Lisa Price, MD

Welcome to Medical Economics' blog section 

which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Lisa Price, MD, board certified in internal medicine and geriatrics and has expertise in managed care, electronic health records, quality improvement and geriatrics. The views expressed in these blogs are those of their respective contributors and do not represent the views of 

Lisa Price, MDThe advance directive. The words instill a sense of foreboding, a finality not many are prepared to face.

	As a geriatrician, I have discussed advance directives countless times throughout my career with older adults and their families. This conversation can be challenging because people often donât want to think or talk about their death or the death of loved one. Physicians also can feel trepidation anticipating this conversation. A 

 of 735 physicians by the John A Hartford Foundation, the California Health Care Foundation and the Cambia Health Foundation reported that 46% felt unsure of what to say.  

How to identify and treat frailty in older adults

	This same study reported 29% of physicians reported they received no formal training on discussing end of life, 29% reported their practice had no formal system for assessing a patients end of life wishes, and 24% report their electronic health record did not have a place to indicate a patient had an advanced care plan. In 2009, the discussion of end-of-life care was linked to a politically-charged term of âdeath panel,â and providers were not reimbursed for having these often complex discussions.

	Despite the barriers, physicians overwhelmingly (99%) recognized the importance of having these conversations with their patients. As Americaâs population agesâ10,000 people turn 65 each dayâimproving our comfort with, and skill at, discussing end-of-life care will become increasingly important.

	In January, the Centers for Medicare and Medicaid Services (CMS) began reimbursing health providers at a rate of $80 for a minimum 30-minute conversation with patients regarding advanced directives. Hopefully, the fact that CMS recognizes the importance of this service will lead to more people having these conversations with their doctors.

Lost in translation: The physicianâcaregiver relationship

	CMS isnât the only one who finds these conversations important: patients value and want to have them, as well. The Centers for Disease Control and Prevention found that 60% of people reported it was âextremely importantâ that their families not be burdened by difficult decisions at the end of their lives.

	The presence of advance directives has been associated with greater use of hospice care and fewer  communications problems with providers. There are resources available to help providers start the conversation and improve their skills. One is The Conversation Project (

), which contains tool kits for starting the conversation. These tool kits are general or disease-specific, and intended for both providers and the community. Another is the Physicians Order for Life Sustaining Treatment Paradigm (POLST). POLST has a website (

) containing information, tools and training resources for providers, patients and families.

Can PACE be the answer to the scare lack of geriatricians in the U.S.?

	Providers must overcome the challenges inherent in having this often difficult, uncomfortable conversation for the good of older patients. Physicians agree nearly universally about the importance of having advance directive conversations as a way to honor their older patientsâ end-of-life wishes. Providers must be the ones to start the conversation with families, caregivers and older adults. By opening the dialogue everyone involved will benefit from âthe talk.â 

Lisa Price, M.D. is chief mMedical officer at Denver-based InnovAge, a provider of health and wellness services for older adults in California, Colorado and New Mexico. She was a private practice geriatrician for 11 years, and then attended on the Acute Care of the Elderly (ACE) service and taught Quality Improvement at the University of Colorado. Price is board certified in internal medicine and geriatrics, and has expertise in managed care, electronic health records and quality improvement. 

http://content.healthaffairs.org/content/20/4/188.full.html

http://www.jhartfound.org/blog/end-of-life-and-serious-illness-a-john-a-hartford-foundation-change-agents-issue-brief/

http://www.jhartfound.org/advance-care-planning-poll

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3979710/

http://www.ncbi.nlm.nih.gov/pubmed/14959592

Articles

The advance directive. The words instill a sense of foreboding, a finality not many are prepared to face.

Physicians shouldn't fear death talk with patients

	The U.S. healthcare system is struggling to address the healthcare needs of country’s growing elderly population, which increases by one person every eight seconds.

Lisa Price, MDFortunately, the U.S. Centers for Medicare and Medicaid Services have taken some steps to meet the increasing needs of older adults, such as calling for quality care metrics and creating codes to reimburse physicians for managing care transitions and complex chronic conditions.

Can PACE by the answer to the scarce lack of geriatricians in the U.S.?

	In the larger sense, pay for quality care is an admirable pursuit when applied at a health system level.  However, when applied specifically to older adults, pursuit of certain quality metrics may actually do more harm than good by encouraging care that is not beneficial to frail seniors. In addition, physicians who primarily care for a geriatric population may be inadvertently penalized for failing to meet the metrics in a patient population where such interventions are not within their goals of care. 

	Failure to recognize frailty and frailty-related conditions may lead to some unintended consequences.

	Pre-frailty and frailty is an example of an elder care issue that, when identified and treated, may negatively impact quality metrics for the simple reasons that older adults don’t respond as well to treatment as younger cohorts.

	Although there is no gold standard for the diagnosis of frailty, it is generally considered to be a geriatric syndrome with a decline in physiologic reserves, leaving a person less able to adapt to stressors such as trauma or an acute illness.

	As in most geriatric syndromes, there are many factors contributing to frailty: age, comorbidities, and environmental and psychosocial factors. This leads to its presentation as a spectrum from pre-frailty to failure-to-thrive. Frailty’s presence is increasingly associated with poor outcomes and increased mortality in older adults.

	There are a variety of tools to help identify frailty, and its prevalence varies depending on the tool used.  A 2009 study published in the 

Journal of the American Geriatric Society

 of 765 community-dwelling seniors in the Boston area identified 18.7% to 38.8% as pre-frail and 4.2% to 10% as frail, depending on the frailty index used and the presence of pre-frailty and frailty predicted falls, ED visits and hospitalizations.

Lost in translation: the physician-caregiver relationship

	One of the tools this research used was the Study of Osteoporotic Fractures (SOF) Frailty Tool.  SOF can be performed quickly by a provider or office staff.  Frailty is defined as the presence of two of the following three:

	·       Weight loss of 5% in the past year

	·       Inability to rise from a chair five times without the use of arms

	·       A response of “no” to the question, “Do you feel full of energy?”

	Another tool that can be done simply with an interview is the FRAIL scale. A “yes” response to two or more questions indicates pre-frailty and “yes” to three or more indicates frailty.

	·       Fatigue: Are you fatigued?

	·       Resistance: Can you climb a flight of stairs?

	·       Ambulation: Can you walk one block?

	·       Illnesses: Greater than five.

	·       Loss of Weight: Greater than 5%.

	With the Silver Tsunami breaking on shores around the world, getting ahead of pre-frailty is important to ensure our senior population ages as successfully as possible. Prevention is the first step in slowing pre-frailty. Although most physicians don’t have specific frailty prevention training, they can take steps to promote exercise among older adults, which has been shown to slow frailty.

Next: Additional ways to prevent and treat frailty

	Daily exercise is an excellent first step in slowing the onset of pre-frailty. Just as younger adults can benefit from regular exercise to reduce their risk of diseases such as heart disease and diabetes, already-frail older adults were able to build muscle and lessen the chance of falls and stave off frailty.

 found weight training among a small group of nursing home residents aged 90 and older had a positive effect by building muscle and improving mobility. Another study published in the 

Journal of the American Geriatrics Society

 showed an almost 48% reduction in the risk of falls after a group of older adults participated in a Tai Chi class.

	There are additional ways to prevent and treat frailty, many of which are simple and can be implemented at home by an older adult’s caregiver with a little help from a physician. These include:

	·       Eating and drinking well, including following a Mediterranean diet;

	·       Developing an exercise program for seniors, including balancing exercises and strength training;

	·       Reviewing a senior’s list of medications to ensure all are needed, as some contribute to frailty or worsen frailty due to side effects; and

	·       Taking note of a senior’s decline in appetite, movement or physical activity, as well as assessing whether a senior is feeling fatigued and weak. 

	Frailty, when it is identified, should become part of the treatment plan.  Goals of care are increasingly important, as the benefits and risks of medications and interventions are less clear and risks greater. With the answers to a few quick questions, and the addition of more exercise and better nutrition, impending frailty can be identified and managed.

Lisa Price, M.D. is Chief Medical Officer at Denver-based InnovAge, a provider of health and wellness services for older adults in California, Colorado and New Mexico. Dr. Price was a private practice geriatrician for 11 years, and then attended on the Acute Care of the Elderly (ACE) service and taught Quality Improvement at the University of Colorado. Dr. Price is Board Certified in Internal Medicine and Geriatrics, and has expertise in managed care, electronic health records and quality improvement. 

The U.S. healthcare system is struggling to address the healthcare needs of country’s growing elderly population, which increases by one person every eight seconds.

Lisa Price, MDPhysicians and non-professional family caregivers 

. Both groups are aligned in the effort to provide high-quality, compassionate care to older adults.  But too often the reality is we are not.

Previous blog: Young doctors are jumping ship to non-clinical roles

			Caregivers are exhausted from essentially working two jobs; and

			Physicians may not recognize the need to include caregivers in treatment plans.

	Family caregivers are under enormous pressures when providing care to an elderly friend or loved one. They face a significant personal burden, both time-wise and financially, in their role as caregivers.

	Consider that 74% of workers at some point during their career provide care to a loved one, according to “Understanding the Impact of Family Caregiving on Work” published by AARP. In the U.S. alone, 65.7 million people provide care to an older adult, according to a 2015 National Alliance for Caregiving report.

	Caregivers get little downtime for themselves because they spend, on average, 20 hours a week providing care for a loved one in addition to their regular job, according to Caregiving in the U.S. 2015. Being a caregiver is a second, unpaid job for which many caregivers are under-qualified, causing stress and anxiety.

	Approximately 18% of caregivers say they are “highly strained” financially because of their caregiving responsibilities, the Caregiving study found. Many are the sole caregiver for a loved one: 1 in 3 have no help at all, paid or unpaid, the report found.

	To make an impact on care, physicians must acknowledge and plan for the daily challenges caregivers face when communicating the older adult’s care plan to the caregiver. There may be times when the caregiver is too stressed or overloaded to fully understand or participate in the care or treatment plans.

 found physicians and caregivers are generally in agreement when it comes to the “day-to-day” management of the older adult, ranging from emotional health to safety. Unfortunately seeing eye-to-eye didn’t find its way to treatment options: “Agreement on treatment goals between family caregivers and physicians for patients at the study site was low. These results suggest that 

encounters between family caregiver and physician may need improvement

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	Not surprisingly, when caregivers approve of treatment options prescribed by the physician, the older adult is more likely to observe the treatment plan.

			“…agreeing with recommendations can promote adherence and that adherence can promote (healthcare) goal attainment,” according to a 2004 study published in the 

Journal of the American Geriatrics Society.

	Finding this middle ground can be less problematic when working with the designated caregiver of a patient with dementia, particularly when the person is in attendance with the patient.

	Physicians may not be aware of the informal caregivers, how much they contribute to supporting the patient, and must be cautious when sharing treatment and condition information without the consent of the patient. Once consent is granted, a delicate balance must be established by the physician to ensure all parties have the same information with the elderly patient receiving those details before the caregiver, as appropriate.

Dismissing patients: How to do it the right way

	If careful attention isn’t paid to messaging, “…there is a risk that communication about care will shift prematurely to the caregiver, even though the patient is capable of making decisions,” according to the 

	Frequent and transparent conversations with the caregiver and elderly patient are crucial to achieving a positive outcome for all involved. Although this communication requires commitment and consistent effort, in my experience, I have found it to benefit everyone involved in the care continuum.

Lisa Price, MD is chief medical officer at Denver-based InnovAge, a provider of health and wellness services for older adults in California, Colorado and New Mexico. Dr. Price was a private practice geriatrician for 11 years, and then attended on the Acute Care of the Elderly (ACE) service and taught Quality Improvement at the University of Colorado. Dr. Price is Board Certified in Internal Medicine and Geriatrics, and has expertise in managed care, electronic health records and quality improvement.

Physicians and non-professional family caregivers are in it together. Both groups are aligned in the effort to provide high-quality, compassionate care to older adults.  But too often the reality is we are not.

Author | Lisa Price, MD

Articles

Physicians shouldn't fear death talk with patients

How to identify and treat frailty in older adults

Lost in translation: The physician-caregiver relationship