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Geriatrics – Forever Young

Geriatrics – Forever Young. By J. Kenneth Brubaker MD, CMD Corporate Medical Director of Masonic Villages of PA Medical Director of Masonic Village Hospice Geriatric Consultant jkbrubak@masonicvillages.org. Objectives. Review the origins of the specialty of Geriatrics in the USA.

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Geriatrics – Forever Young

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  1. Geriatrics – Forever Young By J. Kenneth Brubaker MD, CMD Corporate Medical Director of Masonic Villages of PA Medical Director of Masonic Village Hospice Geriatric Consultant jkbrubak@masonicvillages.org

  2. Objectives • Review the origins of the specialty of Geriatrics in the USA. • Review the creation of the Geriatric specialty by Family Physicians and Internal Medicine. • Review the creation of a Geriatric Fellowship at Lancaster General Health. • Review the development and growth of the Division of Geriatrics at Lancaster General Health. • Look at the potential future growth of Geriatrics in the Lancaster community.

  3. Origins of Geriatrics in America • Dr. Ignatz Leo Nascher – the father of Geriatrics in the USA (1). • American Geriatric Society organized in 1942 with first meeting in 1943. • JAGS first published in 1953. • Dr. Leslie Lebow started the first nationally recognized Geriatric Fellowship in 1968 (2). • Establishment of the National Institute of Aging (NIA) in 1974. • Creation of the Geriatric Research, Education, and Clinical Centers (GRECC).

  4. Who Will Claim the Rights to Care for the Geriatric Population? • AAFP recognized the need to have faculty with interest and training in Geriatrics in 1979. • Intense debate in 1980 by the AAFP’s Congress of Delegates with following resolutions: a. Active public relations campaign to encourage older adults get their care with family physicians b. Opposed to creating a subspecialty of Geriatrics c. AAFP should develop curricula for family residencies to assure competencies in caring for the Geriatric population(3).

  5. American Board of Family Medicine (ABFM) and the American Board of Internal Medicine (ABIM) Collaborate • In 1985 the ABIM completed an application to the American Board of Medical Specialties (ABMS) for a Certificate of Added Qualification (CAQ) in Geriatrics • ABFM quickly completed a similar application to ABMS.

  6. Fellowships in Geriatrics in 1988 1. 74 applications for Geriatric Fellowships in 1988 a. 55 by IM b. 19 by FM 2. July of 2017 a. 107 in IM b. 44 in FM 3. Some differences between to the two training programs 4. Fellows from both programs take the same board exam to earn their CAQ in Geriatrics.

  7. Creation of a Geriatric Fellowship Program at Lancaster General Health • Dr. Zervanos, Founder and Director of the Lancaster Family Practice Program was the chief advocate and visionary for a Geriatric Fellowship. 1. Acknowledged the report by the Institute of Medicine in 1978 (4). 2. 1985 the AAFP approved the creation of Geriatric Fellowships. 3. Dr. Zervanos received strong support by the LGH administrator but lacked support from the medical staff.

  8. Factors Contributing to the Need for a Geriatric Specialty • Increase in life expectancy during the 20th century • Increase in multiple chronic diseases with in the increase in life expectancy – CAD, DM, COPD, cancer, strokes, and memory loss. • Increase in new medications between 1950 to our present era and the development of polypharmacy. • Decline in functions of organs that effected pharmacokinetics and drug metabolism.

  9. Dr. Zervanos Refuses to Accept “No” for an Answer • 14 years later in 2000 the LGH medical staff supported the creation of a Geriatric Fellowship and an application to the Accreditation Council for Graduate Medical Education (ACGME) was submitted. • Drs. Scott Paist and Ken Brubaker collaborated in starting the first class of Geriatric Fellowships in 2001. • First fellows were graduates of the LGH Family Practice Residency Program (Drs. Dale Hursh and Debra Kylander.)

  10. What is Unique About Geriatric Training? • Focus on frail older adults most of whom are nursing home eligible • Training requires a hospital geriatric consultant experience, out-patient office experience, and nursing home experience. • Multiple other rotations include the following: Geriatric Psychiatry, Hospice Care, Geriatric Rehabilitation, Neurology, Cardiology, Office of Aging, Adult Protective Services, Home Health Program, Incontinence Clinic, and Alzheimer’s Memory Center.

  11. What is Unique About Geriatric Training (Cont.) • Education among the following rotations includes Geriatric Syndromes such as incontinence of urine and bowls, high risk for falls, common adverse drug reactions and drug interactions, polypharmacy, evaluation and treatment of various types of dementia, determining decision-making capacity, recognizing and treating for poor vision, hearing disorders, and dysphagia.

  12. Geriatric Training (cont.) • Emphasis upon successful completion of the Physician Orders for Life Sustaining Treatment (POLST) especially among the frail older adults 2. Goals of care with the resident/health care agent with all frail older adults who are nursing home eligible. a. Residents on the PA Wavier Program b. Resident in the Living Independently for the Elderly (LIFE)[same as the national PACE Program] c. Nursing Homes and Personal Care Homes d. Residents cared for by family members living in the community without Medicaid financial support by the state.

  13. Recruiting Success for Fellows • From 2001 to 2017 28 fellows completed our Geriatric Fellowship. • 18 fellows graduated from the Lancaster Family Medicine Residency. • All fellows from our fellowship who took their geriatric CAQ exam passed the exam on their first attempt. (nationally Family Medicine/Internal Medicine runs around 85% first pass) [5]. • The average of all LGH Geriatric Board scores between 2013 and 2017, were the highest in PA ( exceeded Pitt and Penn)[6].

  14. Why This High Success? • Fellowship program has successfully recruited 64% of our fellows from the Lancaster General Family Medicine Residency Program (LGFMRP). • LGFMRP consistently attracts highly motivated medical students throughout the country and consequently has a high historical ranking by reputation among FM training programs in the country (7). • The Geriatric Fellowship Program has a diverse and integrated geriatric experiences which expose fellows beyond the hospital and outpatient office practice settings.

  15. Fellowship Directors • Geriatric Fellowship Directors between 2001 to the present 1. Dr. Scott Paist 2001 to 2002 2. Dr. Ken Brubaker 2002 to 2006 3. Dr. Matt Beelen 2006 to 2015 4. Dr. Christie Stewart 2015 to 2017 5. Dr. Scott Delong 2017 to present

  16. The Geriatric Fellowship Led to the Growth of the Geriatric Services 1. Demand by the Lancaster Community to see a Geriatrician a. Why do I need to see so many specialists? b. Why do I need to take some many medications? 2. Started with an FTE of 1.5 providers in 2001 and a FTE of 31 providers in 2017(16 physicians and 15 CRNPs).

  17. Factors Contributing to the Growth in Geriatrics • Demand from the nursing homes and older residents in Lancaster County • Strong support by the Lancaster General upper level management team. • Visionary leadership by the Geriatric providers and staff. • Geriatric Fellowship Graduates have been attracted and encouraged to join the Geriatric staff.

  18. Geriatricians and Population Health Management • Preventing avoidable hospital admissions and readmissions among nursing home residents. • Reducing medical care costs among the frail elderly population. • Determining Goals of Care for frail older adults which lead to the reduction of over-testing and inappropriate aggressive treatment of medical conditions near end-of-life. • Creating monthly care-giver support program for families who care for persons with memory loss since 2006

  19. Role of Volunteerism by Geriatricians • Geriatricians have volunteered many hours giving community lectures relating to the care of the frail older adults at churches, nursing homes, personal care homes, community centers, and libraries. • Geriatricians have been providing leadership roles in PMDA: The Society for Post-acute and Long-term Care Medicine and in the national organization, AMDA: The Society for Post-acute and Long-term Care Medicine

  20. Creation of a Geriatric Program Directorship • 2002 to 2010 Dr. Ken Brubaker • 2010 to 2015 Dr. Leon Kraybill • 2015 to 2017 Dr. Kristen Nebel • 2017 to present Dr. Dale Hursh

  21. Division of Geriatrics Created in2014 First Director of the Division Dr. Leon Kraybill 2014 to present

  22. Future of Geriatrics in the Lancaster Community • Phyllis Wojtusik, Director of Post-Acute Care/Population Health a. Creation of standards of care for rehabilitation or residents in nursing homes for diagnoses such as pneumonia, hip fractures, congestive heart failure. b. Goals to reduce cost of care and promote aging in place whenever possible. c. Implementation of Interact, a helpful tool to use in assessing residents residing in nursing homes who experience acute changes in condition.

  23. Other Opportunities for the Future of Geriatrics in Lancaster • Implement tele-medicine for nursing homes and personal care facilities nights and weekends. • Develop standards of care for common illnesses among residents residing in nursing homes such as COPD, Cellulitis, UTIs, Pneumonia, Congestive Heart Failure, and Dehydration. • Create an ER track for frail older adults living at home or in institutions such as nursing homes and personal care homes. • Create a local managed care insurance product for dually eligible residents living in the nursing homes.

  24. Create an Institute of Geriatrics • Mission is to provide multiple geriatric educational experiences for health care providers (physicians/CRNPs, PAs), family care-givers, and staff working in hospitals and other community institutions and create an environment that provides multiple services for the needs of the frail older adults and their care-givers such as: a. Geriatric provider offices b. Adult Protective Services and Office of Aging c. Rehabilitation center for frail older adults d. Legal Aid e. Memory Disorder Center f. Physical fitness center

  25. Institute of Geriatrics (Cont.) 2. Multiple services (cont.) g. Adult Day Center for frail older adults h. LIFE Program (called PACE throughout the USA) i. Care-giver support services for family members with dementia. j. Group setting for persons with mild to moderate memory loss (Cognitive Stimulation Therapy {CST} [8]) k. Coffee shop support centers for care-givers needing a break where they can relate to other care- givers in a comfortable and relaxing setting.

  26. Institute of Geriatrics (Cont.) 3. Create opportunities to participate in national and international geriatric research of frail older adults living in our community and our institutions. 4. Promote donations to the Geriatric Endowment Fund in support of geriatric education for professionals and consumers in our community.

  27. Quote by Dr. Albert Schweitzer • Example is leadership. • Example is not the main thing in influencing others. It is the only thing.

  28. Bibliography 1.Nascher, IL. Geriatrics. NY Med J. 1909;90:358 2.Lebow, LS. The Birth of Geriatrics in America. J. Am Geriatr Soc 2014; 62: 1369- 1376 3.Minutes of the Congress of Delegates, AAFP, Oct. 1980 4.https://www.nap.edu/read/20024/chapter/1 5.https://www.abim.org/~/media/ ABIM%20Public/Files/pdf/statistics-data/certification- pass-rates 6.https://www.theabfm.org/caq/geriatric.aspx 7.https://residency.doximity.com/programs?residency_specialty_id=43&sort_by=reputatio 8. . http://www.pchmo.org/services-CST.aspx

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