GeriTech

In Search of Technology that Improves Geriatric Care

Creating Conditions for Humanity in Hospitals

[This post was first published on The Health Care Blog on 8/25/13.]

Why aren’t people in hospitals more attentive to the needs of patients?

In a recent post, Dr. Ashish Jha raises this issue as he relates his own story of coming to an ED with a very painful dislocated shoulder. Unsurprisingly, prompt treatment of his pain was deferred while staff diligently completed registration, sent him for an xray, and waited for a physician to see him.

On the bike path where Jha took his initial tumble, people went out of their way to respond to his injury with attention and concern. But as he lay moaning on a gurney in the hospital corridors, waiting for an xray and not yet treated for pain, people avoided his eyes and even walked by a little faster.

What gives? Why aren’t people in the hospital more empathetic and attentive? Is this a “wonderful people, bad system” issue?

In reflecting on his experience, Jha remarks that people seem to leave their humanity at the door when they arrive at the hospital for work, and posits that we get desensitized to suffering. He notes that some workers were able to “break out of that trap,” and responded to him more empathetically when he directly solicited their help and attention.

“It is the job of healthcare leaders to create a culture where we retain our humanity despite the constant exposure to patients who are suffering,” writes Jha.

Culture change is necessary but not sufficient

Culture is important. Yet I’ll admit that I’m usually a bit skeptical when I hear of a plan to tackle a problem through culture change. In my own experience, this has consisted of leaders trying to “create culture” by describing to front-line staff what they should be doing, and repeatedly exhorting them to do it. (And maybe giving out gold stars to those who do it.)

This, of course, is never enough. Talking the talk does not mean people start to walk the walk, especially if the walk involves a slog uphill rather than an easier stroll down a path of lesser resistance

If we – whether healthcare leaders or just concerned citizens who want to see healthcare improve – really want healthcare workers to demonstrate more compassion and empathy while on the job, then here is what we need to do:

  1. We should take seriously the task of understanding what might be interfering with this compassion and engagement. This means not only studying workflow, but also the behavioral psychology of individuals as well as groups.
  2. We should then be serious about creating the conditions that would allow regular human beings to reliably produce the desired behaviors.

Why it can be hard to help people in the hospital

What interferes with showing compassion and engagement? In reading Jha’s piece, I reflected on my own hospital days. Here are the obstacles that I remember, and the impact on me.

Difficulty meeting the needs of patients and families. I remember constantly feeling that people needed more from me than I could provide. Sometimes they needed to talk for more time than I felt I had available. Or they needed a service or other form of assistance that I wasn’t sure how to get for them.

Especially frustrating was when patients needed something like pain medication on short notice. I have been that doctor very concerned about a patient’s terrible pain. Unfortunately, I discovered that my power to help was quite limited by hospital logistics and workflow: although I could order pain meds right away, the patient could almost never get it quickly. After all, the pharmacy still had to dispense the medication, and the nurse had to administer it.

If you are a conscientious person who wants to help (which I think most healthcare workers are), it’s very stressful to recognize a person’s need and not be able to address it.

Hence, as a coping mechanism, my guess is that many people working in hospitals adapt by learning to “not see” those needs that they feel they can’t address promptly and properly. (Perhaps we might consider this a form of learned helplessness?)

That ED doc that Jha praises for addressing his shoulder quickly? He sounds like a good guy, but it also helps that he had the skills and ability to do something right then and there.

Frustration with workflows and workplace tools. It’s no secret that hospitals and clinics often present a “high-friction” environment for front-line staff. Back when I worked in the hospital, every day involved coping with inefficient workflows that generated various levels of annoyance. There was redundant paperwork. There were computers requiring multiple sign-ins, or repeated sign-ins. There were tasks that took three steps when they really could’ve been redesigned to take one or two.

Along with the expected hassles, one also had to contend with frequent malfunctions in whatever system you were trying to use. A printer out of paper. A computer that mysteriously can’t be logged into. A shortage of staff in a certain department, such that a routine inquiry ends up taking twice as long as usual.

To be fair to hospitals, designing friction-free workflows for clinical staff poses a huge challenge, given the complexity of the work involved and the diverse needs that hospital administrators need to consider. And the nature of life is such that often things do not work as expected.

Still, it all added up to a fair drain on one’s energy and attention, and made it harder to provide patients and families with attention when they needed help.

Inadequate levels and reserves of energy. Compassionately interfacing with patients takes energy, especially if pain or emotionally intense issues are at hand. If one is worn out by earlier encounters, or by a long workday, it becomes much harder to muster the energy to engage with those who need us.

And of course the energy one can bring on any given day is powerfully influenced by the overall balance of exertion and regeneration that one experiences over weeks and months. Long workdays stacked back-to-back (as experienced by many hospitalists) take their toll. Young children at home, or other significant obligations outside the hospital, can also reduce one’s energy at work.

On the flip side, certain activities help people regenerate and restore their energy. Adequate sleep, exercise, and close relationships with friends and family are sustaining staples that are needed by all. Plus everyone tends to have some favorite soul-nurturing activities that help recharge the batteries.

For physicians in particular, the problem is that residency tends to leave people with little time to recharge. We form our habits as doctors during a time of chronic stress and fatigue.

And even after residency, many physicians end up with chronically intense work-schedules. What effect does this have on their ability to be compassionate and responsive to patients and families?

My own experience has been that when I work long hours, it feels much harder to give people the support they want. I still try to do it but I suspect I do it less well. I also know that when I’m tired I make an extra effort with patients but then have much less patience with other members of the healthcare team. (And then when I come home I’m short-tempered and crabby with husband and kids; not necessarily a problem for hospital and patients but concerning to me.)

    Enabling humans to show humanity

    Cultural expectations within institutions and groups are powerful. We do take our cues from peers and leaders. But it’s hard to follow the cues when surrounded by pervasive stressors and obstacles. In fact, it can be demoralizing to be told to do something when your leaders don’t seem to be making enough of effort to enable this doing.

As healthcare leaders take on the important task of making hospitals more responsive to the needs of patients and families, I hope they’ll consider the following:

  • People don’t like being faced with situations that they can’t fix, or that they feel will be a huge time/energy suck to fix. 
    • Make it easier for them to do the right thing.
    • Recognize when you are asking them to do something that is a big time/energy suck. 
    • Try to give them more time. Realize that they’ll have less energy afterward for efforts that are cognitively or emotionally demanding.
    • Provide communication and empathy training. Without explicit training, people often don’t realize that patients and families appreciate sympathy and attention, even when you can’t solve the exact problem at hand.
  • Frictions in the workplace add up to material stress and depletion of energy.
    • Reducing these frictions can enable workers to be more responsive to the needs of patients (and colleagues).
    • Adapting to changes in the workplace — such a new computer system or workflow — does create a drain on staff’s energy and attention. Ideally, this is temporary but poorly designed changes often create permanent energy drains.
  • Be mindful of the overall energy and stress levels of your workers.
    • Workers who are already experiencing chronic stress and fatigue will have difficulty becoming more attentive to patients’ needs.
      Now, if you told me that healthcare leaders already know all this, I wouldn’t be surprised. If you’re in a leadership position, it’s really part of your job to learn about managing human capital.

      The trouble is that for the leaders of a hospital, addressing the obstacles that I experienced in the hospital feels costly to them. It takes time, energy, and money to reduce workplace frictions. And managers are generally very reluctant to reduce a person’s workload in order to free up cognitive and emotional energy so that the worker can then be more responsive to suffering patients, or even adapt to new technology for that matter.

      In principle, these investments in nurturing one’s human capital should pay off down the line: more satisfied patients, less worker absenteeism, better teamwork among colleagues, and possibly even fewer hospital errors and better health outcomes among patients and staff.

      Will healthcare leaders find a way to walk their own uphill path, and really make it possible for their front-line staff to do better work? I hope so.

    Sleep, Stress, and Sustaining Behavior Change

    If you are interested in the non-pharmacological treatment of insomnia, an interesting item ran in the NY Times this week: “How Exercise Can Help Us Sleep Better.”

    This particularly caught my eye for a few reasons. The main one is that sleep problems are a common complaint among older adults. And exercise is something that I’ve often recommended as part of an approach to improving sleep, whether the patient was a sixty-some year old caregiver, or a more elderly person with dementia.
    Plus, as I’ve mentioned in a prior post, I myself have had frequent struggles with insomnia, and have sometimes applied to patients what I’ve learned from myself.
    The thing is, it didn’t really seem that I slept much better on days when I got more exercise. Still, I’ve continued to recommend exercise to caregivers and frailer elders alike, given how beneficial exercise is over all. (It’s linked to better strength, better function, better mood, better health outcomes, better glucose control, etc.)
    Do most of them manage to increase their exercise? Well, no. At least, not as far as I could tell, and determining how much people’s exercise levels have changed is a challenge because so far, I’ve mostly had to rely on people’s self-report, during a visit. (I’m still waiting to have a patient or caregiver use a Fitbit or other activity tracker.)
    And does exercise in fact improve sleep? The Times article describes a fascinating new research study addressing this topic. 

    A clinical study of sleep and exercise

    To summarize: the study randomized 11 sedentary women (avg age 61 years old) with insomnia to a program of exercise 3x/wk versus no change. 
    After four months, the women who were exercising regularly did have better sleep, and were sleeping on average 45-60 minutes longer every night.
    But here’s the kicker: it took literally months of exercising before sleep got better. And on a day-to-day basis, most participants did not sleep better on days when they exercised. 
    According to the Times article (the study’s author was interviewed), this is at odds with most research & the experience of many people, which is that exercise = better sleep that night.
    However, Dr. Baron, the study’s lead author, notes that many studies of how exercise affects sleep used people who didn’t have insomnia at baseline. She goes on to explain that people with insomnia may be “neurologically different,” and have a “hyper-arousal of the stress system.” But if they maintain an exercise program, after a few months they do start to sleep better, which Dr. Baron attributes to a dampening of the stress response.
    The study also found that participants exercised less on days after sleeping poorly, so in the short-term it seemed that sleep had more of an effect on exercise than vice-versa. 
    The Times article concludes with Dr. Baron advising readers with chronic insomnia to start exercising regularly if they aren’t already doing so, but to bear in mind that improvements in sleep probably won’t be immediate and could very well take months.

    Implications for the practice of geriatrics and general medicine

    Would one find similar results if one studied a group of 85 year old women with poor sleep? And what if they had dementia? No one knows, and it’s quite possible that the results would be different since both aging and cognitive impairment are known to modify sleep patterns.
    Still, these results are very important to the practice of geriatrics, because the study group sounded very similar to a population that we often work with: family caregivers.
    Chronically stressed? Not enough time to exercise? Can’t sleep well at night?
    Sound like anyone you know? Actually, it sounds a bit like me and other working mothers who have too much on their plate, but it also sounds like the women I see bringing their elderly loved ones to see the doctor, frazzled by the strains of worrying about a parent and taking on more and more caregiving duties.
    And, the chronic stress of family caregivers is a very serious public health problem. It affects the health, wellbeing, and even workplace productivity of the caregivers themselves. Plus it often has a direct bearing on the health and wellbeing of the elderly person being cared for.
    In general, stress is a huge and thorny problem in healthcare and for society. As a physician, I’ve often diagnosed stress as an important contributor to some significant health problem we’re trying to manage. But it’s very difficult to help people reduce their stress.
    This study sheds some light on why: reducing one’s internal reactivity to stress takes time. A behavior change meant to reduce stress may need to be sustained for months. 
    This is a tough challenge for all involved. Tired and stressed caregivers want relief now, and don’t have a lot of energy and bandwidth to stick with a behavior change for months. Clinicians want to help (and if they’ve kept up with best practices, want to help the patient minimize the use of pills for sleep or anxiety), but it’s hard to find a way to get patients to sustain behavior changes.

    What tech solutions might help?

    It’s not hard to envision how technology solutions might help. For those caregivers who have a smartphone or can access technology, it should be possible to
    • Log sleep and exercise. Ideally, with as little hassle as possible. Collecting this data can be helpful to clinician and caregiver when they meet to follow-up on a plan to increase exercise, decrease stress, and improve sleep. 
      • In some cases following data in real-time might help people maintain a behavior or technique (such as in biofeedback). 
      • Whether caregivers would find it helpful on a daily basis to see how much they’d slept every night is unclear to me; it could potentially be stressful to not see sleep improving as quickly as one wants it to.
    • Provide reminders and support to help caregivers maintain the exercise habit. There must be some way to leverage technology to help caregivers (or any patient/person) maintain an exercise habit, but I’m not sure which would work the best for the caregivers I work with. 
      • In fact, the multiple options available (there are so many apps/services available to help people meet fitness goals!) is a problem: making a choice is difficult!
      • Caregivers and patients would probably appreciate and value a recommendation from clinicians, but it might be hard for clinicians to make a recommendation unless it’s a product the clinician has already tried for him/herself.
        • We may also see companies aggressively market themselves to doctors, in hopes that their fitness app will be “prescribed.” I have mixed feelings about this since historically when business markets to doctors, the patients are not always well-served by the results.

    In search of tech tools to try

    Ok, so now let’s play a fun game called “Help-a-Doc.”
    I am willing to try an app or service in the next few months to log my own sleep and exercise, and also to help me start and maintain a 3x/wk exercise habit. (And let’s see if it improves my sleep, which could stand to get better.)
    If you have a recommendation to meet any of the needs above (sleep tracking, exercise tracking, and behavior change support), please post in the comments below, or drop me a line.
    I’d like to eventually have some specific tools to suggest to caregivers and other non-frail adults who are struggling with sleep, exercise, and stress.

    Individualized medical decision-making: still harder than it should be

    Shouldn’t everyone get an individualized assessment of likely benefits, burdens, and risks before making a big medical decision? 
    I was asked this question recently, during an interview for an Internet radio show on aging, called “Reaching for the Gold.”
    Per my host’s request, I’d been explaining the practice of geriatrics, and talking about the geriatric approach to addressing the medical needs of older adults. Since I’d mentioned that aging often brings on greater risk of side-effects or complications from anesthesia, the host, Harriet Tramer, asked me whether older adults should be trying to avoid surgeries. I responded by trying to explain the idea of balancing likely benefits versus burdens and risks, before making a decision about surgery. Some surgeries seem more likely to lead to substantial benefits than others. Some situations seem riskier, or more burdensome, than others. Hence, an individualized approach is best.
    Which led Ms. Tramer to ask me the question above: shouldn’t everyone — not just the elderly, or those seeing geriatricians — get this type of individualized counseling before deciding to pursue an operation, or making another type of big medical decision?
    Well…yes! Patients of any age can benefit from this type of individualized counseling, which is sometimes referred to as shared-decision making. It enables patients to make more informed decisions. It can also help patients obtain care that is a better fit for their values and preferences. And in some case, it might improve outcomes, if patient and clinician decide to forgo a risky procedure. Last but not least, individualized assessments of likely benefits and risks could improve the value of healthcare (value = benefit/cost), if such assessments result in patients forgoing expensive procedures that are unlikely to be helpful.

    This type of individualized care is good for everyone, but is especially beneficial as people get older. Since older adults tend to have more chronic conditions and disabilities, there is more to consider when trying to identify benefits, risks, and burdens of a given course of action.

    But there is a downside to engaging in this kind of collaborative and individualized medical decision-making: it requires time, energy, and effort. And for clinicians, not only does it take time and energy to have the conversation with patients and families, but it also usually takes time and energy to figure out just what are the risks, benefits, and burdens when a specific patient faces a specific medical decision.

    Could technology make this process of estimating risks, benefits, and burdens easier for clinicians and patients?

    The challenges of individualized medical decision-making

    Several years ago, one of my elderly primary care patients developed memory problems. He had been pretty hale and sharp, in relatively good health. But then he started to complain of difficulty remembering things and organizing himself, and after a thorough evaluation, we diagnosed him with Alzheimer’s disease.

    Before he became too impaired, we talked about his preferences for healthcare in the future. He voiced a preference for not spending too much time in the hospital, and he wanted to avoid surgeries and procedures unless they were likely to really improve his quality of life. And of course, he didn’t want to be kept on life support if he were terminally ill.

    About a year later, he’d progressed to moderate dementia, and his medical decision-making had been taken over by a professional conservator. He developed a bad cold, and the urgent care doctor did an xray to evaluate for pneumonia. On xray, he didn’t have pneumonia. He did, however, seem to have a lump in his lung, and a follow-up CT scan confirmed a small-medium lung mass, suspicious for cancer.

    And now what to do? The usual next step would be to have the lung doctors biopsy the mass. Small localized lung cancers in particular can often be treated with surgical removal (unless the biopsy shows that it’s one of those cancers that is unlikely to be successfully treated with surgery.) But this patient was elderly, and had dementia. Which meant that surgery would be more burdensome to experience, and came with higher risks of complications during and immediately after the surgery.

    The conservator and I weren’t sure what to do. When patients are making decisions for themselves they often just make a gut decision (undoubtedly influenced by the doctors around them) and don’t always want statistics and details. But I wanted to make sure we’d considered the decision properly, and the conservator certainly wanted to be sure of doing right by the patient.

    We needed data:

    • How likely was it that the mass was likely to make him feel symptomatically sick and/or shorten his life, if left untreated?
      • The oncologists refused to answer this question, saying they absolutely needed a biopsy sample before they’d hazard a guess.
    • How likely was the patient to find the biopsy procedure uncomfortable? What was the risk of complications? (And how do we factor in the risk of things like getting delirium or distressed by the procedure, and subsequently falling at home?)
    • If he had the biopsy and it turned out to be the type of cancer that was likely to be cured by surgery, what would be the risks/benefits/burdens of the surgery, and would the conservator consider them acceptable?
    • What was the patients overall prognosis and life expectancy, even before taking into account the new lung mass?
    As you can see, a tailored assessment of risks, benefits, and burdens became very complicated, very quickly.
    We never did get the exact statistics, although I did spend a fair amount of time looking things up in my medical references, and talking to my specialty colleagues. 
    In the end, we decided to not get a biopsy, and instead repeat the scan in several months to see if the mass was growing. Not because we’d biopsy him at that point, but because we decided it would be useful for us to know if the patient was suffering from an advancing lung cancer. We also, of course, made plans to follow the patient’s weight, appetite, and function.
    What would’ve been the alternative to this process? Here are some other ways the situation can play out:
    • Physician decides the patient should next have a biopsy. Patient and conservator go along with what the physicians recommend. 
    • Physician decides the patient is elderly and has dementia and so should not have further complicated medical care. Patient and conservator go along with physician’s recommendation.
    • Physician tells conservator: the decision is up to you, and tries to avoid influencing the conservator’s decision. The conservator may or may not try to look things up on the Internet, or otherwise get more information. Most proxies, in my experience, do not ask the physician “which choice do you think is likely to give this person the best quality of life over the next five years,” but I wish they would.


    Facilitating individualized medical decision-making for everyone

    Individualized decision-making is important. If we want more patients to be able to access it, we’ll need to develop better tools and resources.

    To date, the main resources available are decision aids, many of which have been carefully developed by non-profit experts and are of high-quality. When a good decision-aid can be located and used, patients and clinicians generally benefit.

    The trouble is that decision-aids are often not available for the decision at hand. To begin with, a good decision aid can be hard to find online; many are only made available as an institutional subscription, so individual patients and small clinical practices may not be able to access them.

    Another problem is that decision-aids are usually created for a certain common condition or decision, and are tailored to help an “average” patient. Unfortunately, I know of no pre-made decision aid meant to help elderly patients with dementia consider their options for diagnosis and management of a suspicious lung nodule. Dementia and advanced age are complex factors because they both introduce a lot of variability into the factors of risk, benefit, burdens, and preferences.

    Still, although I don’t expect there will ever be a pre-fabricated decision aid available to help with the situation I described, I do think that the right tools could go a long way in helping clinicians and patients and families make decisions for frail elders. For example, we might eventually have easier access to calculators (perhaps relying on information gleaned from big data) that can capture the patient’s physiologic data and present us with better information on prognosis and risk during procedures. (I like ePrognosis, but it doesn’t yet feel like something I can use in clinical practice.)

    Technology, data, and a new culture of shared decision-making hold such promise. Within the next, say, ten years, will we see it turn into real improvements for the real sticky situations affecting elders and their families? Will it soon be easier for all clinicians to provide better help, to all patients?

    Medication coordination & assisted living

    Recently I’ve been trying to more intensively adjust medications for a few patients who live in assisted-living facilities.

    Intensively, meaning that I might change the medication every 1-2 weeks, as the patient and I engage in a focused effort to figure out how best to manage a certain problem, such as pain, anxiety, insomnia, constipation, or falls.

    Sometimes, I even have to change the medication after a day or two, if the most recent change seems to have made things worse instead of better.

    All of this means lots of communication with the facility, the medication technicians, and the pharmacy. (And with the patient, but that’s often the easiest part.)

    It has, for the most part, been a bit labor-intensive and challenging, especially when it comes to those facilities that use paper-based medication administration records (MARs). Hence, I’ve found myself thinking about how clinicians and facilities can coordinate and communicate regarding medications, in order to improve the care of patients.

    The nice thing about having patients in assisted-living is that many of them use the facility’s medication management service, which means they will be reminded to take scheduled medication, and there will be a record of what has been taken. (For those elderly adults who live at home, figuring out what they take and how often can be quite a challenge.)

    On the other hand, the facility’s involvement means there is an extra party involved in the communications. So as a clinician, you can’t just tell a patient to stop a medication. You also have to write an order for the facility.

    Also, in most cases, if you prescribe a medication PRN (“as needed”), the patient will need to go ask the facility staff in order to get it. Many patients experience this as a barrier to access, and complain that they don’t get PRNs easily from their facility…it seems that they either are uncomfortable asking, or the med techs are hard to find, or something else seems to come up. Of course, the clinician may be able to authorize that the patient keep the PRN medication in his or her room, and self-administer. But in this case, it can be hard to determine just how much PRN medication the patient has taken.

    To summarize, the main hitches I’ve run into are:

    • More effort required to prescribe medications or make changes, since the facility may require orders separate from the pharmacy prescription.
      • Orders and prescriptions usually have to be sent by fax.
      • Clarifications and questions are often sent back to me by fax.
      • Follow-up phone calls are often involved: either I call to make sure they got an order and have no questions, or they call me because they need more information.
    • Effort required to get a copy of the updated medication list, in order to make sure that all changes have been implemented correctly.
      • A copy of the most up-to-date medication list is also important if the patient is seeing other clinicians or specialists, who may have added or changed medications.
      • I usually have to call to request this information; faxing sometimes works but takes longer to get a response and sometimes there is no response. I also sometimes have to walk over to the facility’s med room, to get a copy of the list.
    • Extra effort often required to get a record of how often PRN medications were administered.
      • Some facilities chart this by hand, separately from a pharmacy-generated list of current prescriptions.
      • This information is often not included when a medication list is faxed to me.
    • Patients and families are often concerned that they won’t be able to get PRN medication promptly when it’s needed.
      • Cognitively impaired patients may have difficulty asking or recognizing their own need for medication.
      • Some patients complain that facility staff are slow to respond to PRN requests; I suspect that this is because the med techs tend to be very busy dispensing a lot of medications, and possibly also transcribing the latest changes to the orders.

     

    What would help

    For many of the issues listed above, a solution would be an electronic communication platform that included the providers, the pharmacy, the facility staff, as well as the patient and family.
    Ideally:
    • Providers and families would be able to view the facility’s current medication orders in real-time.
    • Providers would be able to easily make changes, and it would only require one step to notify all parties of any change.
      • Changes should be made electronically, and no one would be copying prescriptions or orders into a binder.
    • Providers would easily see how often PRN medications had been administered. Families may also want to view this information, in order to participate more fully in the plan for managing a certain symptoms or problem.
    • Providers could easily copy or import the latest medication list, and PRN medication use, into their own electronic health records.
      • Families and patients may want to import this data into their own personal health records as well.
    • Patients and families would be easily able to give other providers access to this data.

    Health innovation to the rescue! Some companies are working on just this kind of solution. (I mentioned one of them, Caremerge, in a post last fall.)

    But it’s a long road from good idea to actual implemented solution with good usability. To begin with, it’s quite hard to design a comprehensive solution that works well for all parties involved. Then, there’s the challenge of getting providers and facilities and pharmacies to all use a single system. (Alternatively, we can each use our own system but then we need the systems to talk to each other easily…easy to wish for, hard to achieve.)

    Just as physicians’ offices are slowly but surely moving from paper to electronic record-keeping, I’m sure that eventually all assisted-living facilities will have fully computerized medication management, along with electronic systems of care coordination and clinical communication. But how many different platforms will providers be willing to work with?

    Many providers are already struggling with an EHR in clinic, and possibly another one for the hospital system they might be affiliated with. In such circumstances, providers might well balk at using a facility’s communication platform as well, and instead insist on continuing with the current system of faxing in orders. (Most providers, as best I can tell, don’t feel compelled to double-check the medication list as often as I tend to, so my problems are not quite their problems.)

    As usual, we are left with some thorny issues to resolve as we work our way towards better communication and coordination.

    For now, I am still waiting to be invited to a facility’s communication platform, and am hoping that a nearby facility tries something like Caremerge soon. (I’ve listed a few other issues I try to coordinate with assisted living facilities in this post.)

    If you’re a clinician and have had any experience with a care coordination platform in assisted-living, I’d love to hear your thoughts on it.

     

    Neat idea for financing dementia services

    For those interested in alternative ways to provide geriatrics care, here is a very neat practice that I learned about last month: MemoryCare. (Thanks to Scott Kuhlman of ecpmd.com for the tip.)

    Located in Asheville, North Carolina, MemoryCare is a “non-profit charitable corporation, established to meet the rapidly growing need for appropriate assessment, treatment, and support for memory-impaired individuals and their families.”

    Similar to my own practice, MemoryCare is consultative and is designed to complement existing primary care. They offer an indepth evaluation, expert assistance on managing dementia, and have a special focus on supporting families and caregivers.

    And how is this wonderful service financially feasible for them to provide? MemoryCare has an interesting approach:

    • The “clinical portion” is covered by Medicare/Medicaid. 
    • An additional $495 yearly fee is charged to the caregiver, to cover “supportive care and training of caregivers over a one year period.”

    This is a neat way to offer a service that would be financially unsustainable otherwise. As many people know, helping families with dementia concerns is often very difficult within conventional fee-for-service (or even HMO) care, because it is time-consuming and involves no reimbursable procedures. And Medicare doesn’t allow providers to accept Medicare while also charging extra (for those services covered by Medicare).

    But by taking a fee from the caregiver, rather than the patient, the clinic is effectively able to charge a patient and family a little extra, for what sounds like a whole lot of needed geriatric expertise and support in coping with dementia. This, according to the website, includes phone support between visits, and one hour follow-up visits.

    The fee itself works out to $41.25/month, and the clinic’s website states that they fundraise “so that no family will be denied this service due to inability to pay.”

    Unlike my own consultative services, MemoryCare requires a referral from a PCP or neurologist. It’s not clear to me whether this is out of respect for the traditional habit of allowing PCPs to determine what additional care their patients should access, versus necessary to facilitate insurance payment for MemoryCare’s services.

    In general, I’d expect that most PCPs in the area would be thrilled to refer to a special service that can help families cope with memory-problems. Still, I would think that more patients and families might access this type of service if no PCP referral were required, although it’s also possible that some families need a PCP’s encouragement in order to seek out (and pay for) this extra care.

    I myself am deeply impressed by this model of care, and hope to some day talk to the founders and others involved with the practice. We need more such creative ideas, to better meet the needs of an aging population and their caregivers.

    Also, wouldn’t it be nice if Medicare beneficiaries could set aside some of their outpatient Medicare money for discretionary purposes? (I’m thinking of something similar to a small HSA.) They could then choose to spend it on an additional service such as MemoryCare, or perhaps extra assistance at home, or perhaps a geriatric care manager. This would certainly give the patients/consumers a little more influence in shaping Medicare services to their needs, although I suppose we’d have to take steps to protect the beneficiaries from scammers out to siphon off their discretionary funds.

    Hm. We must keep collectively thinking about all this. The status quo is certainly not sufficient.

    For a more scholarly description of MemoryCare’s practice, there is a nice short article in the Alzheimer’s & Dementia journal here.

    Have you come across any other interesting models for providing — and financing — geriatric care? Post a comment or drop me a line.