Case Study Part III: The PCP’s View on Joan’s Health

Doctor at workPeople often wonder why doctors aren’t more interested in apps for their patients, or in trying something new to help patients. After all, we expect doctors to care about their patients’ health.

Plus, we know that doctors are now being held more accountable for outcomes, because we’re moving towards “pay-for-value.”

I do believe that most doctors care about their patient’s health. But it’s not easy being a PCP, and there are lots of reasons that the average PCP has difficulty optimizing the health of a medically complex senior.

Here is part III of the case study I created for my upcoming ebook: the point of view of Joan’s PCP, Dr. Miller. As you read, consider

  • What’s the doctor focusing on when it comes to Joan’s health? How does that align with what Joan herself is most concerned about, and what her daughter is concerned about?
  • What kinds of tools or services might help the PCP with what he’s trying to do for Joan’s health?

And for extra credit: what’s he overlooking that someone applying geriatrics — the art & science of modifying healthcare so it’s a better fit for older adults — probably would address? (Hint: it’s related to Joan’s vitals.)

Joan’s Health Story (According to Her Doctor)

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Case Study Part II: Joan’s Daughter’s View on Joan’s Health

In my upcoming ebook about better digital health tools for aging adults, I share a case study — an older woman named Joan — and I write about her struggle to manage her health from three perspectives: Joan herself, her concerned daughter, and her busy primary care provider.

Joan has more chronic conditions than most seniors — eight diagnoses, plus she’s had falls recently — but they are a fairly common combination in people who smoked and were overweight in middle age.

In this post, I share part II of the case study: the perspective of Joan’s daughter Susie, who is understandably worried about her mother’s health and wellbeing. (See Part I of the case study for Joan’s perspective, plus a list of her conditions and medications.)

As you read this, consider the following:

  • Do you know many people worried about the health of their older parents?
  • What kinds of technologies, tools, and services have you come across that might help Susie and Joan?

Joan’s Health Story (According to Her Family Caregiver)

Worried family caregiverSusie is worried about her mother almost all the time. [Read more…]

Case Study: The Story of Joan & Her Health

Did you know: in 2010, 46% of fee-for-service Medicare spending went to those 14% of beneficiaries who had six or more chronic conditions. (See Fig 3.2 of the 2012 Medicare Chronic Conditions Chartbook.)

You might think those are unusually sick seniors. But when I practiced primary care internal medicine, I saw people with 6+ conditions all the time. As you can imagine, they tend to see doctors a lot. (That data is in Figure 2.4 of the chartbook.)

It’s actually not that hard to end up with several chronic conditions by age 65: a history of smoking and being overweight in middle age will easily bring on 6+ chronic conditions later in life. And many of those seniors don’t look that sick or disabled.

But they struggle with their symptoms, and they especially can struggle with an overwhelming amount of “self-healthcare” to manage.

If there’s anyone who would benefit from digital health technology, it’s them. They need help with their health. Their primary care providers need help helping them. Their adult children are worrying. Oh and, we want to help them in order to minimize ED visits and hospitalizations, which are distressing for seniors and expensive for all of us.

Unfortunately, over the past three years I’ve found very little that seems usable and useful for these seniors with multiple chronic conditions.

So as part of my upcoming ebook about better digital health for seniors, I’ve written a little story. It illustrates the situation of Joan, an older woman struggling with multiple conditions. I’ve even included her medication list.

As you read this, consider the following:

  • If you’ve developed or are using a digital health app or service: do you think it will work for Joan?
  • More importantly: what do you think would be most beneficial to Joan right now, to help her with her health?

Joan’s Health Story (According to Joan)

Joan, aged 79, is more than a little tired of dealing with her health.

She didn’t always have health problems. She had a career and raised her kids and earned a good pension that supports her now that she’s retired. She lost her husband to a heart attack years ago, but she’d be doing fine on her own if she didn’t have to keep going to the doctor all the time.Maybe she hadn’t taken the best care of herself, but who knew the difference? Everyone smoked. And she quit five years ago anyway. She’s maybe a little overweight, all right, but you try having three kids and see if you stay slim.

She puts on a brave face but she feels a crippling guilt sometimes for not looking after her health. Maybe it’s her fault that she has hypertension now, and high cholesterol. She knows her diabetes and the osteoarthritis in her knees can probably be traced back to her weight, and her doctor’s told her that smoking caused the chronic obstructive pulmonary disease, and maybe the atrial fibrillation too.

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How the White House & Others are “Gauging Aging”

If you were to host a conference on aging, what would you put on the agenda?

And how would you talk about it?

I found myself mulling this over as I watched the first part of the White House Conference on Aging (WHCOA), which took place on July 13th.

What’s your frame on aging? Start with the Gauging Aging report

It’s especially interesting to consider the WHCOA in light of the recently published “Gauging Aging” report by the Frameworks Institute.

“Gauging Aging,” simply put, is a report about the differences in how aging experts and the public think about aging. It’s based on an in-depth analysis of how experts talk about aging and supporting an aging society, compared to how the public views the issues and the potential solutions.

By understanding the differences, experts can then get better as using communications that brings us to a shared understanding of the problems to be addressed,  in order to effect changes that are meaningful and beneficial. After all, narratives and ideas are important in framing how people perceive problems, and their options for addressing them.

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Fascinating Facts on Family Caregivers: Highlights from Caregiving in the US 2015

If you follow aging and caregiving, then you’ve probably already heard about the major new caregiving report that was released last month: “Caregiving in the US 2015,”a joint effort from the National Alliance for Caregiving and AARP. The study was funded by AARP, Archstone Foundation, Eli Lilly, Home Instead Senior Care, MetLife Foundation, Pfizer, UnitedHealthcare, and the Family Support Research and Training Center in conjunction with the University of Illinois at Chicago.

Strangely, this report seems to have been hardly covered by the major newspapers. I say this is strange because the findings are incredibly important and should be part of the national discourse, instead of only being covered by aging and caregiving wonks.

After all, everyone knows someone who’s struggling to help an aging spouse or parent. This nationally representative survey found that 18% of respondents were caregivers. Of those, most (79%) were helping an older person, as you can from this excerpt of the executive summary:

 

Caregiver prevalence & basic, from page 9 of the executive summary

The report also later notes that nearly half of caregivers provide care to someone age 75 years or older.

For this survey, caregiving for an adult was defined as providing “unpaid care to a relative or friend 18 years or older to help them take care of themselves.” (For child care recipients, the survey sought to identify people providing care due to “medical, behavioral, or other condition or disability.”)

 

Highlights from the executive summary

If you are involved in aging, caregiving, or even healthcare, I would strongly encourage you to review the report’s executive summary. It is chock full of fascinating data, which I’ll summarize below.You should also consider signing up for the related webinar, which will be on July 15th from 2-3p EST. Sign up here.

Older caregivers have a high care burden. The survey found that nearly 1 in 10 caregivers is aged 75 or older. They noted that such older caregivers — most of whom care for a spouse — tend to put in a lot of hours (34/wk on average), often are not enlisting paid help, and often have been providing care already for 5.6 years. This group reported being very involved in communicating with health professionals, and said they want more information about making end-of-life decisions.

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GeriTech’s Take on AARP’s 4th Health Innovation @50+ LivePitch

On Thursday May 14, 2015, AARP hosted its fourth Health Innovation@50+ LivePitch event, an event that “features the most exciting start-up companies in the “50 and over” health technology sector.”

In this post, I’ll list brief descriptions of the finalists, comment on how promising they seem to me — in terms of improving the healthcare of older adults — and tell you which products I’m most interested in. To see what I’ve thought of past LivePitch finalists, here’s my coverage of the first, second, and third cohorts. (Now what would be interesting is to see what’s happened to all those companies since, esp the winners. No time now to do it, but let me know in the comments if you have an update re a past LivePitch finalist.)

As usual, the start-ups were judged by venture capitalists and by a consumer audience. No judging or input from anyone whose primary work and expertise is to improve the health of people aged 50+.

See the FAQs for the eligibility criteria for this year. More interesting to me are the judging criteria and AARP’s categories (also listed in FAQs):

“The Judges will focus on these five critical elements:

  • Functionality – Is the company’s product easy to use, and does it get the job done?
  • Potential – What is the company’s business model and likely profitability, size of the market, likelihood of adoption, and growth potential?
  • Team / People – What experience does the team have, and can they make the product or service a success?
  • Creativity/Differentiation – Why would someone use this product and/or service over alternatives?
  • Scalability – Is this a small business not capable of scaling or is it a large business that has a lot of growth potential?

The AARP Consumer voting will focus on these four critical elements:

  • Need – Why should consumers want this product? Does the product/service address a significant unmet or under-met need? Is it unique?
  • Marketing – How easy is it to get the product?
  • Usage – Why is the product easy to use?
  • Value – Why does the value and cost of the product makes it a “must have”? What is the value proposition? Would someone use it and/or refer it to family and friends?”

AARP’s Categories for Health Innovation @50+:

  • Medication Management
  • Aging with Vitality, e.g. increase daytime energy, maintain muscle strength, manage arthritis, improve or aid in memory/cognition, brain fitness improve/aid hearing, improve/aid vision
  • Vital Sign Monitoring
  • Care Navigation
  • Emergency Detection & Response
  • Physical Fitness
  • Social Engagement
  • Diet & Nutrition
  • Behavioral & Emotional Health
  • Other
Compared to last year’s categories, AARP seems to have dropped the category of “aging in place.” They still don’t have a category about managing one’s chronic health problems, which I would argue is extremely important to maintaining the health and wellbeing of people aged 50+.

AARP’s list of this event’s ten national finalists is here. They also had an additional group of five Florida finalists, which I won’t have time to cover.

GeriTech’s quick take on the AARP LivePitch finalists

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Notes from the Institute on Aging’s Tech Conference

 

Last week I attended another one day aging & tech conference. But it was very different in feel compared to most events I go to, because this one was not hosted by an organization with an entrepreneurial background. Instead, the event was hosted by an aging services non-profit: the Institute on Aging (IOA). (Conference agenda is here.)

For those who aren’t familiar with the IOA,: it’s a terrific organization that has spearheaded a number of innovations related to better care of older adults over the past 30 years, including launching the first fellowships in geriatrics and creating the Friendship Line, the nation’s only crisis hotline to address isolation and suicide risk in seniors. (For more on the history of the IOA, see here.) The IOA has also often collaborated with the City and County of San Francisco on aging services.

This conference provided continuing education credits for nurses, social workers, therapists, attorneys, and residential facility providers. So the audience mainly seemed to be those individuals, rather than entrepreneurs and innovators.

This struck me as a bit of a pity, because the content of the talks seemed more focused on what aging people need — rather than how to make your entrepreneurial venture succeed — and I think the more entrepreneurs can hear about this, the better.

In truth, my overall impression was that this conference was “by the aging community, for the aging community” whereas most tech and innovation conferences are “by the innovation business community, for the innovation business community.”

Is there a way to merge these two groups more?? I don’t know the answer to that.

At the end of this post, I’ve embedded the Storify with all my tweets from the day, which hopefully will share a sense of the event, for those who weren’t able to attend.

A few particular talks that I really enjoyed

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Notes from the Aging 2.0 Global Innovation Summit

This past week, I attended the second Aging 2.0 Global Innovation Summit.

I wrote about the first one here. It’s now a year later, and I would say that the health and aging experience of the average older adult still hasn’t changed much.

But this perhaps isn’t so surprising. It’s been said that

“We tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run.”

So presumably we’re on track. The aging innovation community certainly seems to be growing and expanding its horizons, and this year again, I heard about many intriguing ideas and technologies.

I did live-tweet most of the summit, so for details on what was covered and what technologies were presented on stage, see the Storify here, or below. (Full disclosure: Aging 2.0 graciously extended a complimentary invitation to me.)

In the rest of this post, I’ll share some thoughts on what stood out to me during the conference.

Key Themes of the Aging 2.0 Innovation Summit

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What PBS Forgot in its Caregiver Resources Section

As many know, family caregivers of aging adults are of extra-special interest to me. I’ve been studying their needs and creating health content for them since 2008, and these days I spend over half my time working on GeriatricsForCaregivers.net and a related site.

So I was thrilled to find out that PBS was releasing a special titled “Caring for Mom & Dad,” which is premiering this month.

But then I took a look at the website, clicked “Caregiver Support,” and I was a bit dismayed. Here are the resource sections I saw listed:

  • Getting Started
  • Managing Finances
  • Government Resources & Support
  • Workplace Resources & Support
  • Communicating with Family
  • Technology
Notice anything important that is missing? That’s right. Nothing about how to manage health or medical. (Sorry, but the Medicare Nursing Home Locator does not count.) 
I also noticed there is nothing about addressing advance care planning, which is really crucial for family caregivers since nearly half of seniors require surrogate decision support during hospitalizations.
This is a disappointing oversight. Because as any family caregiver will tell you, they spend a lot of time dealing with health issues. 
This was confirmed by an important 2012 report published by the United Hospital Fund and AARP’s Public Policy Institute. Titled “Home Alone: Family Caregivers Providing Complex Chronic Care,” it reports that 46% of family caregivers are performing medical and nursing tasks.
And of course, underlying health issues are why families step in to help aging adults. If it weren’t for health problems, then aging challenges would mainly be about things like dealing with losses and age-related discrimination and loneliness…all of which are very important but those are not why people end up having to take care of Mom and Dad.

Aging Problems, Caregiving Problems, & Health Problems Are Always Interconnected

I am going to say this again, mainly because it seems clear that it’s not top of mind when people think about caring for aging relatives, and it really should be:

Almost all aging problems that cause worry in families track back to underlying health problems.

Plus there’s an additional truth that all seniors and family caregivers should be aware of:

It’s common for those underlying health problems to be sub-optimally managed.

That sub-optimal management is first and foremost the responsibility of the involved clinicians and health systems. But usually there are some things that family caregivers can do as well, such as bringing up a concern at a doctor’s visit and making sure the doctor addresses it. (Did you know: a study of patients with documented dementia found that over half of them had never gotten a cognitive evaluation from their usual doctor. Sad but not at all surprising!)
In fact, although virtually every family caregiver I’ve talked to is at least somewhat involved in health issues, I find that they often underestimate the impact that sub-optimal health management has on their caregiving efforts.
For instance, I’ve come across several cases of families with a memory-impaired diabetic older adult, struggling to manage a complex insulin regimen and also coping with hypoglycemia and falls. 
Often, although not always, we’re able to improve things by simplifying the insulin regimen and relaxing glucose control a bit. This is something that geriatricians think to do, but endocrinologists often do not. 
Another common problem: people with memory problems are often being prescribed anticholinergics or sedatives that can make thinking worse (plus these increase fall risk).
The family caregiver who doesn’t learn to be proactive about asking doctors to simplify medication regimens is at a grave disadvantage. Ditto for the family caregiver who hasn’t learned to ask the doctor to revisit medications on the Beer’s list
Most geriatrics care has to be delivered by non-geriatricians, because there will never be enough geriatricians to go around. All doctors – unless they are peds or OB — will need to get better at providing geriatrics care, but this will take time. 
So providing family caregivers with at least some preliminary resources on how to help their aging relative get better care — and avoid harmful care — is a critical part of providing education and support.

Some Medical Caregiving Resources for PBS to Consider

What is really perplexing about the PBS oversight is that health resources were addressed in a prior PBS production titled “Caring For Your Parents,” which seems to be from 2008.
(How do I know about this prior PBS special? Because they listed it under the “More from PBS” section in the website footer.)
This section is well done, subsections of the health care resources include:

So if PBS wanted to improve the resource section for the current production, they could start by updating the resources for the sections above. I don’t have time to pick my very favorite resources right now, but some resources I’d list include

When will we get better at providing senior health resources online?


A year ago, I wrote a blog post for the #HCLDR blog (Healthcare Leader), suggesting that we 

“adapt the e-patient approach to empower older patients and their families to more actively participate in obtaining better healthcare.”

PBS doesn’t have to spread the word about e-patients and how people can now take advantage of Internet resources to get better healthcare for themselves and their loved ones. (Although it would be neat if they did!)

But I do think they need to make sure health resources are included, whenever they list resources for family caregivers of aging adults.
The nice thing about webpages is that they are easy to update and modify. I hope they consider adding a little extra info to their resource list soon. The media attention associated with this documentary means they have a big opportunity to reach — and helpfully inform — millions of people struggling with aging parents.
I don’t want to see them miss this opportunity to help families. Caring for Mom & Dad means helping them with their health. The sooner we get better at doing this, the better.

My Process for Meaningful Use & Chronic Care Management

What is actually involved, in providing good ongoing medical care to a frail older adult who is medically complex?

I’ve been thinking more about this, since earlier this week I attended a Code for America event about meaningful use. And in an interesting coincidence, Christopher Langston of the J. Hartford foundation published a blog post yesterday titled “Making Electronic Health Records Responsive to Needs of Older Adults (Really Meaningful Use).”

Now, since my consultative geriatrics practice is direct-pay and I’ve opted-out of Medicare, I don’t have to use a certified EHR that is going to help me attest to meaningful use.

Nor do I have to figure out how to qualify for the new chronic care management (CCM) payment.

But of course I use my EHR (MD-HQ) very meaningfully. And the clinical work I do meets the 99490 criteria:

  • Multiple (two or more) chronic conditions expected to last at
    least 12 months, or until the death of the patient,
  • Chronic conditions place the patient at significant risk of death,
    acute exacerbation/decompensation, or functional decline,
  • Comprehensive care plan established, implemented, revised,
    or monitored.

(The one criteria I don’t meet is that I don’t provide 24/7 access to my services, although all my patients can access their clinical information — including detailed clinical notes — via my patient portal. Because my practice is small, solo, and consultative, everyone has to have a PCP and that’s who they can call after hours or on weekends. It’s not ideal but oh well.)

Helping an older person with health is like managing a complex ongoing project

One could write a long book listing everything that goes into providing ongoing health help to an older adult.  Especially since this usually means also helping family, as well as the paid individuals providing assistance.For an older adult with functional impairments, it’s easy to have a very large number of people involved, when you consider specialists, home health, family, residential facility staff, paid in-home caregivers, geriatric care managers, etc. And usually we have lots of ongoing health issues to collectively address.

So those are the circumstances in which I usually do my doctoring. In this post, I’m going to focus on what I’ve noticed when it comes to what I need from my EHR, and my personal clinical workflow.

First of all, it’s important to have a way to capture and store all the relevant data that emerges between face-to-face visits. This includes things like:

  • Test and study results, such as lab results or imaging reports, whether ordered by me (in which case they get faxed to me) or ordered by another provider (in which case I might have to request a copy)
  • Clinical notes from other healthcare professionals, either outpatient or inpatient (ED notes and hospital discharge summaries are extremely important, and usually a hassle for me to obtain)
  • Information from the living facility and/or paid caregivers
  • Vitals or other data collected where the patient is (just who gathers this and transmits to me is always its own small project to work out)

I also need a way to capture and store a record of the communications and conversations that I have with everyone involved in the patient’s care, whether that’s the patient, the family, the care manager, another provider, the facility staff, etc. These include:

Notes regarding a phone call or phone message. This needs to include what each party said, and what was decided or suggested as next steps and plan for follow-up.

  • Written exchanges, such as that within secure messaging or even short text messages
  • Faxed exchanges: it’s quite common for entities such as pharmacies, residential facilities, and home health agencies to communicate their questions by fax. And I fax back, because that’s what’s fastest.

I have even occasionally had to figure out what to do with the communication embedded within a secure “doctor-to-doctor”platform like Doximity, which I’ve occasionally used to communicate with a patient’s PCP.

Capturing and storing data can be a bit of a hassle. You also need to make sure all this data can be accessed or shared with everyone else who needs it. (Someone else might want to know what I said to the patient’s family.) But in many ways, it’s not much effort compared to what really matters: making sense of it all.

Why make sense of it all? Well, the whole point of ongoing outpatient healthcare is to have a meaningful collaboration with a patient and care circle, in order to help the patient move forward towards his or her health goals.

So when we think about meaningful use, and paying for chronic care management, we shouldn’t just ask ourself what does the doctor need to check, document, and share. We need to also ask ourselves:

“What does it take to collaborate long-term on a complex endeavor that involves lots of data, lots of people, and is constantly generating interdependent to-do items?”

What it takes, in my experience, is being able to successfully toggle between all the little tactical things and also the big picture strategy and trajectory. While not losing track of anything important but not super urgent (like discussing prognosis).How can EHR regulations and CCM payments support that? This is what we need to figure out.

Why I’ve found that face-to-face visits are very important, and also hard

I created my practice in part to escape the tyranny of relying on face-to-face visits. I wanted to be in touch with patients and others more often…as often as necessary, really.

Also I wanted to figure out how to work well with their care circle, and with any technology we might be able to leverage in their homes. (Blood pressure cuffs that send their data to the cloud are great! But I can hardly get anyone to use them.)

So in my practice I charge for time, no matter what I’m doing. Most of the time spent on my practice does not involve face-to-face visits.

But, after doing this for 2.5 years, I’ve found that face-to-face visits — which for me are always housecalls — remain essential. Because right now they are the catalyst for three very important processes.

Important Process #1:
First of all, preparing for the face-to-face is when I go back and review all the little bits of data that have come in since the last visit. I do this because I feel I need to summarize the key points in my housecalls note.

And I want to summarize them in my housecalls note for two main reasons. I need to make sure that I know what is really going on, and without going through a process of cognitive synthesis, I’ll just remain buried in a bazillion details.

Obviously, I have to think and take action every time some little piece of data comes in. However, especially when lots of little things keep happening, I’ve found it’s easy to get buried in details and short-term issues. To properly help an older person, one needs a way to keep coming back to the big picture of things and the most important things to do next. Taking time to sit back, synthesize, and summarize helps achieve this.

The other value in documenting one’s synthesizing process is that I see my housecalls note as a useful summary to be used as a reference in the future. I’ll certainly look at it when preparing for the next housecall. And I’d like for it to be useful to the other providers and entities involved in the patients care. (Including the family or conservator.)

Important Process #2:
Now for the second important process that happens during a face-to-face. I have noticed that an in-person conversation is by far the most conducive environment for reviewing the overall plan of care and hashing out next steps — especially the big challenging ones — with the patient and family.
Next best is phone. Email, on the other hand, is terrible for this purpose. It’s basically hard to get people to do something cognitively demanding (like synthesizing a situation, weighing benefits/burdens and deciding which course to try) over email.

Also, addressing fears and emotions, and leveraging the patient/family-clinician relationship are important aspects of collaborating with patients. It’s very hard to do this without at least being in conversation, and it works even better when you are face-to-face.(Hence I’m always skeptical when I hear about email visits. I’ve found they are useful for small things, useless for important things. Other than saying “we need to talk and here’s what we should talk about,” which IS useful.)

Important Process #3:
After going through a synthesis of information, a review of everything going on, and then having a productive encounter in which we decide what we’re doing next, I move on to the third process: carefully documenting the problem list, what we discussed in the visit and decided, and the plan for each item on the problem list.

I do this by writing out a pretty extensive assessment and plan, and also by creating a related — but simpler — list of next steps which I send to the family or whomever is the patient’s point person.

What I need from my EHR

Well, in brief, what I need from my EHR is for it to be easier to do what I just described. This means:

  • Capturing and storing of all the relevant data and communications info.
  • Making it easy for me — and also the patient, while we’re at it — to go through a periodic process of synthesis, recap, and review.
  • Making it easy for us to document an update and plan of action for everything on the problem list — even if we didn’t address it during a given face-to-face visit — along with next steps.
  • Making it easy to share all the above with everyone else who is involved or needs to access this information.

It  seems to me that it’s a pretty tall order, especially if you throw in the need to accomodate billing and admin needs. Especially since healthcare workflows were essentially designed to accommodate short discrete encounters, rather than the ongoing management of the very complex and often changing health needs of an older adult.

But this is a key part of what I need to meaningfully help my patients and synergize with others helping my patients. Yes, I’m direct-pay, but for the most part I am doing what we’ll need primary care doctors to do for complex aging patients.So I hope the next generation of EHRs and payment mechanisms makes all this easier.