A psychiatrist and a new Medical Center program take on the challenges of health care for the growing population of older adults.
By Michael Wentzel
Emmy Award-winning producer and director Manville Jennings never shows a sign of deep depression or anger in a University of Rochester Medical Center video during which he discusses the impact Alzheimer’s disease is having on his life.
He can no longer drive, he says, but then Jennings stops talking, becomes lost in his thoughts and cannot describe how other aspects of his life have changed. No cure to the disease that is erasing his memory will be found in his lifetime but, Jennings says, he considers himself lucky to have nearby doctors and others who are conducting research on Alzheimer’s and also providing excellent care.
Jennings is a patient in the Medical Center’s Memory Care Program, through which patients and their families receive services from a multi-disciplinary team of clinicians, including specialists in neurology, psychiatry, geriatrics, neuropsychology, social work, nurse practice, and marriage and family therapy.
The Memory Care Program provides much-needed care to many like Manville Jennings, but its effectiveness and success are threatened. An estimated 30,000 people in the Rochester region have Alzheimer’s disease or a related dementia. The program is overwhelmed with requests for care.
The Memory Care Program is one of the first targets for the Office for Aging Research and Health Services (OARHS), which was created by the Medical Center this year to investigate, test and develop novel, more efficient and lower cost ways to provide health care to the elderly that are coordinated with community and regional services and partners.
“The Memory Care Program is world class,” said Yeates Conwell, M.D., the director of OARHS. “But, based on a traditional clinic approach to care and constrained by current reimbursement schemes, it is not a sustainable model. They can care for only a fraction of the enormous and rapidly growing number of people who need the services.
“We’re still operating in a fee-for-service reimbursement system through a hospital program that is very constrained by what the Centers for Medicare and Medicaid Services will allow providers to bill for. It’s components of comprehensive care that are not now reimbursed – care management and social work services, for example – that will impact cost and quality and outcomes. Alzheimer’s is a quintessential chronic disease. How do we provide better care, a better experience of care and at a lower cost? The answer lies in innovative approaches that fully integrate and pay for both medical and psychosocial services.”
As a professor of psychiatry at the Medical Center and an internationally known researcher in suicide prevention, Conwell might seem like an unlikely person to direct an office aimed at redesigning health care systems.
But Conwell has helped develop successful programs with community partners that improve mental health care for the elderly. And, earlier this year, he was selected as one of 73 people from across the country, and the only psychiatrist, to serve in the Centers for Medicare and Medicaid Services’ (CMS) Innovation Advisors Program.
The initiative, launched by the CMS Innovation Center, aims to develop a cadre of professionals with the skills to drive improvements to patient care and reduce costs nationwide. Among other duties, the advisors support the Innovation Center in testing new models of care delivery and also form partnerships with local organizations to drive delivery system reform, and improve their own health systems so their communities have better health and better care at a lower cost.
“The advisors program is a wonderful educational experience for me,” Conwell said. “I’m gaining insights into what the large national priorities are for health system redesign and bringing them back to the Medical Center. Through OARHS, we can shape the resources we have here in ways that make us a highly innovative institution as it relates to health care for older people. Over the years I’ve been at the Medical Center, it’s been clear that the University has tremendous strengths in regard to aging, from basic science right up through the design and delivery of health services.
“The Medical Center is a health system that aspires to take on new responsibilities for a large population of older people throughout our region. I see the role of OARHS as helping faculty and staff across our mission areas-clinical care, education, research and community service-to understand the challenges and opportunities, to think creatively and draw on resources across traditional boundaries to achieve better health, better-quality care and lower cost for older adults. This is about facilitation, collaboration, connecting the dots.”
The rewards of collaboration
Clinical depression is common in later life and often leads to other problems, including poor health outcomes, higher costs for health care and institutionalization, and premature death due to suicide or other causes.
Identifying elders at risk and providing care can improve health and hold down costs, as well as prevent self-destructive acts. Because social factors are so prominent in depressive illness, engaging social service agencies in its recognition and management is a promising strategy. In 2006, Conwell received a National Institute of Mental Health grant of $2.57 million for a project that established a unique partnership with Rochester area aging services agencies, Eldersource Care Management Services, Lifespan and Catholic Family Center. The partnership became known as the Senior Health and Research Alliance, or the SHARE Alliance.
SHARE Alliance activities have included: training agency care managers in the detection and basic management of late-life mental illness and the assessment and management of suicide risk, adopting a routine of screening for mental disorders in agency clients, revising the data management systems of the agencies to support research, and conducting research studies. Thousands of people in the Rochester region have been assessed for depression and other issues and received interventions from SHARE Alliance partners.
In 2010, the Centers for Disease Control (CDC) awarded Conwell and the Medical Center $2 million for another project designed to test whether linking lonely and socially disconnected seniors with other caring older adult volunteers reduces the risk of suicide. The volunteers have been recruited, trained and supervised by Lifespan Inc., the largest aging services agency in the Rochester region and the Medical Center’s partner in the research.
These projects demonstrated to Conwell and others the rewards to older adult health of linking an academic medical center with community-based social service agencies in collaborative projects.
“The nature of the work we do as care providers will change a lot over the coming few years,” Conwell said. “Health care inevitably is moving farther afield. We need to be providing support for the delivery of care to older adults in primary care offices and other sites beyond the walls of the Medical Center.
Conwell and his colleagues at URMC recognize that to meet the Institute for Health Care Improvement’s Triple Aim – improving the patient experience, improving the health status of populations, and reducing the cost of care – will require approaches that are both multidisciplinary and highly coordinated. “We have to raise awareness of people in our community about the challenges we face and the importance of working together to come up with creative solutions. I don’t believe you can give cost-effective health care, for example, to someone with a complex disorder that has social implications without engaging social services in the care of that person.”
Among other goals, OARHS aims to obtain grants from the Center for Medicare & Medicaid Innovation (CMMI), the federal Patient Centered Outcomes Research Initiative (PCORI) and other sources to support the study of new approaches to care from health care systems and community organizations.
“Calls for proposal come out and suddenly you have people sitting around the table who have never sat together before and they are coming up with ideas and generating care models that show we can get better outcomes and for less money,” Conwell said. “Now that these discussions have started, OARHS has a responsibility to nurture them and
to help ensure they yield fruit.”
A map for patients
Another OARHS activity is the recently inaugurated, “Aging in Context Project,” a geospatial mapping and database linkage project that will build a foundation for future regional health and services initiatives.
“The objective is to make a comprehensive repository of data that is useful to patient-centered medical homes, the service system, policy makers and others for personalizing care and tailoring the array of resources to what the community needs,” Conwell said. “In addition to the health and service utilization information available from the medical record, we’re collecting information, for example, on the location of parks, bus lines, sidewalks, shopping malls, types of housing. There are data on crime, outlets where alcohol is available, but also places where fresh produce is available.”
With such a set of linked databases, a physician could ask specific questions about an individual patient. Say you wanted to define the risk of an elderly patient being hospitalized or requiring readmission after discharge. In addition to the usual risk stratification metrics, put in the addresses of the patient, the primary care office and of the patient’s caregivers and relatives, and information about the means by which they interact. Add information about access to exercise options and proper nutrition, or the closeness of a bar or place to buy alcohol.
“With the necessary research and sophisticated computer modeling, we might get much better at determining who needs what kinds of extra services to remain safe and well in the community after discharge,” Conwell said. “With new financial penalties to hospitals for readmission of Medicare patients within a month of discharge, there is a strong financial incentive to do this kind of work as well.”
At the practice level, the database could give a patient-centered medical home a portrait of its population of patients and how that population related to community-based services most needed by patients. At the system level, policy makers could see utilization of services, the needs of patients and the availability of services that could result, for example, in a decision to relocate bus lines.
Another OARHS target is mobility. Falls account for a large proportion of costs of emergency room visits and hospitalizations, as well as mortality, of older people.
The Geriatric Fracture Center at Highland Hospital has taken a lead in management of fall-related injuries and in the prevention of falls. Conwell wants to find ways to coordinate Highland’s expertise with that of other centers of excellence in the Medical Center that are relevant to falls prevention – orthopaedics, physical rehabilitation, neurology and ophthalmology – to create a more complete continuum of care that excels not only in the treatment of fractured hips following a fall, but the prevention of falls and injuries as well.
The Silver Tsunami
The Memory Care Program project showcases what Conwell hopes to accomplish with OARHS.
“People with memory disorders are more than two times likely to end up in the hospital, where care is often chaotic,” he said. “Take them out of their familiar environment and put them in a noisy, fast-paced, scary place like a hospital and they don’t do well. So, they take a lot of hospital resources. The hospital experience is bad for them and expensive and the outcomes are not very good.
“Dementia is a complex illness, a long process that unfolds in variable ways over time. At each stage, there is need for services that under current payment schemes are unreimbursed or poorly reimbursed. Without attention to these elements of care, patients utilize greater amounts of expensive services to their detriment. We think we can prevent some of that by redesigning a system upfront that cares for more people in better ways. And we think that by doing things differently we can ultimately save the Medical Center money.”
Conwell is working on the pilot project with Carol Podgorski, Ph.D., M.P.H., associate professor of psychiatry, Lisa Boyle, M.D, M.P.H., assistant professor of psychiatry,
and Frederick J. Marshall, M.D., associate professor of neurology and director of the program. It targets a segment of the program’s patients by adapting elements of a dementia collaborative care model developed at Indiana University Wishard Health Aging Brain Center. The key element of the model, according to Boyle, is using a team-based approach for assessment and management of both the patient with mild cognitive impairment or dementia and family caregivers. The pilot incorporates the use of a dementia care coordinator, who works along with specialists at the Memory Care Program, and the patient’s primary care physician.
The dementia care coordinator’s role includes conducting systematic screening for common problems associated with dementia and caregiver-related stress, coordinating the recommended treatment for the patient and family caregiver with the providers, and linking the patient and family to community resources.
“By improving our interface with primary care practices and supporting providers’ ability to diagnose and manage the most common forms of dementia, our goal is to extend
the highest level of care to the community,” said Marshall. "In so doing, our hope is to create systems of care that decrease the rates of potentially avoidable hospitalizations for these patients, and that buttress the supports available to care-givers.
OARHS will have results from the pilot project sometime in 2013.
“Older people are the fastest growing segment of our population,” Conwell said. “Whether you call it the Silver Tsunami or the Golden Wave, the challenge is real. This is a large group of people that consumes a tremendous amount of health care services and a lot of health care dollars and we are not prepared for their care. The challenge is local, regional and national. We have a set of resources in the Rochester area that are very strong in relation to issues of aging and health but they haven’t really been knit together in a way that allows us to optimally meet this challenge. This has to go forward.
We can’t stand still. OARHS gives us a framework to do so.”