers who care for the sickest, highest need patients as part of the Integra complex care management team. Additionally, since September of 2018, Integra has formed a hospital at home program (Integra @ Home). This program focuses on the care of frail older adults over age 80 who meet certain criteria and have chronic conditions and desire hospital-level care at home.
All the programs developed at CNE are ones that exist in other health systems nationwide and have long been considered geriatrics “best practices,” with strong evidence bases for improved outcomes, quality of care and patient satisfaction. The exciting development is that now, with the encouragement of the age-friendly health system culture change movement and value-based care ACO evolution, the resources to build and spread these models of care is becoming available and embraced by C-suites that in the past have been reluctant to commit to the up-front costs to build these interdisciplinary models that could only promise cost avoidance and not always increased revenue.
It’s an exciting time to practice as a geriatrician and with the increased spread of awareness by the powerful organizations behind the Age-Friendly Health Systems, a future where the field will receive increased support, growth and new interest is tangible. However, the work must not stop at health systems. Next steps will be needed to make communities, housing, transportation and other infrastructure just as age-friendly for the rapidly growing older adult population. While much work lies ahead, the challenges now seem surmountable and support for doing the work, high.
Ana Tuya Fulton, MD, FACP, AGSF, an internist and geriatrician, joined the faculty of Brown University in 2006 and holds Associate Professorships in Medicine and in Psychiatry and Human Behavior. Dr. Fulton is Executive Chief of Geriatrics & Palliative Care for Care New England health system and Medical Director for Integra Community Care Network, LLC. Additionally, Dr. Fulton is the Care New England Co-Project Director for the Rhode Island Geriatric Workforce Enhancement Project (RI-GWEP). This is a HRSA-funded collaborative agreement to integrate geriatrics and primary care and to improve the care of older adults across the state of Rhode Island. Dr. Fulton’s clinical and academic work focuses on improving serious illness care for persons with cognitive impairment as well as integrating geriatrics best practices into primary care, hospital-based care and accountable care entities. She has done multiple national presentations in these areas and has published over 26 peer-reviewed articles.