Friday, January 23, 2015

Flipping the Clinic: On Brainstorming Innovation by Patient Type

Last week I attended the Flip the Clinic Lab event in San Francisco, which was co-hosted by the UCSF Center for Excellence in Primary Care, and sponsored by RWJF. (See my Storify of related tweets here.)


It was a fun and engaging day, but it left me thinking something that I often find myself mulling over at health innovation conferences:

Is it possible to constructively brainstorm about healthcare when thinking about everyone's health needs at the same time?

In other words, are we likely to come up with good ideas when we're striving for ideas that work for all patients? Are we likely to come up with really useful ideas when a pediatrician and a geriatrician and a 30 year old Type 1 diabetic get together and envision a better patient-clinician experience?

The difficulty, of course, is that different types of people need different types of help from the healthcare system.

A generalist pediatrician presumably has many patients who are overall fairly healthy. They do need monitoring, and health education, and also help when a new health problem comes up. Many of them might be struggling with weight and healthy eating, and some are at risk due to their social determinants of health. Some of these patients will develop a chronic disease like asthma, and will need ongoing help with their chronic illnesses. And a minority of pediatric patients have the kinds of health problems that require frequent hospitalizations.

A geriatrician like me, on the other hand, cares for older adults who tend to have multiple "mundane" chronic illnesses. Many of them have chronic impairments of the brain or body. Many of them have caregivers assisting them with life tasks, including "self-healthcare" such as symptom monitoring. Many of them experience hospitalizations, and life-threatening health crises.

The truth is that when we brainstorm flips for our clinic, or any other kind of improvement to healthcare, we generally aren't thinking of everyone at once.

Instead, we are either thinking of our own needs as patients and families. Or if we're a healthcare provider, we're thinking of the needs of those patients that we spend the most time with, or are most interested in.

Common Types of Patients

Friday, January 9, 2015

Resolve to Become Fit for Frailty & Do Great Things in 2015

This week I came across a fantastic resource that I want to recommend to any and all who are serious about solutions to support aging adults. (Or healthcare, for that matter, since older adults are the power users of healthcare.)

It is the Fit for Frailty report, the second part of which was recently released by British Geriatrics Society.

Part 2, "Managing Frailty" is particularly important, as implementing good care is generally much harder than identifying those in need of better care. (Focus on the constraint, people. Implementation is almost always the constraint.)

For geriatricians, this is a nice resource summarizing the best of what we do. If you're in geriatrics, read it and enjoy.

But I think this is especially valuable for the entrepreneurs, innovators, and health problem-solvers who are interested in aging.

Your job, as I see it, is to take the best of what we know and do in geriatrics, and make it more easily doable by everyone: older adults, families, communities, clinicians with no particular training in geriatrics, and even geriatricians. (I am eternally in need of tools that will make doing what I'm trying to do easier.)

Now here is a wonderful document that outlines how we go about modifying healthcare so that it's a better fit for frail older adults.

Thinking you're interested in older adults but not frail older adults? Think again.

Although frailty does have its own characteristics and isn't the same as being old, or having multiple chronic conditions, products and services that meet the needs of the frail are the healthcare equivalent of universal design.

That is to say, the approaches we've developed for frail older adults -- like carefully weighing the benefits and burdens of medications, and tending to the needs of the family -- are generally good for all patients.

Plus, frailty is strongly correlated with healthcare utilization, so if you develop tools to better help frail older people, someone might be willing to pay for them.

Must-reads from the Fit for Frailty report

Friday, December 19, 2014

The Trouble with Home Health Care & Care Coordination


Home health care is in many ways a fantastic service, especially for those Medicare beneficiaries who are essentially home bound due to frailty or illness.

But it's often feels surprisingly hard to synergize with home health care.

The main problem, as I see it, is that home health care agencies have set themselves up to provide only administratively required communication with the ordering doc. (There are rules governing home health care, you know!)

Now, what I need is clinically relevant communication. As in, how is the patient clinically doing, so that you and I can coordinate our efforts together. This has apparently not been built into the home health care workflow.

And things get even more complicated when it's a patient in assisted living, because then you have the facility nurse who should be kept in the loop as well.

Right now, I am trying to follow up on an elderly woman who lives in assisted living and has paid in-home aides (which are provided by a separate company).

I referred her to home health care a few weeks ago for help managing her skin. On one hand, she was starting to develop a pressure sore from sitting too much in the same position. And on the other hand, she had a fungal rash in her groin, under her incontinence brief.

I prescribed an antifungal cream to be used twice a day for two weeks.

Now it's been three weeks, and the pharmacy is requesting a refill.

Well...what's going on with that rash?

What I want to do is send an email to everyone who is involved and might know something. That means an email that would include:

Friday, December 5, 2014

Health Care for Dummies (and Innovators): In search of a practical definition of health

[This post was first published on The Health Care Blog on 11/26/14.] 

For a while now, I've been working on an ebook about making digital health more useful and usable for older adults.

(Don't hold your breath, I really have no idea when it will be done. I can only work on it for about an hour every weekday.)

In reflecting on the health innovation conferences and conversations in which I've participated these past few years, I found myself musing over the following two questions:

  1. What is health? 
  2. What does it mean to help someone with their health?
After all, whether you are a clinician, a health care expert, or a digital health entrepreneur, helping people with their health is the core mission. So one would think we’d be clear on what we’re talking about, when we use terms like health and health care.

But in fact, it's not at all obvious. In practical parlance, we bandy around the terms health and health care as we refer to a wide array of things.

Friday, November 21, 2014

What A Caregiver Said Was Hard About Hospice

[November is National Family Caregivers Month. In this post, I share the eye-opening letter I received from a Geriatrics for Caregivers reader who has cared for his mother -- now 100 years old -- in his own home for 3 years. She is now on hospice. 

The writer has given me permission to share this letter, noting that his mother, a former teacher, would have been glad to know people were learning from her story. Please note: all emphasis below was added by me.]

Howdy Dr. Leslie -
Mom has progressed quite a ways down the road and actually I am quite amazed that she is still with us. I think that, somewhere in the back of her head, she had the 100th birthday in her mind as a goal. She has deteriorated quite a bit in the last 10 days since her birthday.

Two months ago we placed mom on the local hospice program (we have one, run by the hospital) and we were just recertified for another 60 days. You may remember the difficulties our hospital was having and the possibility that it might actually close due to some incredibly bad CEO's and bad management. Fortunately, they have located a fellow who used to be the CEO here about 15 years ago and he has gone on to form his own hospital management company and they have several hospitals located around the country. Things appear to be on a new track.

Now to your question - the thing that has probably frustrated me the most in caring for my mother are two:
  1. the lack of resources and available training to function as a caregiver and
  2. the continuing lack of resources that I have received from our hospice program. 

As mom progressed, I had located several dementia units that I felt would be a good match and found that unfortunately 3 of them have discontinued their dementia care units due to rising liability issues. The remaining ones didn't make me feel comfortable.

Since mom has been unable to walk back in February, I have had one night off and I know it is beginning to affect me. I have found caregivers (including my sister when she is able to come up) but none will stay overnight and none will do any lifting. Even the hospice program offers volunteer caregivers but only for about a two hour time period and they do not do lifting. We tell caregivers to watch out for their health, but then don't provide the resources to accomplish that.

A local nursing home now offers respite care and our hospital has once again started accepting Medicare and Medicaid patients for respite care up to 5 days. (Prior to this, the other CEO refused to accept anyone except self pay for respite care).

Much of what hospice offered I didn't need: harp player, chaplain, social worker, respite volunteer (although I have utilized her 3 times when I haven't had a choice). What I have taken advantage of is a personal care individual who washes mom's hair and trims/cleans her fingernails as my eyesight made this difficult), a physical therapist to see if mom could improve her ability to stand on her own as an assistance to me when I was changing her and of course, the nurse. All of them, with the exception of the physical therapist seemed to come with their own agenda of what they wanted for mom's care - despite my stating and restating what I wanted done.

Friday, November 7, 2014

What Caregivers Say is Hardest About Helping Aging Parents, and Atul Gawande's Insights in Being Mortal

Several weeks ago, I asked my caregiving audience at Geriatrics for Caregivers a question:

What’s your biggest frustration with helping aging parents, or aging loved ones?

The answers were enlightening. Nobody, unsurprisingly, said avoiding delirium, or minimizing medication side-effects, or any of the other very important things we talk about in geriatrics.

Instead, the biggest frustrations overwhelming had to do with managing relationships, and finding ways to provide help and support, while respecting the older person's desire for autonomy and independence.

(Want to see just what people said is hard? I highly recommend you read their quotes here.)
So, I had a real "Aha!" moment when I read Atul Gawande's new book, "Being Mortal," shortly after hearing from the Geriatrics for Caregivers readers.

It turns out that "Being Mortal" is mostly about getting old, and about caring for those who are getting old. 

In other words, he has brought his signature style to the topics of aging, and caregiving.

But you could easily not know this if you've mainly read the press about the book. The media has mainly focused on this book being about "end of life," and Gawande himself chose to highlight a cancer-and-the-magic-of-hospice story in his widely read New York Times op-ed

He also, when I saw him speak in San Francisco last month, chose to deliver his prepared remarks on the same topic: the better cancer death of his daughter's piano teacher.

This struck me as a shame. Although as a society we certainly need to have more conversations about how we die, and how to make it better, we really need to have more conversations about aging, declines in independence, and caregiving.

(Full disclosure: My father died of cancer at age 61, while I was in medical school, and we certainly could have used more palliative care involvement. Rest assured that I consider terminal cancer a devastating experience well worth any and all improvement efforts. But I still think cancer and death are hogging the limelight.)

As far as I can tell, people would rather plan to die than plan to be old and slowly declining.

And I am pretty sure that right now people would rather train in palliative care than in geriatrics.

So. We need people to champion and spearhead a thoughtful discussion about what's hard about helping older people, especially when they become frail and start to need more assistance. 

And we need good, compelling, readable books that can help people reframe how they might offer help to an aging parent, and what kinds of goals to strive for during those last years. 

I personally think Being Mortal is one of those books: a compelling read that could give families throughout the country some really valuable insights on how to help aging relatives during the last few years.

But in the end it will come down to what the family caregivers think, not me.

(I've already had one person tell me she thinks it's "good for doctors." Which it surely is, but I'm especially eager to find books that are good for families.)

At some point, I'd like to write a more in-depth summary of the many insights Being Mortal offers, when it comes to helping people manage aging and declines in independence. But as I'm not sure when I'll have time to write it, I offer you instead a substitute: my tweets from Atul Gawande's talk at the Commonwealth Club last month.

Friday, October 24, 2014

Props to RWJF for Improving #CultureofHealth, & the power of social media

In my last post, I explained why I felt that #CultureofHealth wasn't quite working for me, and I proposed that we try to brainstorm complementary memes.

In particular, I was concerned that an intense focus on "being healthy and staying healthy" might not offer enough support to those who struggle with illness, or to clinicians whose work it is to care for "sick people."

The CEO of the Robert Wood Johnson Foundation, Dr. Risa Lavizzo-Mourey, was kind enough to write a response on THCB, and several people commented on both posts.

Furthermore, on October 17th, Dr. Lavizzo-Mourey posted a comment announcing that RWJF had made some tweaks to their message, to better clarify that a Culture of Health includes everyone, "be they sick or well."

I am, of course, hugely grateful to RWJF for taking the time to thoughtfully consider the issue. 

I'm also especially grateful to those who took the time to comment and relay their own reactions to RWJF's previous definition of a Culture of Health; I'm sure this input was vital to the process of considering the Culture of Health messaging.

In this post, I want to share the "tweaks" so far in defining the Culture of Health. I'll also share some of the complementary meme ideas I heard from other people this month. And then I'll close with some thoughts on the power of blogging and social media.

Culture of Health before and after



“We believe an American Culture of Health is one in which:
  1. Good health flourishes across geographic, demographic and social sectors.
  2. Being healthy and staying healthy is valued by our entire society.
  3. Individuals and families have the means and the opportunity to make choices that lead to healthy lifestyles.
  4. Business, government, individuals, and organizations work together to foster healthy communities and lifestyles.
  5. Everyone has access to affordable, quality health care.
  6. No one is excluded.
  7. Health care is efficient and equitable.
  8. The economy is less burdened by excessive and unwarranted health care spending.
  9. The health of the population guides public and private decision-making.
  10. Americans understand that we are all in this together.”

As I said, other people's comments provided truly vital input to the conversation. I especially want to highlight Dr. Peter Elias, a remarkably thoughtful primary care physician who I know through the Society of Participatory Medicine. He commented:

"[This] talks about being and staying healthy, but doesn’t speak to the people who are ill and struggle for even some improvement in health, let alone those who just want dignity and comfort because health is no longer an option for them. 
I think I understand the intent: a society that values the things that foster health. But the message I hear (and my patient heard) is that health is not just the goal, but the only acceptable state. That’s pretty hard on the ill. It lends itself to a culture of blaming patients for their misfortunes, something I see on a regular basis. 
How does a dying patient related to a culture of health? Probably by feeling alienated, disrespected and disposable. How will clinicians behave in a medical culture of health? Will they be unwilling to care for patients who cannot become healthy or do not try hard enough (by someone’s definition) to get healthy? 
I fear that a culture of health would make it less acceptable to care about those who are not healthy."
Again, it is a HUGE credit to Dr. Lavizzo-Mourey and RWJF that they really took these comments under consideration. They could have ignored me and Dr. Elias and kept doing what they do, and we all still would have mostly kept loving them because their foundation plays a vital role in improving health and health care.

But instead, RWJF made some modifications. And here's how they are now defining a Culture of Health: