Aging Reimagined: Vital Care
For older people, falling and breaking a hip is a sentinel moment. For some, it marks the beginning of the end.
In 2004, a team of orthopaedists and geriatricians at Highland Hospital saw an opportunity to change that trajectory. Realizing that medical issues that complicate later-life surgery weren’t being addressed, they created a model of geriatric fracture care that would be replicated around the world.
The Geriatric Fracture Center at Highland, developed by Daniel Mendelson (MD ’95, Res ’98, Flw ’00), clinical professor of Medicine, and now directed by Corey Romesser, MD (Res ’06, Flw ’07), associate professor of Clinical Medicine, screens patients with fractures for specific age-related surgical risks, such as medication interactions or delirium. Patients have beds in the orthopaedics unit, where staff are trained in geriatrics care, and are fast-tracked to surgery (within 24 hours of admission). They have fewer complications, such as pneumonia, and are up and walking sooner.
In addition to designing a better way to treat fractures in older people, the center has spawned a journal and several dozen publications. Doctors in the center have traveled to at least 30 countries to share their knowledge and methodology. They are developing a national teaching program to expand these and a database documenting treatment and outcomes around the country.
“That’s something you can do in a community hospital with connections to an academic medical center. It’s a really great example of optimal care,” says geriatrician Robert McCann, MD, former chief of Medicine at Highland and CEO of Accountable Health Partners, URMC’s clinically integrated network of hospitals and physicians.
In 2017, the Geriatric Fracture Center at Strong Memorial Hospital was launched as a model of co-management among hospital medicine, geriatrics, and orthopaedic surgery. Directed by Jenny Shen, MD (Res ’13), assistant professor of Medicine, this fracture center models the original Highland Hospital-based center—with equally successful patient care metrics and outcomes. “Sharing best practices among our own providers and other Age-Friendly Health System (AFHS) institutions will result in the best, most consistent care possible.”
The Geriatric Fracture Center is just one of dozens of programs in the UR Aging Institute’s (URAI) Vital Care pillar. Guided by the AFHS model, together they focus on education and multidisciplinary patient care.
The Extension for Community Healthcare Outcomes (Project ECHO®), a video-based mentoring model, reduces health disparities by bringing specialist expertise to frontline staff who work in underserved communities. Under the leadership of Michael Hasselberg (MS ’07, PhD ’13) and Elizabeth (E.J.) Santos, MD (BA ’94, Flw ’06, MPH ’13), URMC chief digital officer, the University of Rochester launched Project ECHO® Geriatric Mental Health, targeting primary care offices throughout New York state. This model was soon extended to more than 100 nursing homes throughout the Greater Rochester region and the state to improve geriatric behavioral health and successfully reduce the use of psychotropic medications in nursing homes. That sparked creation of a full geriatric telepsychiatry program to support multidisciplinary teams working in nursing homes and rural hospitals.
Workforce education creates channels for spreading best practices and care models for older adults in hospitals, nursing homes, and clinics. Disciplines come together to research and treat conditions in a way that is tailored to the needs of older patients.
A spirit of creativity and curiosity is essential for this kind of collaboration to thrive, but that rarely pops up out of nowhere. Layered underneath is an educated workforce, which brings people together in a united cause.
Having staff with the knowledge and skills to care for an aging population is nothing short of a system transformation—and long overdue, says geriatrician Thomas Caprio, MD (Res ’03, Flw ’05, MPH ’10, MS ‘15). Caprio is principal investigator of the University of Rochester Geriatric Workforce Enhancement Program (GWEP), now in its second round of funding with a $3.7 million grant from the Health Resources and Services Administration (HRSA) to support URMC’s Finger Lakes Geriatric Education Center, which Caprio directs.
“There aren’t enough geriatricians in the country,” Caprio says. “We’re pushing out the appropriate education and training across all professionals so they are sensitized to the unique challenges and risks of older adults, so they can provide the best care possible. It’s sort of geriatricizing the health care system.”
Training is for all kinds of health care professionals, and they learn together in an interprofessional approach—from physicians, nurses, nurse practitioners, physician assistants, and pharmacists to therapists, dietitians, and students of all disciplines. Issues discussed relate to the Four Ms of the AFHS, addressing everything from cognitive changes and loneliness to medication and advanced-care planning.
The workforce enhancement grant also funds training to help age-focused nonprofits and primary care practices diagnose dementia and other cognitive conditions. And spurred by the pandemic, online and videoconference trainings have exploded, reaching more than 15,000 professionals across the state and nation.
The GWEP grant was the first in the state to use Project ECHO® for geriatric training. In this case, it links URMC geriatrics specialists with doctors, nurses, social workers, pharmacists, and others at 60 nursing homes in the Finger Lakes region. Sessions cover geriatric behavioral health, the AFHS, and quality improvement and patient safety related to the COVID-19 pandemic.
The School of Medicine and Dentistry is one of very few that emphasize an aging curriculum from the first year to fellowship, and it is even taught to undergraduates. Its foundation is in the biopsychosocial model, which treats the person and not just the disease. An integrated aging theme instilled geriatrics into all four years of the undergraduate medical curriculum and is replicated nationally. Students continue with early exposure to older adults in clinics, hospitals, and nursing homes to battle ageism and ensure competency in nationally established geriatrics training benchmarks.
“On Day One of medical school, 100 students listened attentively as a geriatrician sat down with a geriatric patient and showed us how to talk to an older patient,” recalls Heather Hopkins Gil (MD ’12, Res ’15, Flw ’16), a geriatrician and palliative medicine physician at Northwestern Medicine in Chicago.
“Rochester’s training for geriatrics is integrated so well that you do not always realize you’re learning fundamental geriatric medicine,” she adds. “This is critical because the majority of patients admitted to hospitals or facing serious illness are older or frail.”
Groundbreaking geriatrics educator Rosanne Leipzig, MD, PhD (Res ’82), vice chair for Education in the Department of Geriatrics and Palliative Medicine at Mount Sinai’s Icahn School of Medicine, says her Rochester geriatrics residency training pushed her to be the best clinician possible.
“All medical residents spent at least six weeks at Monroe Community Hospital, and with T. Franklin Williams,” she says. “UR geriatrics has developed an excellent national reputation. Many of the most well-known geriatricians have trained there.”
As a geriatrics educator focused on hospital and long-term care, Jennifer Muniak, MD (BS ’06, Res ’13, Flw ’15), assistant professor of medicine, is invested in equipping health care workers with the skills to treat older patients. But how well it works in practice must be quantified, she says.
“Our population is aging, and older adults are interfacing with a health care system that was not designed for them. To find a way forward for all older adult patients, doctors need the skills to look at data critically and change systems of care based on the problems we see,” she says.
Muniak recently received the highly competitive Geriatrics Academic Career Award, a four-year career development grant from HRSA for junior faculty. One of only 26 national recipients, she studies quality metrics data to get a sky-view of how well hospitals and nursing homes care for their older patients, using AFHS benchmarks. The data are voluminous, she says, and as technology takes over, she worries patient stories could be lost.
“We have to think about how we care for older adults at the population level, looking at big data and using quality improvement methods; the challenge is that now, more than ever, patients need medical care that is tailored to the nuances of their individual circumstances. That’s where the skillsets of geriatricians thrive—structuring systems of care in such a way as to keep what matters most to patients at the center of each patient’s care.”
Geriatricians have an opportunity to take leadership in this new space, Muniak says.
“We can offer that perspective. We can keep helping build all these tools and the big data sets to decide what to track and to keep that patient perspective at the forefront.”
During the pandemic, AFHS was a lifeline for hospital workers and the many older patients in their care who had the virus. Tested under fire, AFHS and the Four Ms are spreading in URMC doctors’ offices, hospitals, and nursing homes around the region. In the Age-Friendly Health System Work Group, URMC specialists from multiple departments, Strong Memorial and Highland hospitals, Eastman Institute for Oral Health, and the Center for Perioperative Medicine are mapping their rollout.
The need is dire: Only 3 percent of social workers, psychologists, doctors, and other professionals choose a geriatrics specialty. Fellowships go unfilled. But older adults account for 31 to 36 percent of inpatient encounters at Strong Memorial and Highland hospitals, and up to 30 percent of outpatient visits. That was more than 485,000 patient encounters in 2021, and it’s on the rise.
“Every health care professional in every discipline needs the skill set to provide high-quality care for older patients,” says Annie Medina-Walpole, MD, director of URAI. “And the Age-Friendly Health System is something that people can grasp. It is the driving force of our Vital Care initiatives in the Aging Institute. We will make Rochester the healthiest place to age in America.”
The Beauty of Co-Management
The Geriatric Fracture Center is a geriatric co-management model at URMC that has been replicated around the world to improve patient outcomes in a cost-effective way. It’s the kind of thing the UR Aging Institute (URAI) is ideally suited to help foster. Others include Geriatric Trauma Surgery at Strong, led by Ciandra D’souza, MD, MPH, assistant professor of Medicine; and Geriatric Oncology at Highland, led by Corey Romesser, MD (Res ’06, Flw ’07), associate professor of Clinical Medicine.
URAI is also helping to partner the Division of Geriatrics & Aging with colleagues in surgery, hospital medicine, anesthesia, and nursing so that every older adult undergoing surgery has the same high-quality standard of care. A work group is spearheading efforts to prepare for geriatric surgery verification from the American College of Surgeons, under the leadership of Gabriella Poles, MD, MPH, assistant professor of Surgery, and Heather Lander, MD, assistant professor of Anesthesiology. Poles and Lander are both former Geriatric Faculty Scholars.
Growing Geriatrics and Aging
To enlarge the ranks of geriatrics and aging specialists and researchers, the University is teaching the next generation through a network of programs under the UR Aging Institute umbrella. Clinical training is through the Department of Medicine’s Division of Geriatrics & Aging, the Department of Psychiatry’s Division of Geriatric Mental Health and Memory Care, Finger Lakes Geriatric Education Center, the Geriatric Medicine and Geriatric Psychiatry fellowship programs, and the School of Nursing Adult Gerontology NP Program. Basic research in labs on both campuses includes undergraduates to postdocs.
And training is not just in the sciences: The Warner School of Education offers coursework and research opportunities in aging, such as mental health; cognitive development; and the social, cultural, and historical influences on individual development in late life.
Highland Hospital has a wealth of geriatricians on staff from the Division of Geriatrics & Aging—more than all other Rochester area hospitals combined—so it’s uniquely suited to address issues related to the stress of hospitalization from an older person’s perspective. Two nationally replicated, evidence-based initiatives show how Highland is helping to prevent delirium, the most common complication for older hospital patients.
Studies have shown that a third of patients over 70 experience some level of this disorienting condition.
- Acute Care for Elders Unit (ACE)—Teams of social workers, nurses, doctors, advanced practice providers, and occupational, speech, and physical therapists meet with patients and their families in a continuous quality improvement model of care to prevent functional decline during hospitalization. Individualized care plans are tailored to patients’ needs. For example, IVs and catheters are removed as soon as possible, allowing patients to regain mobility, which is important for healing.