Health Care Disciplines and the Older Adult Dentists Physicians - PDF document

8/28/2012 Gregg Warshaw, M.D. Professor of Family and Community Medicine Semmons Professor of Geriatric Medicine University of Cincinnati College of Medicine Health Care Disciplines and the Older Adult  Dentists  Physicians  Health Educators  Physician Assistants  Nurses  Physical Therapists  Occupational  Speech Therapists Therapists  Social Workers  Pharmacists  Other 1

8/28/2012 Primary Care  Family Medicine Family Medicine  General Internal Medicine  Geriatric Medicine  Advanced Practice Nurses (clinical nurse specialists, nurse practitioners)  Physician assistants Physician assistants Some practitioners derive much of their fee schedule payments from primary care services Practitioner and specialty P titi d i lt P Percent of charges from t f h f primary care services Nurse practitioner 65.4% Geriatric medicine 65.0 Family medicine 62.5 Internal medicine 44.4 Physician assistant 34.8 All other 13.4 . Source: MedPAC analysis of 2006 claims data for 100 percent of Medicare beneficiaries . 2

8/28/2012 Summary  Considerable progress achieved over past 30 years to p g p 3 y prepare health care providers to provide optimal care to older adults  Facilitated by: geriatrics clinical research, development of geriatrics and palliative care specialties, accreditation and certifying bodies, professional societies, foundations, and dedicated clinician educators  Barriers: Reimbursement, care system, and ageism , y , g  Pace of change needs to accelerate in the training of health professionals, care system innovation, and reimbursement reform to ensure quality care and control health care expenditures Case: Susan and Her Father 3

8/28/2012 Four Simultaneous Initiatives  Increasing the workforce of PCP and other I i h kf f PCP d h health team providers  Preparing PCPs and other health team providers to provide expert geriatrics chronic care  Paying adequately for quality chronic care  Cost ‐ effective models of chronic care Health Affairs 29, 811 ‐ 818, 2010 Questions  Why are well trained primary care and health team providers essential to addressing the medical care needs of older adults?  How well are we doing preparing current and future practitioners to care for a rapidly growing older population? older population?  What more can be done to improve the capabilities of current and future providers to care for older adults? 4

8/28/2012 AGING OF THE US POPULATION 82 90 80 Number of people  65 yr, in 70 60 millions 50 36.8 40 30 20 3 1 3.1   10 0 1900 2005 2050 Slide 9 LIFE EXPECTANCY IN 2004 (Mean) All R All Races All Male Female At birth 77.8 75.2 80.4 Age 65 18.7 17.1 20.0 A Age 85 85 6 8 6.8 6 1 6.1 7 2 7.2 Slide 10 5

8/28/2012 Projected Total Number of People With Chronic Conditions (in millions) 180 171 164 157 160 149 141 140 133 125 118 118 120 120 100 1995 2000 2005 2010 2015 2020 2025 2030 Sources: Partnership for Solutions. “Multiple Chronic Conditions: Complications in Care and Treatment”; RAND Corporation, 2000. Medicare Spending on Beneficiaries with Chronic Conditions 4 Chronic Conditions 12% 12% 3 Chronic Conditions 10% 5+ Chronic 2 Chronic Conditions Conditions 68% 6% 6% 1 Chronic Condition 0 Chronic 3% Conditions 1% Source: G. Anderson, “Hospitals and Chronic Care”, PowerPoint Presentation to the American Hospital Association. Partnership for Solutions. 16 June 2004. 6

8/28/2012 Annual Prescriptions by Number of Chronic Conditions 49.2 50 33 3 33.3 Average Annual 40 Prescriptions* 24.1 30 17.9 10.4 20 3.7 10 0 0 1 2 3 4 5 Number of Chronic Conditions *Includes Refills Sources: Partnership for Solutions, “Multiple Chronic Conditions: Complications in Care and Treatment,” May 2002; MEPS, 1996. Hospitalizations for Ambulatory Care Sensitive Conditions 300 261 261 ospitalizations per 1000 236 Medicare Beneficiaries 250 219 200 169 131 150 95 100 62 36 M 18 18 Ho 50 50 7 0 0 0 1 2 3 4 5 6 7 8 9 10+ Number of Chronic Conditions Sources: Partnership for Solutions. “Multiple Chronic Conditions: Complications in Care and Treatment,” May 2002; Medicare Standard Analytic File, 1999. 7

8/28/2012 Ambulatory Care Visits to Primary Care and Specialist Physicians, United States, Patients Age 65 and over 1980 1990 2006 Primary Primary Primary Care Specialist Specialist Specialist Care Care 38% 38% 62% 62% 47% 47% 53% 53% 59% 59% 41% 41% Source: CDC, NCHS, National Ambulatory Medical Care Survey Utilization of Physician Services by Number of Chronic Conditions 37.1 Unique Physicians Physician Visits 19.5 14.9 13.8 11.3 8.1 7.8 6.5 5.2 4.0 2.0 1 3 1.3 0 1 2 3 4 5+ Number of Chronic Conditions Sources: R. Berenson and J. Horvath, “The Clinical Characteristics of Medicare Beneficiaries and Implications for Medicare Reform,” prepared for the Partnership for Solutions, March, 2002; Medicare SAF 1999. 8

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8/28/2012 Questions  Why are well trained primary care and health team providers essential to addressing the medical care needs of older adults?  How well are we doing preparing current and future practitionerss to care for a rapidly growing older population?  What more can be done to improve the capabilities of current and future to care for older adults? Quality of Care Provided to Vulnerable Community ‐ Dwelling Older Patients (I)  Assessed quality in two managed care organizations Assessed quality in two managed care organizations (1998 ‐ 99)  Observational cohort study of care processes of 22 conditions; 420 vulnerable older adults  General medical: CHF, pneumonia, etc.  Geriatrics: Dementia, incontinence, etc.  Chart reviews and patient interviews  Mean age: 80.6 years; 64% female 11

8/28/2012 Quality of Care Provided to Vulnerable Community ‐ Dwelling Older Patients (II)  Overall quality indicators passed Overall quality indicators passed  General medical 52%  Geriatric 47%  Chronic care quality indicators passed  General medical 51%  Geriatric 29% 9  Least well managed: falls and mobility, urinary incontinence, cognitive impairment, end ‐ of ‐ life care Quality of Care Provided to Vulnerable Community ‐ Dwelling Older Patients (III)  Possible reasons why geriatric conditions may receive y g y inadequate attention in primary care  Skills not well taught during training  Skills may not be maintained if conditions seen infrequently  Assessment tasks may be perceived as too time consuming  Conditions may not be recognized  Little feedback from third parties  Inadeqaute team ‐ care Ann Intern Med. 2003;139:740 ‐ 747 12

8/28/2012 Medical student geriatrics curriculum (2008)  23% of medical schools require a geriatric 23% of medical schools require a geriatric clerkship  56% of medical schools integrated geriatrics into a required clinical rotation Schools could report more than one type of experience Geriatrics Workforce Policy Studies Center Surveys of Geriatric Academic Leaders in US Medical Schools 2005 & 2008. Geriatric Physician Workforce Pipeline 9,666 MDs graduated from FM & GIM 9 g residency programs in 2008 Only 3% entered a Geriatric Medicine fellowship program in 2009 Source: AMA and AAMC data from the National Survey of GME Programs 2008/2009 & 2009/2010. 13

8/28/2012 Required Time devoted to clinical instruction in Geriatric Medicine D During 3 year Internal Medicine and Family i I t l M di i d F il Medicine Residency program  20 days (Median) Internal Medicine  12 days (Median) Family Medicine Geriatrics Workforce Policy Studies Center. Surveys of Program Directors in Internal Medicine (2008), Family Medicine Residency Programs (2008) Geriatric Medicine Training in FM and IM Residency Programs as rated by Program Directors as rated by Program Directors Geriatrics rated second most important curriculum area by IM and FM  ICU/CCU first for IM  Ambulatory Adult Medicine first for FM Curriculum conflicts #1 obstacle to implementing GM curriculum Geriatrics Workforce Policy Studies Center. Surveys of Program Directors in Internal Medicine (2008), Family Medicine Residency Programs (2008) . 14

8/28/2012 Other Disciplines Training in Geriatrics PHARMACISTS • There are 1,219 certified geriatric pharmacists and 269,900 staffed pharmacy positions. • Less than half of all pharmacy schools have a full ‐ time geriatric pharmacy specialist. SOCIAL WORKERS • In 2006, 12 percent of licensed social workers (38,400) identified their practice areas as “aging”. Elizabeth Bragg, Jennie Chin Hansen. A Revelation of Numbers: Will America’s Eldercare Workforce be Ready to Care for an Aging America? Generations ; 2011; 34(4):11 ‐ 19 15

8/28/2012 Other Disciplines Training in Geriatrics PSYCHOLOGISTS • 70% of practicing psychologists provide some services to • 70% of practicing psychologists provide some services to older adults. • A sample of the American Psychological Association found that most respondents lacked formal training in geropsychology and perceived themselves as needing additional training. PHYSICAL THERAPISTS PHYSICAL THERAPISTS • From 1992 through 2010, 1,109 physical therapists have been certified in geriatrics by the American Physical Therapy Association (nearly 200,000 PT positions) . Elizabeth Bragg, Jennie Chin Hansen. A Revelation of Numbers: Will America’s Eldercare Workforce be Ready to Care for an Aging America? Generations ; 2011; 34(4):11 ‐ 19 16