Calls for a de-youthanized science are not lofty, liberal political appeals; they are attempts to actually purify gerontological science and practice. A de-youthanized science means a more valid, generalizable science—a science, for example, that adequately samples older adults in the service of providing sufficiently evidence-based recommendations for diagnosis and treatment
What does successful aging look like? In one of the more influential papers on the subject published in 1987, Rowe and Kahn describe successful aging as involving freedom from disease and disability. This definition has been adapted over time but is still being used today. Take a recent study published in CMAJ defining “successful aging” at 60 years of age or older as satisfying each of following criteria . . .
Rafael Romo, Alex Smith, and colleagues recently published a paper that further challenges the notion that “successful aging” is aging without disability.
Few details are actually known about the proposed settlement of a nationwide class-action lawsuit against Medicare that would do away with the requirement to show a likelihood of medical or functional improvement before Medicare would pay for skilled services such as physical therapy. However, unless there is a monumental change in how we deliver skilled care to Medicare enrollees, there are two conclusions that I feel safe in making:
- More individuals will be using the Medicare Skilled Nursing (SNF) benefit at the end of life
- The ability to provide high quality palliative care to these individuals will be diminished
Why will more individuals use Medicare SNF Benefit at the end of life?
There will be little incentive to prevent more and more individuals with limited ability to improve with skilled care to move quickly from hospitals to SNFs. It is easier, quicker, and often feels “safer” to send someone to a SNF from a hospital than it is to spend hours on having difficult discussions about a patient’s end of life preferences and goals. And please make no mistake about it, this is a hospital to SNF problem, as SNF’s are the discharge pathway of choice for those at the end of life.
To highlight the magnitude of the problem, I’d like to share some of the findings of a recent study published by some of our GeriPal colleagues: Katherine Aragon, Ken Covinsky, MD, Yinghui Miao,
John Boscardin, Lynn Flint, and Alex Smith.
The authors of the study used data from Medicare claims and the Health and Retirement Study (HRS) to look at the prevalence of use of the Medicare SNF benefit in the last 6 months of life. Data from the 5,163 HRS respondents who were 65 years or older and had died between 1994 and 2007 revealed that:
- The vast majority (88%) of SNF stays originated from the hospital
- Nearly a third (31%) of decedents had used the SNF benefit in the last 6 months of life
- One in every 11 (9%) decedents died while receiving the SNF benefit.
The 1990’s showed a dramatic increase in SNF benefit at the end of life among community dwellers, increasing from 20% to 31%. Since then, things have been somewhat stable in regards to SNF use in the last 6 months of life, hovering in the low 30%’s.
Why will the ability to provide high quality palliative care to these individuals be diminished?
This one is easy. Most patients enrolled in the SNF benefit are not eligible to receive concurrent hospice care, and furthermore, they likely would not have access to any other form of palliative care.
Medicare regulations prohibit dual enrollment in both the SNF benefit and the hospice benefit for the same diagnosis. Occasionally individuals can receive both benefits if the SNF care is for a diagnosis unrelated to the hospice diagnosis, but this is a rarity. It also means that the hospice benefit will likely lose out if someone is considering which one to enroll in, as Medicare will pay for room and board with the SNF Benefit as well as reimburse the nursing home at a higher rate. No such luck with hospice care.
Data from the above study confirm this as they found:
- only 0.5% of all decedents were enrolled in hospice during their SNF stay, although 9% of decedents died while enrolled in the SNF benefit.
What about other forms of palliative care? This study does not address whether these patients were receiving other forms of palliative care, but it is unlikely considering the low penetrance of high quality palliative care into skilled nursing settings.
What Will Need to Be Done to Address this Problem?
Considering it is election season, I’m going to end this post with a simple two point plan. Presidential candidates, feel free to steal these ideas:
- Increase palliative care expertise in SNF’s by first passing the Palliative Care and Hospice Education and Training Act (PCHETA) into law
- Rethink whether the hospice benefit and the SNF benefit should continue to be mutually exclusive.
by: Eric Widera (@ewidera)
It’s time to up the ante on the push to get more GeriPal readers on twitter. Today, we have Nancy Lundebjerg (@nlundebjerg), Deputy Executive Vice President and Chief Operating Officer of the American Geriatrics Society, answering some questions on why twitter matters. She also just gave me word that all Reynolds Grantees Attending #DWRF12 can win an iPad by tweeting and successfully answering short daily questions via @theBlueCast (for more info on the game check out AGS’s website here.
Widera: In your opinion, why should we get on twitter?
Lundebjerg: It’s a very powerful tool for getting the word out about geriatrics and palliative care You can use it to communicate to the world and with each other. Most politicians are on twitter and we have not yet begun to tap the power of including a mention of them in our twitter messages.
Widera: Can you give an example of an interesting way twitter can be used in geriatrics or palliative care?
Lundebjerg : There are two debates left to go – use it to message about what needs to happen in care for older adults.
Romney says best plan is Massachusetts plan – the basis of Obamacare…
— Louise Aronson (@LouiseAronson) October 4, 2012
Widera: Do you use twitter during national meetings? If so, how and why?
Lundebjerg: Yes. I use it to bring some personality to the meeting (see Where in the World is Jim Pacala) and to share inspiring statements from speakers with peers who are not in attendance.
Widera: How do you find the time to read and respond to all those tweets?
Lundebjerg: I follow an eclectic bunch of people on twitter – making it a great news feed. I generally pop in about 3-4 times a day to see what is going on. Retweeting something takes a nanosecond and modifying a tweet takes slightly longer. You don’t have to respond to everything nor do you need to read everything.
Widera: Do you use twitter to talk about something other than geriatrics or palliative medicine?
Lundebjerg: Yes, I’ve used it to get refunds for terrible service. Right now I use it mostly for work but plan to transition to include tweets from my blog or Pinterest. Some people have more than one handle and I’ll probably do that for when I want to tweet about my personal blog or Pinterest. By the by, I am waiting for someone to crack the mystery of Pinterest when it comes to family caregiving. The demographic is exactly right but anything remotely serious seems to go just go thud.
Widera: Any tips for someone new to twitter?
Lundebjerg: Following others is a great way to build up a follower base. People will generally follow you back if you follow them. Don’t use the approval process for letting people follow you – it’s pretty easy to weed someone out if they are inappropriate. Start by retweeting and build your original tweet muscle up slowly – it does take practice to get to where you can say something pithy in 140 characters but you will get there. Have fun!
Widera: Who do you follow?
Lundebjerg: I follow you (@ewidera), Ken Covinsky (@geri_doc), Diane Meier (everyone follows Diane!) and am now following any Reynolds attendee (go to @TheBlueCast for a list of those folks). I also follow a bunch of tech folks, the usual suspects in terms of organizations, reporters that cover health and Washington politics, and a number of medical journals.
Widera: You keep on mentioning @TheBlueCast. What is it and what are you trying to do with it?
Lundebjerg: Our Titter team grappled for a while with what handle to use and decided that because we are running a special contest for Reynolds attendees, we would create a new handle. From there, it was a question of whether we wanted to do something a little mysterious with the potential to go viral (we dream of being Big Bird here at AGS!) and TheBlueCast was born. The interesting thing about the handle is that it could easily be used to illustrate problems with activities of daily living throughout the year so the handle may live on beyond the meeting!
by: Eric Widera (@ewidera)
Are you still not convinced that you should sign-up for twitter? Will take more than a “genius” for you to understand the value of a 140 character haiku? Well, maybe Christian Sinclair can convince you as part of our second installment in o…
What happens when the head of one of the most prominent medical education journals publishes a call for every medical school and teaching hospital to develop educational experiences in nursing homes? Will a system that bows down at the alter of th…
A dominant focus of research in Geriatric Medicine has been on the prevention of the types of disability that are common in older persons. This research is important, because if it is successful it will lead to more years of independent living in which seniors do not need the help of caregivers or care in nursing homes.
But in our zeal to prevent disability in older persons, we sometimes paint an overly bleak picture of disability.
A dominant focus of research in Geriatric Medicine has been on the prevention of the types of disability that are common in older persons. This research is important, because if it is successful it will lead to more years of independent living…
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Read the Associated Press article in the Seattle Post Intelligencer, about the the shortage of geriatricians. In Boomers’ Aging Casts Light on Geriatrics Shortage, reporter Matt Sedensky describes the increasing shortage of geriatricians ̵…
I am a rare breed of physician who specializes in the care of older people – a geriatrician. More than 30,000 geriatricians are needed to care for America’s coming age boom. But shockingly, there are fewer than 6,000 and the number is dropping. The reason for this enormous shortage can be explained with a single word: ageism.