Thursday, October 9, 2014

Why We Need a Complement to #CultureofHealth

[Action alert! This post was very recently published on THCB and RWJF's president has already posted a response. Esp if you are involved in the care of older adults or people who are medically complex, please consider posting a comment at THCB. Memes can be very influential, especially when they are promoted by major organizations. I hope you'll weigh in on the conversation!]

Last week, I attended the Fall Annual Health 2.0 conference. There was, as usual, much talk of health, total health, and of extending healthy years. 

And this year, there was a special emphasis on promoting a “Culture of Health,” a meme that has become a centerpiece of the Robert Wood Johnson Foundation’s work.

So much so, that when I approached a conference speaker, to briefly comment on my interest in helping beleaguered family caregivers with their carees’ health and healthcare issues, I was advised to work on promoting a culture of health.

Hm. Funny, but as a generalist and geriatrician who focuses on the primary care of older adults with multiple medical problems, I’d been thinking more along the lines of:
  • Promoting the wellbeing of older adults and their caregivers.
  • Optimizing the health – and healthcare -- of my aging patients.

In other words, I’d been thinking of a “Culture of Care.

As in: “I care about how you are doing, and I will provide care to help you with your health.”

Since all my patients have multiple medical conditions, that care means finding ways to help them with their many health concerns. These include diseases, such as diabetes, COPD, heart failure, and Alzheimer’s, as well as “problems,” such as pain, falls, depressed mood, and worrying about whether some recent snafus are a sign of dementia.

It even includes issues like tense relations with anxious children who think Mom should move to assisted living; a common “relationship issue” that inevitably tracks back to the present and future state of Mom’s underlying health problems.

My work, as a doctor, is to collaborate with my patients in order to minimize symptoms, maximize function, improve wellbeing, and prevent health complications. All of which, if I do it well, generally ends up helping their family caregivers.

Is promoting a #CultureofHealth the same as promoting a #CultureofCare? As a front-line clinician, they feel very different to me.

Namely, one strikes me as about working way upstream to prevent health problems before they happen. (“We shouldn’t need a sick care system!”)

And the other is about responding to people who are suffering, and need our help to feel better. No, this is not the hallowed work of preventing chronic diseases from emerging. But it is preventing – or at least delaying -- further deteriorations in health and function. It is helping people make the best out of the situation they are now in.

If you are working with people who are already downstream, and are coping with the burdens of chronic illness, should your priority be #CultureofHealth? Or #CultureofCare?

Consider, for instance, the family described in Knocking on Heaven’s Door. If Katy Butler’s parents, struggling with cognitive impairment and progressive decline in the aftermath of a stroke – and this after a lifetime of “healthy living” – ask their primary care doctor for help, is he more likely to offer the right assistance by thinking “Promote Culture of Health”? Or “Promote Culture of Care”?

After all, one way leaders can test a guiding principle is to ask themselves: as people in my organization face their work challenges, will this help them know how to do it right, or better?

I don’t think #CultureofHealth helps me do my work better. Instead, it leaves me wondering how on earth I’m going to get help doing my work.

This is not to say, mind you, that I don’t have great respect and appreciation for the work and ideas of the Robert Wood Johnson Foundation. If you’re someone like me, who went to medical school planning to work on improving primary care, you can’t not love RWJF. (Nor can you avoid hoping that they’ll someday find you worthy of funding.)

Furthermore, as someone with a MPH degree, an interest in systems, a background in quality improvement, a focus on person-centered care, and unqualified admiration for Alex Drane’s work highlighting the Unmentionables that affect people’s lives, I absolutely believe in what RWJF is championing.

That is to say: I believe that we as a society must address the social determinants of health, help people feel well, and work within but especially outside of doctors’ offices, to prevent chronic health problems before they develop.

But I worry that #CultureofHealth isn’t quite right, as the guiding principle for certain aspects of health care.

So I’d like to respectfully propose we look for some complements to #CultureofHealth. It’s a great concept, but we likely need more if we are going to find a way to offer all our citizens – including the aged and the chronically ill – the care they need and deserve.

(Are you a data junkie? For data on the scope of multimorbidity and associated utilization in the healthcare system, see the figures in the Medicare Chronic Conditions Chartbook. For data on how many older adults have difficulty walking, doing errands, etc, see Figure 2-14 of the Census Bureau report on seniors.)

ISO a meme for the primary care of the medically complex


We need a meme that speaks to better primary care for people with chronic health problems, and that helps us – as healthcare providers – do our job better. Specifically, we need a phrase that reminds us to be better at:

Friday, October 3, 2014

Recap on Caregiving & Technology at Health 2.0

Last week I attended the Annual Fall Health 2.0 conference in Silicon Valley. It's a big event and there was lots to see and think about.

Of particular interest to me was a set of pre-sessions titled "Future Technologies for Caregiving" and "Easing the Burden: Connected Caregiving Tools."

The first session was based on the "Catalyzing Technology to Support Family Caregiving" report which came out this past summer; the report itself was based on an expert roundtable convened in April. That group identified three types of tech solutions as especially interesting to them:
  • An “Intelligent Family Care Assistant” to help with day-to-day caregiving by helping to coordinate the family’s tasks in the context of the family’s other activities.
  • “Wearable technologies”—devices worn on or placed in the body, with sensors and/or human interfaces—to help monitor a person’s health and overall condition.
  • Technologies that provide better connections between family caregivers and health professionals, enabling them to work more effectively as a team in providing care.
(Clinicians, how do these sound to you? Post a comment below!)

The report's core recommendations included:
  • Create better “concept maps” and find more appropriate language to describe the varied and complex caregiving landscape. 
    • LK's note: the report doesn't cite much academic literature, but caregiving scholars have been working on this for a while. Some, like Professor Rhonda Montgomery at the University of Wisconsin, have even developed really nifty practical caregiver assessment tools, like this "Tailored Caregiver Assessment & Referral" tool, which improved outcomes in this preliminary randomized study.)
  • Continue to collect extensive data about the prevalence, burden, and impact of caregiving and the role of technology.
  • Spur a broad national conversation on caregiving.
  • Develop compelling business cases for employers and healthcare providers to support caregiving.
  • Provide caregiving coaching as an integral component of all solutions.
  • Inspire social conversations about caregiving to encourage more learning and support within families and communities.
(All main bullet points above are verbatim from the executive summary of the report.)

In the "Connected Caregiving Tools" follow-up session, four companies demoed their products, and then their executives took questions from the crowd, and from the moderator, RWJF Senior Program Officer Michael Painter.

The four companies were CareSync, CareTicker, Independa, and GrandCare.

Below is a Storify with my tweets related to these sessions, and to a few other Health 2.0 moments related to innovation and caregiving.

What I was most excited about: Kaiser Permanente's exhibit on Imagining Care Anywhere. Although KP's website for this model doesn't seem aging-specific, the exhibit at Health 2.0 centered around -- get this -- a Medicare patient who is diagnosed with early dementia.

The exhibit modeled a comprehensive family-centered care plan, which included safety sensors in the home. And there was a whole panel on how employers and health providers can support the patient's wife, a working caregiver. It was really nice, and I hope to see more similar things at Health 2.0 in the future.


Friday, September 19, 2014

Why Doctors Shouldn't Prescribe Apps, and what we can do instead

 [The following post was first published on The Health Care Blog, where it was titled "Should Docs Prescribe Data?"]

I’ve always been a little skeptical of the push to get doctors to prescribe apps.

To begin with, it would be awfully easy for us to replicate the many problems of medication prescribing. Chief among these is the tendency for doctors to prescribe what’s been marketed to them, rather than what’s actually a good option for the patient, given his or her overall medical situation, preferences, and values.

Then there are the added complexities peculiar to the world of apps, and of using apps.

A medication, once a pharmaceutical company has labored to bring it to market, basically stays the same over time. But an app is an ever-morphing entity, usually updating and changing several times a year. (Unless it stops updating. That’s potentially worse.)

Meanwhile, the mobile devices with which we use apps are *also* constantly evolving, and we’re all basically forced to replace our devices with regularity.

Last but not least, how can we know the benefit of prescribing one app compared to another? Studies are few and far between. And by the time a study is published, everything – the app, people’s use of technology, the mobile devices, the sensors – will have gone through several phases of change. This means we generally won’t have much of an evidence base, when it comes to the prescribing of a given app.

All of this means that it would be a Herculean task for physicians to maintain enough current knowledge about apps, such that they could prescribe them in a thoughtful and informed matter.

So let’s scrap the talk of prescribing apps, and instead focus on what we really can prescribe: what a patient should track.

Friday, September 5, 2014

Advance Care Planning Online: GeriTech takes a look at MyDirectives.com

A few weeks ago, a visitor to Geriatrics For Caregivers sent me a message via the contact form.

He explained that he is a hospital chaplain and that his workplace is considering using MyDirectives.com to help their patients with advance care planning.

"I would love to hear your opinion of the service," he wrote.

I'd actually never heard of this service, but that's not so surprising...new healthcare services for consumers emerge and evolve so quickly that even if I followed tech for aging adults full-time, I'd have difficulty keeping up.

But I have a soft spot for advance care planning. So I decided to take a look at this website, in order to let the chaplain know what I thought.

And, as an experiment, I also decided to try recording myself visiting this advance care planning site.

So if you are wondering what I thought, or if you'd like to see what a practicing doc might do when a patient asks about some new-fangled web-based service, you can watch me explore MyDirectives below. (For audio-only, click here.)

Friday, August 22, 2014

Using Checklists to Improve Primary Care for Seniors: the Oak Street Health Story

[Today's guest post is by Dr. Griffin Myers, whose innovative primary care system for Medicare patients, Oak Street Health, launched in September 2013. To read his prior posts about Oak Street Health, click here.]

Forgive me, I know it’s been a while. We’re now at 5 clinics, 2 more coming in the next few weeks, so I’ve been a bit distracted. That update another time. Here's what I've been thinking about...

In a previous guest post, I blogged about building a foundation to collect data within the practice. Having data is nice. Of course, using it is better. As with my previous posts, we’ll use the Institute of Medicine report “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America” as our guide. Here is the third of the 10 recommendations.

Recommendation 3: Clinical decision support. Accelerate integration of the best clinical knowledge into care decisions.
First of all, I think it’s fair to say that my idea of clinical decision support is different from yours. 

My clinical training is in emergency medicine, and within that field there is a large and compelling body of evidence around decision rules. The Canadian Head and C-Spine CT Rules and Pulmonary Embolus Rule-out Criteria (PERC) are just a few of the most well known examples. These “rules” are all based upon large, multicenter trials, and are validated in later studies. 

Where I trained at the Brigham & Womens’ Hospital in Boston, these rules were integrated into radiology order entry system. In other words, if I wanted to order a head CT, it had to meet those criteria…and I had to answer those questions in the computer. 

It’s a nice way to build the evidence into the workflow, but it’s also pretty unrealistic to think that every primary care practice can build these tools into the EHR. And keep them up to date. And so on... 

What about guidelines, such as those from CMS or the US Preventive Services Task Force? How are those coded in, and what if they change? And for everyone or just for the specific subpopulations to which they apply, say women between the ages of 65 and 75? What about which patients need an end-of-life plan documented?

Like I said: my idea of clinical decision support is probably different from yours. The simplest way I know of to manage through complexity is checklists.

How Oak Street Health Uses Checklists to Improve Primary Care

Friday, August 8, 2014

Personal health record needed for these two use cases

A friend called me the other day: he is moving his 93 year old father from New England to the Bay Area.

This is, of course, a relatively common scenario: aging adult moves -- or is moved by family -- to a new place to live. 

Seamless transition to new medical providers ensues. As does optimal management of chronic health issues. Not.

Naturally, my friend is anxious to ensure that his father gets properly set up with medical care here. His dad doesn't have dementia, but does have significant heart problems.

My friend also knows that the older a person gets, the more likely that he or she will benefit from the geriatrics approach and knowledge base. So he's asked me to do a consultation on his father. For instance, he wants to make sure the medications are all ok for a man of his father's age and condition.

Last but not least, my friend knows that healthcare is often flawed and imperfect. So he sees this transition as an opportunity to have his father's health -- and medical management plan -- reviewed and refreshed.

This last request is not strictly speaking a geriatrics issue. This is just a smart proactive patient technique: to periodically reassess an overall medical care plan, and consider getting the input of new doctors while you do this. (Your usual doctors may or may not be able to rethink what they've been doing.) But of course, if you are a 93 year old patient -- or the proxy for an older adult -- it's sensible to see if a geriatrician can offer you this review.

Hence my friend's situation illustrates two common core healthcare needs that families of older adults often have:
  1. To successfully manage a transition to a new team of medical providers.
  2. To obtain a second opinion regarding a person's health, chronic conditions, and the medical management plan. (For more on how this approach can can help patient assess the quality of their outpatient care, see this post.)
To address both of these needs, older adults and family caregivers need a good personal health record (PHR).

So, I find myself -- yet again -- on the hunt for a good PHR system to recommend to families. 

As some might recall, I blogged about PHRs back in January. (See this post.)  

And now the time has come for me to take another look at what's out there for PHRs. Let's see what people can recommend for these two family caregiver use cases.

Two use cases for personal health records

Tuesday, July 22, 2014

Thoughts on two tech innovation reports & a real family in need

From pg 4 of "Challenging Innovators"
Recently I read two reports on developing technology innovations to help us care for older adults:

"Challenging Innovators: Matching offerings to the needs of older adults" by Laurie Orlov, sponsored by AARP's Thought Leadership group, and




From pg 2 of "Catalyzing Technology"
 "Catalyzing Technology to Support Family Caregiving" by Richard Adler and Rajiv Mehta, sponsored by the National Alliance for Caregiving (NAC).

Both reports are based on expert opinion (as opposed to survey data), and seem to be primarily geared towards helping entrepreneurs develop better solutions related to the care of aging adults. (Note: the NAC report isn't specifically about caring for older adults, but acknowledges that much family caregiving activity is driven by the needs of older adults.)

Although these reports are worth reading, I'll admit that they both left me a bit perplexed and dissatisfied.

Undoubtedly this is partly because the authors -- and the primary intended audience -- are not "people like me."

Meaning they aren't practicing clinicians or academic experts embedded within geriatrics divisions, or even healthcare improvement circles.

The AARP report is very "business-y", and the NAC report seems to have purposefully excluded the perspective of healthcare professionals. (Perhaps to counter the way that healthcare professionals have historically dominated conversations about aging and caregiving?)

But let's set the needs of doctors and quality improvers aside for now. In the end, this is supposed to be about helping people, right? As in, helping patients, helping older adults, and helping the families and friends and many others -- like front-line clinicians -- who help them.

So, I tried to think of older adults and their caregivers as I read these reports. And I found myself still struggling to see just how these ideas and approaches were going to turn into materially better experiences for the patients and caregivers I work with.

Failure of my imagination? Or weakness of the proposed ideas and conceptual foundations?

Janny: A real boomer who could use tech help for aging and caregiving


Personally, when I find myself getting confused by concepts and improvement ideas, I resort to the concrete. 

As in, I think of people I know who have common problems, and need help. And then I try to follow a mental path from some entrepreneur's ideas to actual help for an older person, and/or the family.

This week I read about a family caregiver, whose problems are very common. Her handle is "Janny57" and I read about her situation on the AgingCare.com caregiver forum. (Now there is a GREAT way to learn about what family caregivers are struggling with: read the questions they post on active forums.)

Last week, Janny57 posted asking if anyone else had left husband and kids to care for a parent.