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Aging Issues

Aging Issues

 

Historical Archive

The 2018 UGS Annual Fall Meeting was held November 14 at the Health Insight Board Room. Dr. Richard Lassere from IHC  was the guest speaker and talked about his Geriatric Clinic's Multidisciplinary Model. Kate Nederostek of the Utah Alzheimers Association showed us the services that they offer. Julie Preston briefed us on Health Insight's current activities. Finally, this years Geriatric Advocate of the Year Award went to two deserving awardees in Representative Rebecca Chavez -Houck and Dr. Stephen Fehlauer. Dr. Richard Lassere has been nominated to the position of Vice President/President elect. The food was sponsored by the AMG group providing home based primary care to over 1000 patients in Utah. The event was attended by a good cross section of individuals from different organizations and fields working to help our older patients. 

As promised, I am sending you more information about the committee on which I serve.  The name of the program we discussed is: Health Care Workforce Financial Assistance Program. It was started to address the shortage of rural health care professionals. As I mentioned, the Geriatric Workforce law (and the one for nurse educaters) hitched up with it for appropriations. The position that will be open in the fall of 2019 is on the Advisory Committee, and the position I fill is the one needed from a geriatric professional organization. As I review my letter of appointment to the committee, I am reminded that Butch Abueg nominated me as the president of UGS. Also, the letter came from the Utah Department of Health, Executive Director, Joseph K Miner (not the Governor). Don Wood MD, is the director of the Office of Primary Care and Rural Health. Applicants and sites usually send questions and inquiries to his office.  I see from the website that there is another application cycle opening up on June 1st and they have not posted the closing date yet. Applicants must have a site application submitted from their employer. The rules for site and applicant eligibility are also found on the website.   Here is the link to the application website: http://health.utah.gov/primarycare/?p=prgWf If you know anyone who qualifies, please have them submit an application. They cannot have worked at the site for more than 18 months.  Miriam Beattie, DNP, GNP, ANP, APRNGerontological Nurse Practitioner – Board CertifiedElder Life Nurse SpecialistHospital Elder Life Program (HELP) Division of Geriatrics30 North 1900 East, AB193 SOMSalt Lake City, UT 84132-0001O: 801-587-9103F: 801-585-3884    

Dear Older People Aficianados (OPAs), We have conducted our first contested election in UGS - I have done my best to solicit votes from all current active members of UGS through SurveyMonkey. I'm pleased to announce our slate of officers for the coming year:  Vice President /  President-Elect:  Elle Sugerman, PhD (term to run from Dec 2017 to Dec 2018)Secretary-Treasurer: Anne Asman, MS (term to run from Dec 2017 to Dec 2019)President: Michael Galindo, MD (continuing my term from Dec 2016 to Dec 2018, to be succeeded by Dr. Sugerman in Jan 2019 through Dec 2020) It's great to have our Officers and Board at full strength, and I'm excited about our prospects going forward. I'm especially encouraged to have a psychologist as our President-Elect, as our first President (Tony Morrison, PhD) was also a clinical psychologist and Elle's term will fall during our 10th anniversary. Clearly, this is an important time to be grappling with the challenge of cognitive disorders in the community.  Please join me in welcoming and supporting our Officers and Board in the coming year. We have big plans to reach out, educate, and lead our community!

This year's 2017 Annual Utah Geriatrics Annual Dinner Gala was held at the Eduro Health Care Building. Dr. Carole Baraldi was honored with this year's Geriatric Advocate of the Year Award Dr. Tim Farrell delivered a presentation on on "Hotspotting in Geriatrics". Dr. Michael Galindo UGS president, presented his vision of how we can promote for our patients and our profession.  It was a well attended event. 

Michael Galindo and Butch Abueg represented the Utah Geriatrics Society during the Alheimers Walk sponsored by the Utah Alzheimrer's Association held at the Capitol Hill on 9/23/17.

The 15th Annual Rocky Mountain Geriatrics Conference entitled "Getting to the Heart of Aging: An Interprofessional Approach to Cardiovascular Health" was held at the Snowbird Resort Conference Center on August 28-29, 2017. The UGS  held a breakout meeting at lunch hosting Nursing Home Medical Directors from Hillside Rehabilitation, Brookdale, Highland Care and the Salt Lake Veterans Home to discuss ways by which we can better collaborate and pool our resources.  

The Utah Geriatrics Society, Regence, and the Utah Partnership for Value held a Dinner Panel Discussion with prominent Palliative Clinicians: “Where Can We Create Value in Palliative Care Transitions? A Clinicians’ Perspective” on Tuesday, May 2nd, 2017 at Regence BlueCross BlueShield of Utah .

UGS President Michael Galindo led a panel discussion with panel members with very substantial experience in community work in the field, tackling patient cases that illustrate where value was created at the level of the patient/family and how work was measured and how things might change to better capture value.

Members of the panel included:
Leslie Foren: Regence Blue Cross Blue Shield
Perinne Anderson, GNP-BC: House Call Doctors
Cliphane Brough, FNP-D: Community Nursing Services (CNS) Hospice
Aoril Krutka, DO: Intermountain healthcare Outpatient Palliative Care
Holly Peterson, LCSW: Intermountain Healthcare Senior Clinics
MJ Tran, RN, MBA: Granger Medical Clinic, Population Health Innovations
Florentino Abueg MD: University of Utah Geriatrics, Salt Lake Veterans Home

UGS receives award

Dr Michael Galindo received the 2017 Continuum of Caring Award on behalf of the Utah Geriatrics Society presented by the Senior Charity Foundation during the Hope Benefit Held at the Tower at Rice-Eccles Stadium on April 25,2017. The Continuum of Caring award is presented to individuals or groups who have made a significant difference in the lives of seniors over a significant period of time.

On November 10, we held our 2016 Annual Fall Meeting at the Alta Club. It was a well attended event. The Advocate of the Year Award went to Becky Kapp. She was honored for her years of service with the Salt Lake County Aging and Adult Services. Anna Driesel received the award on her behalf. Sarah Woolsey, MD, Health Insight’s Medical Director gave a talk on the changes that are presently developing related to Health Care Reform, Value Based Care and Transparency. Michael Galindo,  laid out our goals for the future as our incoming UGS President. We will have our first Board Meeting on January 10 at noon. I can send you the details for any of you who want to attend. 

July 13, the UGS held a Dinner Presentation at the Marriott City Creek where Dr. Bruce Smith, the Palliative Care Medical Director for Regence Blue Cross and Blue Shield was the Guest Speaker. He gave an update on Payer Innovations on Palliative Care the from Regence's perspective. It was a well attended event and Leslie Foren, our Regence representative should be complemented on her food selection. We had a lively discussion.

For the sake of some of our members who were not able to attend, I am attempting to give a summary . The key points that I was able to take from this is that Regence Blue Cross Blue Shield as well as CMS is cognizant of the importance of Palliative Care as reflected in two of Regence's programs. One is that they have set up an Education fund to train new physicians who want to go into Palliative Care. Another thing he talked about is Coding for Patient Goals of Care Discussions. One can bill separately for a Patient Goals of Care Discussion. This is reimbursed similarly to a 99214. This can be billed separately from a patient's other codes. A modifier is not necessary except in the ICU setting. The physician does not need to have a face to face encounter with the patient himself. A social worker or physician extender who is working with the physician can satisfy the requirement as long as that person is inside the facility at the same time as the physician. Also, it is not necessary to have a discussion with the patient. One can have the discussion with a caregiver. An Advance Directive is not he same as a Patient Goals of Care Discussion. Another key take away point is that although Payers are aware of how money Palliative Care saves the system. For example, avoiding just a few days of Intensive Care Unit stay would more than pay for the cost of Palliative Care. The issue is that Payers still have to abide by General Accounting Rules where Predicted Savings do not count. At present, studies are being done to validate savings that are accrued from Palliative Care. Regence's Palliative Care Program is a work in progress. The key is to be able to align financial incentives, whether it be from ACO's and other Shared Savings Program. I welcome you to ask us any questions and I can forward them to Regence Blue Cross Blue Shield and Dr. Bruce Smith.

To view an excerpt of the talk on you tube, please click on this link: https://www.youtube.com/watch?v=qYVcLmUQjxU

I am also attaching a copy of the Palliative Care Codes that Leslie Foren sent me and you can find them under attachments on the home page.

The 2015 AGS Annual Fall Meeting was held on November 18.2015 at the Alta Club. It was a well attended event. Dr. Gerald Rothstein received the first UGS Geriatric Advocate of the Year Award. This was followed by the night's guest speaker, Dr. Dot Verbrugge, the Medical Director of Select Health, who gave a talk on Medicare Health Care Financing, specifically Medicare Advantage Plans. Juliana Preston, the Executive Director of Health Insight then introduced Health Insight and the Utah Partnership for Value, The Utah Partnership for Value-driven Health Care (UPV) is a community collaborative comprised of stakeholders representing health care purchasers, payers, providers and the public. UPV seeks to advance higher value health care in our community, through shared strategies that address transparency, variation in cost and quality, and community approaches to delivery system improvement.

Thank you all for attending our yearly UGS Meeting. This is the only time of the year when we as geriatricians have a chance to meet and discuss issues related to our work in caring for our geriatric patients.

The UGS was incorporated in 2009 and became an affiliate of the AGS in 2010 this would be our 6th year. Generally there are five stages as to an organizations life cycle
Stage one existence
Stage two survival
Stage three maturity
Stage four renewal
Stage five decline

we are presently still in the survival stage we look to pursue growth establish a framework and develop our capabilities we’re regularly setting targets for our organization but with the aim of generating enough revenue for survival and expansion we can either enjoy adequate growth to be able to enter the next stage or fail in achieving this and consequently fail to survive

The main driver for growth will be engagement to our mission. Our mission is UGS’s mission which is to improve the health independence and quality of life of all older people. To me a mission should be a concrete, tangible vision that one can almost feel and touch, something that you can sink your teeth into, a more useful mission would be to identify problems in geriatrics and find solutions to these problems
Donald Berwick, MD, who formerly headed CMS and the Institute for Health Care improvement first articulated the now often quoted Triple Aim
1. Improve the experience of care
2. Improve Population Health
3. Reduce the per capita cost of care

Most of Health Care Reform is now moving towards the achieving these goals.

The sustainable Growth Rate Formula has been repealed, but we need to support the viability of Medicare by providing appropriate Geriatric Care. The oldest segment of our population accounts for most of our Health Care Costs. In order to provide appropriate Geriatric Care, one of our goals has always been to correct the perceived lack of Providers and Geriatricians in particular. The recent appropriation of funds for the Loan Repayment Program of the Utah HealthCare Workforce Financial Assistance Program is one step in the right direction. But providing appropriate Geriatric Care means not just providing enough Geriatricians but in actually identifying and fulfilling unaddressed needs in Geriatric Care, just as in the case of the iPhone. Before the iPhone existed, we just did fine with our old dumb cellphones. Now, everyone seems to need smartphones.

So what are these unaddressed needs?
1. Integration of Care-Elderly Care is fragmented which contributes to inefficiencies and costs that are out of proportion to care. There is no coordination of care from one environment to another, from the nursing home to the hospital and vise versa, from the hospital to outpatient clinic. There is no integration in financial reimbursement. Fee for service rewards episodic care and there is no mechanism to reward for overall health outcomes of the individual patient, there is no reward for health promoting and preventive kinds of health care

2.We have seen medical care become more focused on specialization, yet common sense dictates that specialized care does not fit care of the elderly with its multiple complexities and comorbidities. There is a need towards improving integrated coordinated patient centered care instead by promoting excellence in Geriatrics.
The University of Utah Division of Geriatrics has currently started working on PCMH. This is an important step in the creation of accountable care organizations. The utah partnership of value of health insight has recently held a forum on 3 utah health organizations that have become aco's

  1. The AGS is presently paying attention to a lack of Geriatric Branding.
    We need to define what is Geriatrics
    what do geriatricians do
    what does the public know about geriatrics
    what should geriatricians focus on population health? health promotion?, chronic disease and syndromes?
    how do we increase awareness among physician colleagues and what geriatricians do?
    Are there other segments of the population we need to reach and support with geriatric care?

At the beginning of the year we had a strategic meeting to lay out our goals and plans
so what were the goals we talked about a at the beginning of the year
a.To promote geriatrics and improve geriatric expertise one of our plans was to hold after hours educational conferences we’re able to have just one, pain management in the older adult held at the auditorium of saint mark’s hospital

b.Increase membership- In 2015, we had 42 members, we will see how many members we will have this year. I urge you to invite anyone washo may be interested in joining UGS.

c.Increase Revenue- We currently have cash assets of 3263.30 $ as of 10/31/15 as compared to 2716.80 last year. Please review our handouts. Most of our revenue has come from membership fees. We welcome donations or any ideas on how to generate more revenue.

  1. Reach out to more Geriatricians. Michael Galindo and Health Insight are spearheading an effort to gather all nursing home medical directors in Salt Lake City to improve the quality of medical care in nursing homes.
    the Special Forum, "Who is the 'House MD to Follow' at Nursing Facilities?" was held on August 31 at Snowbird Resort, immediately following the day's program at the Rocky Mountain Geriatrics Conference.
    The forum was presided by Dr. Michael Galindo and was attended by individuals representing different disciplines in Nursing Home Care. Of note was the presence of Dr. Sarah Woolsey, the Medical Director for Health Insight a private, non-profit, community-based organization dedicated to improving health and health care.
  2. And finally, Another goal, that is very important to me that we should have is to improve the status of Geriatricians. Dr. Joseph Ouslander once said that Geriatrics is like the Rodney Dangerfield of Medicine, “We don’t get no respect. “.Physicians are generally getting discouraged as they are feeling the loss of autonomy. We are seeing Medicine being more and more subservient to business. We have no control. This is being felt more in primary care. The problem is we have ceded control of how we take care of our patients to business. In order to be able to exert more control we should learn more about our economic environment. There should be a more equitable decision making relationship between business and medicine. One example is the HEDIS measures that are presently being used by insurance companies as pay for performance measures. Some of these measures are not appropriate for older patients. A more appropriate quality indicator is the ACOVE set of measures. (Assessing Care of Vulnerable Elders)

I believe that we in the UGS, can improve the status of Geriatricians by being the answer for these unmet needs and being properly recognized and rewarded for this.

We also have the American Geriatrics Society, which is attentive to our needs and is our link to policies that impact us on the Federal level. COSAR Co-Chairs Jim Powers and Kathy Frank drafted a set of COSAR goals where each state representative are invited to submit comments/prioritize items. Please let us know your needs and priorities by logging on to our website, www.utahags.org under the contact us page.

I have invited staff members from Health Insight and they will talk about the Utah Partnership for Value, We are hoping to collaborate with them in the future to provide value driven instead of fee for service Geriatric Care

Going forwards, I would like to introduce our new leaders, Dr. Michael Galindo, Vice president and president elect, and Kim Dansie, secretary treasurer.

In order to promote Geriatric Adovacy, we felt that we should acknowledge the achievements of a deserving individual as a model for all of us working in the field of Geriatrics. This year, we had 4 deserving candidates:

  1. Becky Kapp, the Director of Aging and Adult Services for Salt Lake County
  2.  Senator Brian Shiozawa, who has been instrumental to the funding of the Rural Physician Loan Repayment Program
  3. Anne Palmer, the Executive Director of the Utah Commission on Aging

The first recipient of the first Geriatric Advocate of the Year Award is someone who has my utmost respect, my mentor and someone who I would like to call my friend, Dr. Gerald Rothstein.

Florentino Abueg, MD
UGS President
November 18, 2015

The most recent AGS-COSAR ( Council of State Affiliate Representatives ) meeting was held as a telephone conference on October 9, 2015. The following is an outline.

Public Policy Update
Physician Fee Schedule
LTC changes on rules
Code separately for Advance Care Planning
Comments on Chronic Care Management
Payment for Chronic Care Management Code
Quality Measures PQRS
Value Based Modifier
Implementation of SGR Reform Law
Physician Fee Schedule
Merit Based Pay System
CMS rules for Meaningful Use Stage III
EHR Standard
Alternative Payment Models
Population Based Health

Policy Side of Advocacy
Advance Care Planning Code
Care Planning Act
Advance Directives across State Plan
Payment to Interdisciplinary Care Team
Drug Prices
Workforce Issues
Legislation of Primary Care Nurses Geriatrics Progeram

2016 AGS Annual Meeting cosponsored with ADGAP
Geriatric Orthopedics
Wound Care
Cancer

COSAR Co-Chairs Jim Powers and Kathy Frank drafted a set of COSAR goals where each state representatives could add comments/prioritize items. Please discuss with your local colleagues and send back the completed COSAR Goal 2016-2017 excel spreadsheet to Jason at jpark@americangeriatrics.org. We will use your comments for future COSAR meetings.
Thanks,
Jim Powers and Kathy Frank
COSAR Co-Chairs

Re: COSAR Community blog on MyAGSOnline – we would like to offer the following below. Can you help us?
Thanks, Jim

COSAR Community Conversation for MyAGSOnline
Topic: Geriatric Branding
World Health Organization’s recent report, Aging and Health, suggests that society needs to think differently about aging. Do you agree?
Johns Hopkins Geriatricians sampled Baltimore residents and asked, “How well can a sample of individuals encountered on the street describe what geriatricians do?” They posted the results on the link below.

https://www.youtube.com/watch?v=VCrqrLt0S_8

As COSAR members we need to constantly re-examine our goals and objectives, and we want to hear from you. What does Geriatrics mean? What do geriatricians do? What does the public know about geriatrics? Should geriatricians focus on population health, health promotion, as well as chronic disease and syndromes? How do we increase awareness among physician colleagues of what geriatricians do? Are there other segments of the population we need to reach to support geriatric care? What do you think?

We are pleased to announce our newly elected incoming officers. Dr. Michael Galindo has been formally elected for the position of Vice-President/ President Elect and Kim Dansie has been formally elected for the position of Secretary-Treasurer.

Good morning all,

Thank you again for taking the time to come together last week to discuss how we can cooperate on improving SNF medical care. Our first meeting showed a lot of energy, and I think we accomplished a lot!

The approach with this group will be to use periodic meetings to promote the concerns of individuals and see if there is a consensus area of need. Between meetings, we hope to work with you and others outside this group to turn good ideas into progress. We will reach out to you individually, and I encourage you to also use this network to make your voice heard and to contribute.

What we discussed:
- Improving handoffs from the hospital (streamlining discharge summaries)
- Improving handoffs to the ED (using INTERACT program)
- The INTERACT Program in general
- Medical records interoperability/ the UHIN
- The general desperation to find nursing home physicians and nurse practitioners
- Educational opportunities:
"Pain Management in the SNF: Quality Measures and QAPI for Medical Directors":
7 to 8:45 AM on Oct 1, 2015 at South Towne Exposition Ctr, 9575 S. State St, Sandy

Near-term action items from the meeting:
- Improve networking through sharing contacts
- Assess discharge summary transmission gaps both from the SNF and hospital perspective
- Explore the interest of the ED working with INTERACT forms coming out of SNFs
- Promote education on SNF-relevant topics

Membership in UGS:
Please support elders and the work of geriatric clinicians in Utah by joining the Utah Geriatric Society (UGS).
You can go to the website to complete your membership form and pay dues: www.utahags.org
- Your involvement is crucial!

The UGS Annual Meeting at the Alta Club:
If you decide to join UGS, please join us for dinner on October 18 at 5:30 PM at the Alta Club

We are tentatively planning to meet again in early April 2016.
Stay tuned for other developments before then.

Please see the attached Excel directory of SNF providers. If you have additional contact information for people on this list, please share it if you can. If you do not want to be on this directory, please let me know.

Again, thank you for a successful meeting! With your continued support, I know that we can improve care in this under-recognized area.

Best regards,

Michael Galindo, MD
Utah Geriatrics Society

It is the middle of the year and I find it useful to review our status and performance so far.
At the beginning of the year, we had a strategic meeting to lay out our goals and plans,
All our our goals and plans should stem from our mission. Our mission is the AGS' mission which is to improve the health, independence and quality of life of all older people. To me, a mission should be a concrete vision that one can see, feel hear and touch. It should be something that would engage us into action. To me, a more useful mission would be to identify problems in Geriatrics and find solutions to these problems and I would like to hear any opinions to the contrary that Geriatrics has a lot of problems.

So what were the goals that we talked about during the beginning of the year?
1. To promote Geriatrics and improve Geriatric expertise.
One of our plans was to hold after hours educational conferences. We were able to have just one. Pain Management in the Older Adult held at the Lamb Auditorium of St. Marks Hospital. Bryan Culliton and Holiday Retirement provided the food. Attendance was moderate, around 15 and so was the participation.

2.Increase membership and participation- how has our membership fared compared to previous years? We have 42 members right now. How would we measure our member's engagement? What can we do to improve membership and participation?

3.Increase revenue- What is our revenue right now and how does it compare to previous years? What can we do to improve revenue?
4. Reach out to Nursing Home Medical Directors- Michael Galindo and Health Insight are spearheading an effort to gather all nursing home medical directors in Salt Lake City to improve the quality of medical care in nursing homes.


5. To promote integration of care. This smacks of socialism. Yet this seems to be the way to go. Elderly Care is fragmented which contributes to inefficiencies and costs that are out of proportion to care. There is no coordination of care from one environment to another, from the nursing home to the hospital and vise versa, from the hospital to outpatient clinic. There is no integration in financial reimbursement. Fee for service rewards episodic care and there is no mechanism to reward for overall care of the individual patient, there is no reward for health promoting and preventive kinds of health care. I believe that Patient Centered Medical Homes and Accountable Care Organizations are the way to go and we should have a discussion, here in Salt Lake City about that.


6. In order for Geriatrics to survive, it needs to be able to differentiate itself from Primary Care. By its nature, Geriatrics is similar to Pediatrics in that it is Primary Care which means that it should provide comprehensive care to a particular age segment of the population with its own unique needs and situation. Yet just like Pediatrics, it needs to set itself apart from Primary Care. What I see right now is due to a lack of Geriatricians, by default, the role that Geriatricians are supposed to assume are being assumed by Primary Care Internal Medicine or Family Practice. The distinction between them is becoming more and more blurred. The Geriatrician is disappearing. Sometimes no one is even sure what a Geriatrician actually is. Its the classic problem of the chicken and the egg. There are not enough Geriatricians so the job that needs to be done cannot be done. Since the job cannot be done, then there is no job position( or the lack of ability to perform the job is compensated by something else) , so there is no demand for Geriaticians as reflected by a lack of proper financial reimbursement. And what does that lead to? Not enough Geriatricians. What the job description is, can be a topic for another discussion. This is just one of the problems that the AGS and UGS should be tackling. The recent appropriation of funding for the loan repayment program is just one small step towards solving this problem. Yet attracting more Geriatricians by providing incentives like loan repayment just addresses one end of the problem. One needs to address the other end, which is to establish demand.

7. To support the viability of Medicare - Medicare has been a godsend to our impoverished elderly and yet it has a lot of deficiencies and as a result is presently financially unsustainable. Steps are being taken with the Affordable Care Act to remedy this situation. Does it not seem like a no-brainer that a Geriatrician should be intimately involved in solving Medicare's problems ? Yet this does not seem to always be the case. I sometimes feel that the Geriatrician is relegated to the background.

Our performance should be measured against how we meet our goals. It is also of paramount importance that we have the right goals. These are some goals that I have found worthwhile. I would appreciate your input. I would like to hear from you what goals are important to you or if you feel that we are not gong in the right direction. Our success will rely on everyone's engagement and participation.

To our UGS Members,

Health Insight an Quality Improvement Organization here in Utah is holding a Hypertension Seminar on June 17. Please let me know if you are interested. I am passing along to you the message I got from Sarah Woolsey. End of Registration is on May 29. I think they have provided one spot for us.

Butch Abueg

Hello,

The Utah Million Hearts® Coalition, in conjunction with the National Association of Chronic Disease Control (NACDD), invites your organization to participate in a Million Hearts Workshop on June 17, 2015 from 8:30 am - 4:30 pm. The focus is on coordinating efforts to diagnose and control hypertension in Utah.

We have reserved a spot for your organization. Please identify the most appropriate person within your organization to participate in this workshop. Ideally, they would be someone who can be a champion or catalyst for blood pressure measurement and control.

Please register by May 29, 2015 here: https://www.surveymonkey.com/s/MHRegistration

I believe that conferences are only as useful as to the extent that you can put what you have learned into practice. This year's conference was shorter in terms of the number for days and yet there were a few aspects of the conference that made me feel I got my money's worth. The one thing that impressed me the most was the the Public Policy Lecture which was conducted by decision makers who work within Medicare, two of whom were Geriatricians. It fueled my hope that public policy is being shaped into a form that best addresses the problems we are currently facing with geriatric care. Through public advocacy, AGS was able to convince congress to repeal SGR and take steps to replace our current fee for service based system to a more cost effective value based care.

Just as I did last year, I attended this year's ADGAP meeting. This year's format was different in that the organizers chose practice challenges submitted by attendees. The challenge I submitted dealed with outpatient geriatric clinics. What I learned was that outpatient geriatric clinics, the way we are running it now is becoming more and more difficult to sustain. The challenge is how to maintain financial viability of a geriatric clinic, which due to increased complexity of the patients it sees, can only about 13 to 16 patients a day, as opposed to a regular primary care clinic which can see about 20 to 23 patients a day. And yet no one can deny the value of what we do in taking care of these patients with multiple complex problems where we can prevent unnecessary and expensive hospitalization and institutionalization. The case was presented before a panel of peers where suggestions were given. The recommendations were useful and yet do not seem to deal with the root cause of the problem. The problem which is that financial incentives are not aligned with the desired behavior which is appropriate care for patients with multiple chronic conditions.

Recently, AGS was able to convince Medicare to allow for a chronic care management code 99490. This is a step in the right direction, however this code only financially makes sense in large physician practices and the small reimbursement of 42 dollars does not justify the added paperwork and time just to submit the claim. This was discussed in the CPT coding session where I could sense Dr. Zorowitz’s frustration with the way Medicare has set up its CPT coding. Yet there is not much we can do about it. It is not for us to ask why it is only for us to do and die.

Just as in last year’s COSAR meeting, they invited speakers talking about significant issues in Geriatric Care. During this meeting, the invited Dr. Alan Lazaroff, a very interesting physician. He is the CPT adviser in the AMA Advisory Panel. He talked about the Chronic Care Management Code. He is one of the physician who understands the importance of aligning financial incentives with desired outcomes.

The conference was a showcase of different models of care, PACE, GRACE, Independence at Home Demonstration. It should be our task to study their usefulness and applicability and apply them to our own practices.

Butch Abueg
UGS President

To our members,

We are extending an invitation for nomination to the position of Utah Workforce Program - Geriatric Advisory Committee member.

Utah's Health Care Workforce Financial Assistance Program was refunded this year for the first time since 2009. This program offers loan repayment contracts to specified health care providers who are willing to serve in medically underserved areas of Utah for at least two years. This program is administered by a committee that is selected by the Executive Director of the Utah Department of Health based upon suggestions/nominations from knowledgeable organizations. One of the members of this committee must be a "geriatric health professional (who has had advanced training in geriatrics) nominated by their professional association." Committee members serve without compensation, but they may receive mileage reimbursement and a meal allowance for attending meetings. In the past, we have usually held two, half-day meetings in Salt Lake City, each year to operate this program. An additional meeting may be required the first year since the program has not been funded for so long. Questions may be sent to Dr. Marc Babitz at mbabitz@utah.gov.

Butch Abueg
UGS President

The Pain Management Lecture was held at the St. Marks Lamb Auditorium on March 25,2015. Thanks to everyone who attended, to Dr. David Byrd and Dr. Richard Glines from the Utah Pain Clinic who gave an informative lecture, to Holiday Retirement who provided the food. You can download a copy of Dr. Abueg's power point slides under the home page.

9th Annual Research Retreat - 2015

April 2-3, 2015

The 9th Annual Research Retreat will feature a Poster Session on Thursday April 2, and a Keynote/Symposium Session on Friday, April 3. We are pleased to announce our distinguished Keynote speaker will be Dr. Ken Rockwood, MD, FRCPC, FRCP - Geriatrician, Professor, and Director of Geriatric Medicine Research at Dalhouse University in Halifax, Nova Scotia. Dr. Rockwood has alongstanding interest in clinical and epidemiological aspects of frailty, delirium, and dementia. Dr. Rockwood’s keynote address will be followed by a series of symposia that will highlight “Effective Management of Comorbidities in Older Adults.”

All events will be held at the James L. Sorenson Molecular Biotechnology / USTAR Building, 36 South Wasatch Drive, Salt Lake City, UT 84112.

The January 2015 Stategic Planning Meeting was just held at the Large Conference Room at the Division of Geriatrics. Present were the UGS Board Members as well as Erika Noonan, Michael Galindo and Meg Skibitsky who will be heading the Membership Committee. A copy of the minutes of the meeting is available under the home page.

I want to thank you all for joining us today. I appreciate your interest in improving the care of our elderly patients and the promotion of Geriatrics.

First of all I want to thank our outgoing president Mimi Beattie and her unselfish efforts in making possible our productive last two years.

As incoming President, it is my responsibility to lay out our Society’s goal and direction. Last year, I remember during my speech that I mentioned that we are now in a crossroads. On one hand, we are finally aware of the financial unsustainability of our so-called entitlement programs, Medicare, Medicaid and Social Security. On the other hand, we are witnessing an explosion of that portion of our population we call the elderly. Herein lies our challenge. As Geriatricians, we can either sit by or watch Medicare fail and with it, the only working health care system for our elderly since Lyndon Johnson passed the Medicare Act in 1965. Or, as healthcare providers in the frontline where we can see for ourselves during the course of our day to day encounters with our patients the unique problems in their care. We can come up with solutions to the present crisis.

Now, you may ask what influence can we have in shaping our present health care system? But then I ask you, do you feel that you are content with what is being done at present to right the dilemma than Medicare has found itself in. Are you aware of the things that are being done right now to save our Health Care System?

I attended the AGS meeting in Orlando last May after last having attended it 15 years ago. I found it to be more relevant. In addition to Geriatric Medical updates a lot of time was spent on things like business systems, Marketing of Geriatrics, Innovative Practice Models and National Policy Changes that affect the care of our patients.

The preconference Association of Directors of Geriatric Academic Programs leadership meeting was about payment transformation and opportunities for innovative geriatric programs with focus on bundled payments, accountable care organizations and capitated programs for dual eligibles. They discussed the trend towards risk shifts from government to providers, from fee for service to fee for value.

On the session entitled the ABC’s of ACO’s , the presenters gave a description of three Pioneer ACO programs in Montefiore in the Bronx, The University of Michigan and Physician health Partners in Denver.

114 ACO’s generated savings to the Medicare Trust Fund of 128 million dollars
There were 60 ACO’s not generating savings
29 generated savings of 129 million dollars
25 ACO’s had less spending than the target benchmark but without shared savings.

Spending targets are determined by CMS. If actual spending is lower than target savings, the savings are shared if quality targets are also achieved.

There are 33 quality measures across 4 equally weighted domains including
patient caregiver experience
care coordination and patient safety
preventive health
At risk populations

ACO’s must achieve at least the 30th percentile or 70% of measures in each domain to avoid placement in a correction action plan.

Some markets are easier than others. To achieve cost savings, the rate of cost growth in a prospectively aligned population should be lower than the rate of cost growth of a national comparison group. Cost baseline is calculated for each PACO from that site’s historical cost perspective.

Are anyone of you involved in an ACO, planning to start one or know of anyone who is involved? To me, communicating with Medicare is like trying to communicate with God. Right now, it seems like the only way that Medicare is allowing cooperation or coordination with us geriatricians working in the trenches is through innovative programs like ACO’s

It was interesting to see some people whose names I have only come across in books and journals like Joseph Ouslander. Mary Tinetti and David Reuben discussed recent policy changes in the care of older adults with multiple and chronic health needs.
Included among the things they discussed was the Annual Wellness Visit, Geriatric Quality Measures like the Physician Quality Reporting System, CMS Complex Chronic Care Management Services is a new G code for Procedures and Professional Services for nonMD services and is part of the effort to reimburse for MD/ staff time (also care transitions and home care supervision) The UGS was instrumental in bringing this about. They mentioned the transition to ICD 10, the Medicare Choices Model which is an option to receive palliative care services from certain hospice providers while concurrently receiving services provided by their curative care providers. Mary Tinetti and David Reuben have been working on Goal Oriented Patient Care, which is care focused on patient-determined outcomes over traditional measures like survival, biomarkers, disease specific signs and symptoms of function.

Mary Tinetti emphasized the need for Geriatrics to come up with a standardized set of quality measures to present to Medicare.

I attended the session ran by Dr. Louise Aaronson of the University of California San Francisco Division of Geriatrics on Rebranding Geriatrics. She is part of the AGS National Rebranding Geriatrics Workgroup. It was an interactive group session with exercised on Geriatric Messaging trying to answer the question, “What is Geriatrics?”

I attended a session on awardees on Innovative Geriatric Models like GEDI-WISE which stands for Geriatric Emergency Department Innovations in Care thru Workforce Informatics and Structural Enhancements. It is a unique model of ED care for older adults—one that employs geriatric-specific assessments, multidisciplinary care coordination, and geriatrics-trained ED personnel to reduce preventable admissions for older adults by assessing and meeting their geriatric-specific, non-acute care needs in the ED

Finally, I attended the Council of State Affiliated Representatives or COSAR. This is a forum by which affiliate representatives can exchange ideas, discuss public policy issues and communicate and collaborate with the American Geriatrics Society. During the last COSAR meeting there was a guest from the Voices for Better Health Program from Community Catalyst a program currently operating in Ohio, Michigan New York, Rhode Island and Washington focused on Improving the care of older adults who are dually eligible for Medicare and Medicaid by building partnerships between geriatric care providers and consumers. They had a guest from the National Partnership to Improve Dementia Care in Nursing Homes, a private-public collaboration working in every state to reduce the use of antipsychotics in nursing homes as well as implement non-pharmacological interventions and person centered dementia care.

It is apparent that a lot of things are happening related to geriatric health care in the country and it will only be a matter of time until we here in Salt Lake City feel its effects. Now the question is can we afford to be passive or should we be proactive in dealing with these changes.

In the May 2012 article of the Annals of Internal Medicine, I came across the article “Is Geriatric Medicine Terminally Ill?” I found it interesting that I should see an article such as this in the Annals of Internal Medicine and not in JAGS. In its conclusion it said, and I quote ” Unless major Changes Occur that promote equitable compensation, professional recognition and measurable improvement in health outcomes for elderly patients, the subspecialty of geriatrics may be headed towards extinction”

I considered that statement a challenge and not a death sentence to get up off our butts and do something and we have so much opportunity to do something.

 
The Affordable Care Act is one step being taken to avert a possible collapse of our present medical safety net for the elderly. The premise is by developing innovations in the system of care, we can recreate a more efficient and cost effective health care delivery system.
 
Why is our present Geriatric health care system inefficient? 
There is a disconnect between what we want to achieve and how the behavior associated with what we want to achieve is being rewarded. We incentivize the wrong behavior. One example is the fee for service system. It incentivizes more procedures more hospitalizations, more admissions to nursing homes. We do not give proper incentive to prevention of falls, prevention of adverse drug reactions, prevention of fractures, treating delirium, diagnosing dementia, preventing constipation, etc.
There is no ownership. No one person responsible for a patient's overall care through different levels of transition from home to hospital to nursing home to outpatient clinic.
There is no uniform standard way of measuring quality of care.
The medical system is fragmented.

Also, the problem with Geriatrics is that unlike other fields such as Cardiology or Gastroenterology, I feel it is finding a hard time in defining or distinguishing itself. Perhaps some of the problem is in marketing. Because it does not have a distinct business niche and therefore no competitive advantage, it reflects on its relatively low financial compensation. In fact it is the only Internal Medicine Subspecialty where it is possible to have a smaller salary than primary care Internal Medicine. Supply follows Demand and not the other way around. The fact that there are so few geriatricians implies that the demand is not there. The problem perhaps is not in the supply of geriatricians but rather in the demand for geriatricians. Think about this last sentence carefully. Unless we can satisfy our patients’ and our nation’s needs in a way that is perceivably better than anyone else then our jobs may truly be headed towards extinction.
 
If we do not tackle these important problems, who will?
 
I do not have the answer to these problems. But I was hoping that through more individuals networking and involvement in the UGS and the AGS, perhaps we can find some answers. I believe in the group brain. I would like to see increased involvement from physicians and geriatric care providers in our community. The problem I think is that we doctors are busy and cannot find the time to physically attend meetings. That is why I feel that improving our UGS website is important.
The website can be a virtual meeting ground where ideas can be heard, improve involvement and engagement. I was thinking of perhaps using the website as a blog site where we can discuss these issues. I am also thinking along the lines of a regular web/newsletter. Perhaps we can have regular case conferences where we can discuss interesting cases over dinner.  On these dinners I am hoping to develop relationships that will enable us to solve these problems that I have discussed.
 
I have looked into the Pennsylvania Geriatrics Society Western Division, which seems to be the model AGS Affiliate.  It has about 133 members and hosts two conferences that invite renowned speakers and invites participation not only in the state but nationwide. Its financial status is excellent. They have been able to sponsor attendance to the UGS Meetings to worthwhile awardees. Obviously we cannot even nearly be as accomplished as the Western Pennsylvania Geriatrics Society. They started in 1990. It would take several steps, and each step should be taken before the next one. One of the first steps is member involvement, then, generating revenue. Worthwhile goals like being able to sponsor education of worthwhile students would be in the future. Right now, we should focus our efforts and resources only to the most worthwhile causes aimed at growing our organization.
 
 
I was in the U of U Geriatric Fellowship Program from 1997 to 2000 under Gerry Rothstein. After fellowship, I realized that I needed to keep myself up to date on Geriatrics and to maintain my edge. We all need to aspire toward excellence in Geriatrics. So about 2 or 3 years ago, I started attending Geriatric Grand Rounds And now I have attended the annual AGS meeting. The UGS can be a medium by which we all can hone our Geriatric skills as community providers without necessarily becoming part of the University Geriatrics Division. We as Geriatricians should be able to offer a value proposition.

In January, the UGS board will be having a strategic planning meeting to set specific goals for the coming year. We would also like to ask for nominations for the position of president elect. Nomination forms are available if you do not have them yet.

I am also trying to improve our website. It is very basic right now but we would like you to visit it to check on news, the calendar of events, and perhaps we can develop a blog through which you can give your opinions and communicate with us.

We do need your participation and involvement. This is a very important task that will affect all of our patients and us. Obviously the more we are, working together, the more chances we have to succeed.

Florentino Abueg
UGS Incoming President
( Copy of Speech during UGS Leadership Meeting November 13, 2014 )

Last Updated: 11/2/21