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EDITORIAL: Leading on Behalf of an Aging Society

2008; Wiley; Volume: 56; Issue: 10 Linguagem: Inglês

10.1111/j.1532-5415.2008.01939.x

1532-5415

Linda P. Fried, William J. Hall,

Global Health Care Issues

The recent Institute of Medicine report "Retooling for an Aging America" has stated clearly that "healthcare workers are inadequately prepared in geriatrics and that the current workforce is not large enough, by far, to meet older patients' need."1 The National Institute on Aging has characterized the aging of our society as a "silver tsunami approaching for which we are unprepared."2 Abundant evidence in our daily lives supports these analyses. Health policy experts have issued warnings that the Medicare Health Insurance Trust Fund faces insolvency in the next 12 years,3 flawed and unsustainable physician payment systems have yet to be solved,3 and unanticipated long-term care expenses continue to bankrupt families. Even the popular press has raised concerns over perceived gaps and flaws in older adult health care. An article on health and aging by Atul Gawande, MD, cogently described the needs of older patients in an aging society by stating that "good medical care can influence which direction a person's old age will take: an old age of enfeeblement and dependence, versus preserving, for as long as possible, the ability to control your own life."4 He concluded by describing geriatric medicine's effectiveness in meeting those needs and our society's lack of preparedness to provide such geriatric care. There are few if any dissenting voices in the profession or on the streets: this is no country for old men and women. The Gawande article noted that, despite the rapidly expanding older population, the number of geriatricians is declining, having fallen by one-third from 1998 to 2004, and the plummeting of applications to primary care medicine is intensifying the dearth of geriatrics fellows in the pipeline, those being trained. Recognizing this deficiency, and the limited history of societal investment in expanding this specialty, there are pernicious speculations by some that there will never be enough fellowship-trained geriatricians, or the academic programs that train them, to make a difference. This line of reasoning suggests that geriatric medicine therefore has a relatively minor future role to play in rectifying the healthcare system serving older adults. Gawande succinctly summarized one possible outcome of the "perfect storm": "It's too late" to ensure that there are enough geriatricians for our country's surging elderly population. To the readers of this journal, who have dedicated our professional lives and considerable passion to the care of our older patients, such a conclusion would be a bitter pill to swallow. This editorial proposes that it is not too late, but much more aggressive action and advocacy by geriatricians will be required. The timing is urgent. The article in this issue of the Journal of the American Geriatrics Society5 that proposes to prioritize and target geriatricians' care provides a first step (a basis for deploying scarce geriatricians for the short and the long term) and a basis for building a coalition across geriatrics and primary care disciplines with the goal of improving the care of older adults. This article, the first of its kind, reports a consensus among academic leaders in geriatrics that, given the current shortage, care by geriatricians in the United States circa 2008 should be targeted to patients who will most benefit. This analysis had its inception at the 2007 annual Association of Directors of Geriatric Academic Programs (ADGAP) retreat sponsored by the John A. Hartford Foundation. Subsequently, a detailed, iterative survey process of program directors was conducted, culminating in two symposia at the 2007 American Geriatrics Society Annual Meeting and this article, which the ADGAP membership has approved. Two articles by Callahan et al.6 and Phelan et al.7 and a recent white paper on geriatric primary care from the Department of Veterans Affairs (VA) perspective complement this work (unpublished data). Collectively, these articles5-7 suggest that, in the short term, we should target deployment of geriatrics expertise so that patients who would most benefit from geriatrics care actually receive such care. Specifically, these patients who would most benefit are aged 85 and older or are older patients with complex medical problems, frailty or other geriatric conditions, disability, dementia, or need for palliative or end-of-life care (Table 1). These patients benefit from the expertise of geriatricians in managing complex problems with a holistic, patient-centered approach, incorporating knowledge of the physiology of aging and of managing geriatric syndromes and multiple chronic conditions (Table 2). These articles6, 7 all indicate that natural selection seems to operate in clinical practice, often allocating patients to geriatricians in a manner consistent with that recommended by this survey of academic geriatrics leaders reported by Warshaw et al. (Table 1) as to those who would most benefit from a geriatrician's care. The data from the ADGAP survey suggest that, as a first step, we should preferentially target training adequate numbers of geriatricians to be primary care providers or co-managers of care for the 25% to 30% of older adults who fall into the categories of "most vulnerable" described above. This is graphically indicated in Figure 1, displaying the heterogeneity of health status among older adults (in the left-hand column) as a basis for targeting care by geriatricians to the most vulnerable third with complex multiple health conditions, frailty, disability, and need for end-of-life care. Simultaneously, primary care internists and family physicians would manage the healthier and better-functioning 70% of older adults (Figure 1) and would be universally trained with essential knowledge of basic geriatric principles1 and of when and how to involve a subspecialist geriatrician in care (Table 2). The involvement of geriatricians in the care of more-robust older adults could involve geriatric research and its translation into approaches to screening, case finding, and prevention, as well as differentiating prognosis and risk and with consultation by geriatricians as indicated. When the care needs become highly complex, a geriatrician could become involved as a co-manager or the primary care provider, depending on preferences of patient, family, and physician. This complementary knowledge and responsibility would provide a basis for a formal partnership in care by internists and family physicians with geriatricians, deploying them according to their relative numbers and complementary expertise in ways that would likely provide better care and health outcomes for our older patients. Roles of geriatricians in caring for older adults according to patient health status. Consensus as to the subset of patients for whom geriatrics care should be targeted would provide a basis for developing more-effective coalitions on behalf of older patients and mounting an even greater immediate national effort for a long-term investment in optimizing the health outcomes of older patients. This effort needs to evolve, now, with increasing investment in training expert geriatricians. With this, a work force with the requisite knowledge to care for older Americans could be meaningfully increased by 2030, when the full force of the silver tsunami hits. The VA experience indicates that each geriatrician can manage a patient panel of, on average, 700 of the VA's most-complex older patients (compared with an average panel of 1,200 older adults managed by primary care providers).7 Based on these numbers, 12,500 geriatricians are needed now to care for one-quarter of people aged 65 and older (35 million people aged ≥65, at present); by 2030, when the number of people aged 65 and older will increase to 72 million people, 26,000 geriatricians will be needed. Given that there are currently 6,000 geriatricians, this would conservatively, require training 869 geriatricians per year over the next 23 years to meet the targeted need for 26,000 geriatricians by 2030. Additional numbers would be needed for system leadership, research, and education. Although a large number, this may be feasible with significant changes in national investment now, including setting national goals, and resources committed to training and better financial reimbursement for care of these complex patients, as well as committed and effective professional education to attract clinicians to primary care and geriatrics. These recommendations are consistent with those of the recent Institute of Medicine (IOM) report.1 Now is also the time to redouble our collective efforts to design and implement new coordinated systems of care that will optimize the effectiveness of all clinicians caring for an aging population, with partnership among geriatricians, primary care physicians, and interdisciplinary teams. This partnership would be most effective if employed within a continuum of coordinated geriatric care models, as exemplified in Figure 2. Geriatricians offer skills in system leadership, including direct experience with models of geriatric care, a commitment to and expertise with interdisciplinary teams, and knowledge of specific geriatric care (Table 2). They have developed the evidence supporting the effectiveness of geriatric models and methods of care that have been demonstrated to improve the clinical outcomes of older patients (Table 2). System leadership by clinicians with geriatrics expertise would probably enhance the coordination of care across physicians and venues of care and most effectively use interdisciplinary teams (Figure 1). These suggestions are aligned with the recent Position Statement of the American Geriatrics Society Task Force on the Future of Geriatric Medicine8 and offer an approach to implementing the IOM recommendations.1 They offer an opportunity for strengthened partnership with general internal medicine and family medicine as well, as we collaboratively seek to effect a high-quality system of care for our aging population. Continuum of geriatric care models.ACE=Acute Care for the Elderly; PACE=Program for All-Inclusive Care for the Elderly. If the current system of care persists, the vast numbers of Americans aged 85 and older who will be cared for by internists and family physicians will rapidly inundate the present healthcare system over the next 30 years. If our high-technology, event-based approaches to care continue without geriatrics expertise and input, the costs of care for this vulnerable population will continue to escalate to financially unsustainable levels.3 Alternatively, geriatrics models of care have the potential to offer approaches to care that moderate costs for these vulnerable subsets of the older population while improving patient-centered outcomes.9 Working harder in the present system is unlikely to result in any long-term substantive change. Instead, we need to prioritize a short- and long-term plan that will involve selective physician redeployment, as described above; recruit and train substantially greater numbers of expert geriatric physicians and nurses; critically evaluate how our training of future geriatricians will equip them with the leadership skills needed to lead system change; train all internists and family physicians, as well as nurses, in basic competency in geriatrics care; and design and implement a geriatrically informed, coordinated system of care. Consideration of the new skills—in health systems, education, multidisciplinary research, and leadership of medical systems—that the geriatrician–leader of 2020 will need might inform the ongoing debate among program directors as to the advisability of a 1-year, versus 2-year, training requirement for board eligibility. It is unlikely that these additional skills can be acquired during the current 1-year training program. We posit that the current flaws in the healthcare arena provide the ideal time for the academic geriatrics community to exercise unprecedented leadership. We need to contribute our enormous knowledge and skills to effect a timely sea change in the care of older adults in this country. How can the collective geriatrics professional community most effectively mount the social change necessary to make meaningful systems change in the care of older adults? We know from abundant work on successful social entrepreneurship from other fields of endeavor that success is a result of working smarter rather than harder. As a discipline, we must become more effective at communicating the societal import of what geriatrics can offer to patients and society. We need to more effectively and forcefully articulate how we are working to enhance care and our patients' well-being so that all stakeholders in the system, including insurance systems, regulatory and governmental bodies, and our patients and their families, have a clearer understanding of the import of the discipline of geriatrics in American medicine. We can learn from other examples of highly effective communication that have changed medical systems, as exemplified by the hospitalist movement; this has grown from a small, dedicated cadre of leaders to one of the most popular career choices for graduating medical students.10 After only a little more than 20 years, geriatrics can already offer a strong evidence base for the benefits of its contents of care and its systems of care. The Warshaw report from ADGAP5 now provides additional recommendations as to how to target such care for the short term and a basis for partnership between medical disciplines in caring for an aging society over the long term. We need to focus on the needs of society and the benefits that increasing geriatrics training and effectively deploying geriatricians will offer. We need to develop concerted, legislatively driven investments in attracting physicians and nurses to geriatrics and funding their training in significantly increased numbers. One program director has described geriatricians as the "Labrador Retrievers" of medicine. Perhaps it is time to behave more like Pit Bulls in our tenacity for leading needed change. In 2007, the IOM convened the ad hoc Committee on the Future Health Care Workforce for Older Americans to "determine the healthcare needs of Americans over 65 years of age through an analysis of the forces that shape the healthcare workforce including education and training, models of care, and public and private programs." The Committee has recommended a three-pronged approach to enhancing the geriatric competence of the entire workforce, increasing the recruitment and retention of geriatrics specialists and caregivers, and improving the way care is delivered.1 Although the ADGAP deliberations proceeded independently of the IOM committee, the conclusions of the two studies are remarkably concordant. The current "perfect storm" presents once-in-a-lifetime opportunities for partnerships and synergy. One of the timeliest and most intriguing potential partnerships results from the widespread enthusiasm developing for the concept of the advanced medical home (AMH). This proposal, currently endorsed by the American College of Physicians, American Academy of Family Practice, American Academy of Pediatrics, and American Geriatrics Society, envisions a healthcare system that provides "patient-centered, physician-guided, cost-effective care that encompasses and values both the art and the science of medicine (unpublished data). Attributes of the AMH include promotion of continuous healing relationships through delivery of care in a variety of settings according to the needs of the patient and skills of the medical provider" (ACP). The AMH has received endorsement from Centers for Medicare and Medicaid Services, leading foundations, and the AARP in their massive "Divided We Fail" campaign to effect meaningful health reform.11 A continuum of care, across settings and well coordinated, is the ideal of general medicine. It used to be practiced by a single practitioner. We suggest that, although one provider can no longer do it all, geriatrics has developed the basis for a system and contents of a continuum of care that can be deployed to optimize health at different stages. Internists, family physicians, and geriatricians could be effectively deployed along this continuum of health, in partnership on behalf of the patient (1, 2). The work reported by Warshaw et al. from the ADGAP provides a basis for such shared responsibility by providers for care for an older patient as their health status evolves through targeting care of geriatricians to the most vulnerable subsets. Family medicine and internal medicine organizations must contribute to this consensus simultaneously. This partnership between generalists and geriatricians in primary care of older patients might occur through a variety of methods, depending on patient and physician preferences: transitions in care from generalist to geriatrician as the patient becomes frail or disabled or dependent, often with multiple chronic conditions; co-management of such care; or ongoing consultation. The details remain to be developed within systems and between providers, although this important report offers the roadmap for effective targeting of geriatrics care so as to optimize its benefits and to offer a basis for partnership with other primary care disciplines. Who better to lead this effort than geriatricians? Consider the expertise that results from geriatrics training and practice: Geriatricians are complexivists. They have the cognitive skills to analyze complex health issues and establish priorities consistent with patient goals, the ability to practice effectively in interdisciplinary teams, and the knowledge of models of care delivery across a coordinated continuum that best matches the healthcare needs of patients at different health status levels (Table 2). If we now learn from our failures as well as our successes and demonstrate the courage to assume leadership in reform of the healthcare system we can make a major contribution to helping transform to a better healthcare system for all in this country. This ADGAP consensus offers an important step. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this editorial. Author Contributions: Both authors wrote the editorial. Sponsor's Role: None.