Why Is It So Hard to Get Detailed Medication Info from Assisted Living?

pills isolated on white background

pills isolated on white background

Here is a need which I’d like to see new technologies address: the need for improved and facilitated communication about medications in assisted living.

This comes up often in my clinical work and in this post I’ll share a recent true story, illustrating some of the issues. But it’s not just a problem for me; it’s an important aspect of the care of a growing aging population, which will require better integration of health care and “life care.”

Today, it’s common for people in assisted-living to be on many medications; residents of these facilities tend to have many chronic health conditions. (For an excellent overview on who’s in assisted-living and the challenges facing the industry, see Howard Gleckman’s post “The New World of Assisted Living.”)

And many of them pay to have the facility do “medication management”; this gerontology article states that this is a major reason for moving into assisted-living.

What exactly “medication management” means seems to vary a bit depending on the facility, and perhaps also on state regulations. Generally, the facility obtains medications from a pharmacy – it often seems to be one they have contracted with — and dispenses medications to the residents, based on the orders of clinicians.

Having a layer of professionals involved in medication dispensing can be pretty useful, especially when older adults have developed cognitive impairment. After all, you have someone else making sure the medications are obtained from the pharmacy, keeping medications in a safe place, and reminding patients to take them.

As a clinician, I greatly appreciate being able to know whether a patient actually took a prescribed drug. That’s because when people live independently, they often don’t take their medications as prescribed, and it can take a lot of effort to find out just what they are taking, and how often they take it. (Never mind the time and effort required to go into the reasons why they may not be taking their medications consistently, which is important and patients often have good reasons.)

So medication management in assisted-living should make this problem easier for me. But so far, it’s not all that easy for me to leverage the information that a facility has, regarding medications.

I’ve been thinking about this recently because one of my patients in assisted-living fell seriously ill recently. And it was her leaving me a message complaining about her PRN pain medication that alerted me to her significant decompensation.

Does Anyone Track Changes in PRN Medication Use?

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The Physician and the Fitbit

IMG_4643About six weeks ago, I lost my Fitbit Flex.  I’d been wearing it for two years, almost to the day.

This apparently makes me an anomaly. Consumer surveys suggest that many people — perhaps even most — lose interest in their devices within a few months.

I’m not surprised that many people would abandon using their tracking devices. People have a lot going on in their lives. It never seemed very plausible to me that vast numbers of “ordinary” people would adopt technology to change their health habits.

But does that mean wearables will be useless in healthcare (the organized part of the system) or “health care” (the way people take actions to improve their health or the health of someone else)?

It is really too soon to say. So much depends on whether a company like Fitbit can better understand what different types of users want and need from a device. I personally believe that the people who are most likely to benefit health-wise from the data-gathering capabilities of a device are also the ones who are most likely to be involved with healthcare professionals. People like Joan, for instance.

This is actually why I purchased a Fitbit in the first place. In the fall of 2013, it was a popular wearable device and I wanted to see whether it might be able to help address some common issues that we often help people with in primary care.

In this post, I’m going to share my own experience with my Fitbit, including how I can envision it being useful in the context of primary care. But if you are interested in wearables for older adults, I highly recommend reading this AARP report (July 2015), in which they studied the experience of 92 older adults using sleep and activity trackers. (Lots to pick apart in that report; perhaps in a future post.)

There is also some extremely interesting information on the state of the digital health industry here, summarizing Rock Health’s 2015 report on consumer adoption trends in digital health.

Could a Fitbit Help With These Two Primary Care Issues?

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Louisville & Creating the Future of Aging Care in a City

ok louisvilleLast week, I had the honor of speaking at the Louisville Innovation Summit, where the theme was “Creating the Future of Aging Care.” This was my first time visiting Louisville, which is the home base for several large organizations in healthcare and long-term care.

Much of the conference was interesting (you can see the program here) but what captured my interest and imagination the most was this: in his keynote, Paul Bennett, the Chief Creative Officer of IDEO, urged the city of Louisville to take the lead in reimagining aging.

Now, in truth I’m not really sure what he has in mind when he says this and I suspect that it’s different than what I think of. To begin with, he explained that IDEO is launching a global project on aging called The Powerful Now. Here’s how the project is described on their site:


Doesn’t that match your own hopes, wishes, and desires? To become more curious. More engaged. More vibrant. Physically and emotionally. Deeply connected to the ideas and the people who matter to you.

The Powerful Now is about bringing the power of creativity to how we conceive of, design, and experience aging. If you were to add up all the people who are fifty years and older, they would be the third largest economic superpower on Earth.”

Hm. I am all for reimagining aging in positive terms. But what I care most about is solving the age-associated problems that cause older adults and their families the most excess suffering.

What I want to see is a city that creates or implements effective systems for optimizing the health, function, wellbeing, independence, and dignity of older adults. And I want to see a city that succeeds in doing so especially for older adults who are experiencing:

  • Medical complexity, meaning multiple chronic illnesses or health problems such that they often encounter the hospital or emergency room
  • Chronic impairments of mind, body, or both, meaning dementia or chronic impairments of physical function
  • Difficulty managing ADLS and/or IADLs (which is usually due to acute or chronic impairments of body or mind, obviously)
  • Residence in assisted-living or a nursing home.

The images we use as we articulate our vision of better aging are important. Paul Bennett spoke of how moved he was by seeing older adults in a Shanghai park, waltzing as they did their group exercise.

Very nice. But I want to see images of people with walkers waltzing. I want more images of people who need support, and yet are still living vibrant lives and contributing to the community around them. You might have mobility impairments and need services and because you are GETTING the services you need, you are able to volunteer and help your community benefit from your wisdom or experience or education or even just presence as a friendly person.

I also want to see a city that effectively helps family caregivers support their older loved ones with the problems above.

Taking on such a project at a city level actually makes a lot of sense. To help older adults live their best lives, even as they face the common challenges of aging, you need to integrate health care, social services, housing, employment policies (esp as regards family caregivers), and much more. Seems to me that a city would be a good laboratory for experimenting or attempting to implement best-known practices. Once one city has made progress, it can serve a  model for other cities.

So if Louisville wants to do this, what needs to happen?

I actually know very little about what enables cities to mobilize on a big project like this. But if I were to get going on this, I’d start by making a list of what’s needed, and then I’d look for promising approaches to meet each need. Then I’d work on implementing those approaches and making a plan to assess how well it’s working as you go along, a la Plan-Do-Study-Act method.

(After drafting this post I found that AARP does have a network of “age-friendly cities” and offers a toolkit here. If anyone knows how well that’s been going for those cities, post a comment! And do they ever have conferences related to this project??)

A list of what’s needed and promising approaches would make a good agenda for a future conference.

What’s needed for a city to better support an aging population

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Health 2.0 in 2015: Big steps forward

This week I attended Health 2.0’s Annual Fall Conference for the third year in a row.

I came away more impressed than I’ve been in previous years. Here’s why.

The Unmentionables Focuses on Aging, Caregiving, and Hospice

The Unmentionables session hosted by Alex Drane is always terrific, but this year was especially so, since it focused mainly on aging and caregiving.

If the video is ever made available I’ll post it here. In the meantime, you’ll have to make do with my Storify collection.

Particularly notable: [Read more…]

Aging, Health & Innovation as Geritech turns 3

Exciting times are afoot these days.  The end of this month will mark three years of the Geritech blog, so seems like a good time to step back and consider how things are progressing with aging, health, and innovation.

What is kind of neat is that the blog’s anniversary coincides with two major health and innovation conferences: Stanford’s Medicine X, and Health 2.0 (the flagship Annual Fall Silicon Valley conference).

The medical education part of Medicine X is underway as I write, with the main conference events scheduled for Sept 25-27. I’m sad to not be attending Medicine X this year  –have to be in New York for a family event — but I plan to attend Health 2.0 in early October. (I will also be attending — and speaking! — at the Louisville Innovation Summit in October, which will focus on aging.)

Both Medicine X and Health 2.0, which I attended in 2013 and 2014, are hugely influential, albeit in different ways. So it’s very interesting to review their programs (see here and here), and consider what they are presenting in terms of aging, the care of people with multiple chronic illnesses, and helping older people with functional limitations.

I’m happy to say that both conferences are featuring more programming specific to aging this year!

But first, my own gut impressions when thinking about what’s changed — and what hasn’t changed — over the past three years.

Then I’ll briefly share which upcoming sessions at Medicine X I’ll be especially sorry to miss. I can’t even watch the Medicine X livestream as I’ll be on planes or with family for the next three days. But you could watch! (And I’ll cover Health 2.0 in a future post.)

What’s changed in aging and health over three years

Honestly, at a high level and considering what counts the most — the experience of average older adults and their families — I would say not much, although good things do seem to be brewing. For instance:

The average healthcare experience of older adults and caregivers hasn’t changed much. This is my impression, based on what I hear patients and families complaining about and based on the stories I read in the mainstream press.

Now, many facilities and providers are innovating and trying to improve healthcare, and technlogy is playing a factor in that.

But the improvements seem to either be quite localized (I’m thinking of Mayo’s August 2013 study using Fitbits to improve recovery after surgery; this hasn’t become the post-op norm as far as I know) or of middling impact when it comes to people’s healthcare experience (e.g. more widespread patient portals, Blue Button downloads).

This isn’t to say that all the work on innovation and digital health has been useless, of course. It’s more to say that I don’t see major change. Yet. (Do you??)

Which means that either

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Case Study Part IV: What Joan Really Needs From Her Healthcare

senior health and medications

Today, I’m going to share the fourth and final part of my case study about Joan, a 79 year old woman struggling to manage her many chronic conditions.

I created this case study for my upcoming ebook, because over the years I’ve noticed that different people can have very different perspectives on a single person’s health challenges.

So in the book, I cover the perspective of Joan herself, the perspective of Joan’s worried family caregiver, and then the viewpoint of Joan’s primary care provider, Dr. Miller.

But of course, there’s one more perspective that’s essential to consider, if you are developing tools to help people with their health. That’s the external “expert” analysis and perspective, which I share below.

When it comes to healthcare — or anything important — we can’t assume that front-line users know just what is best, and what’s most likely to help them achieve their goals. That’s why truly useful tools must facilitate “best care,” or at least better care. Here’s what that could look like for Joan.

What Joan Really Needs From Her Healthcare

Dr. Miller’s not a bad doctor. But he’s busy, he’s under pressure to meet quality measures, and he hasn’t been trained to modify healthcare for older adults.

Like many doctors, he’s pretty focused on Joan’s documented health diagnoses. But what Joan really needs is for someone to help her with her health problems. I’d list these as follows: [Read more…]

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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