Teaming Up on the Gray Tsunami: Radical Shifts as Physicians and Patients Age

In his 40-year career, Steven Rothschild, MD, has trained residents in geriatrics, had a robust practice in family medicine, acted as chair of a community hospice program, and done National Institutes of Health-funded research on healthcare quality.

For most of that time, he’s been the youngest person in the room, says Rothschild, director of community and social medicine at Rush University Medical Center in Chicago. Now, he says, he’s among the most senior.

When he looks at the wave of older adults who need care across the United States, and at physicians who will be retiring from healthcare soon themselves, he believes the solution may come from the same source.

“Team-based care,” Rothschild explains. “I know this is something physicians can be resistant to.” But it’s also something that could be just what patients and physicians need.

There aren’t enough physicians now to serve the Baby Boomer generation, let alone Boomers and Generation Xers in 20 years. As a result, physician leaders are working to transform almost everything about healthcare, from how care is reimbursed to who actually leads care teams. Physicians are leading in many areas of care for older adults, including training the next generation, creating age-friendly care approaches, and showing what physician leadership looks like as part of a bigger team.

“We were never, never, never going to be able to train enough geriatricians for the aging population,” Rothschild says. “Everyone has to push to the top of their license.”

Where Did All These Old People Come From?

This was a crisis that everyone knew was coming.

“In 1985, the projections were clear,” Rothschild says. “It’s not like we woke up yesterday and said, ‘Holy cow, where did all these old people come from?’ ”

Indeed, the silver tsunami that geriatricians have been warning about for decades is upon us. Today, 50 million Americans are age 65 or older, with an additional 30 million joining them by 2040.

At the same time, the overall physician workforce is falling further behind demand. The Association of American Medical Colleges projects that the physician shortage may surpass 121,000 by 2032, and the need for geriatricians will increase by 45 percent by 2025, while more and more geriatrics fellowships go unfilled, according to the American Geriatrics Society.

Consider also shortages in specialties that will be key for an aging population, such as rheumatology and cardiology, the higher likelihood that all Americans will have multiple chronic conditions, and reports that as many as half of physicians exhibit symptoms of burnout, and you have a recipe for a system in crisis.

“The greatest success story of the 20th century is longevity,” claims Terry Fulmer, PhD, RN, president of the John A. Hartford Foundation, which has spearheaded quality geriatric care in the United States. “Now we need to make sure we’re using the science to make the changes in care that will provide the best outcomes for older patients and their families.”

Adapting the System to the Patient

Rothschild hired his first nurse practitioner 25 years ago, and decades later he is still ahead of the curve. According to a 2019 Health Affairs survey, 40 percent of primary care physicians or geriatricians have no social workers or registered nurses on their teams, let alone practice an approach like Rush Medical Center’s, with physicians as equal members of care teams that include physician assistants, nurse practitioners, pharmacists, social workers, medical assistants, physical therapists, and other allied health professionals.

Evidence shows that such team approaches improve outcomes for older adults and physicians. Physicians have been calling for team management of complex patients for years, including their appeals in the New England Journal of Medicine.

Back in 2012, Ann Lindsay, MD, and Alan Glaseroff, MD, were building a model that Lindsay is now adapting to a senior living community under development in Humboldt County, California. The model, called Stanford Coordinated Care, was charged with reducing the cost of care for Stanford University’s most complex, and most medically expensive, employees.

Glaseroff started out by negotiating pay — not for himself, but for care. His priority was to get off the fee-for-service treadmill. The result was an agreement that Stanford’s self-insured health plan would pay Lindsay and Glaseroff $286 a month per patient. In return, the clinic was expected to reduce costs to Stanford University’s self-insured health plan.

That was enough money for them to build a team. They hired the equivalent of two full-time physicians. (Lindsay and Glaseroff made up less than one full-time equivalent between them.) They added a registered nurse, a social worker trained to provide mental health care, a pharmacist, and a physical therapist. After conducting a survey of prospective patients, they included a pain specialist, too.

Importantly, four medical assistants were trained as care coordinators, frequently reaching out to patients, asking about patients’ goals, answering simple questions, and generally helping them manage care between specialists who weren’t part of the clinic.

The result was that patients came in less often — but also went to the emergency department 59 percent less frequently and were admitted to the hospital 29 percent less often, for an annual savings of $1.4 million to the insurance system.

What’s more, as medical assistants learned to offer care navigation, they were more satisfied with their jobs. So were the nurse practitioners, pharmacists, and social workers.

As the layers of scut work moved from their plate to others’, they found themselves sitting with patients for 30 minutes and working on complex medical issues.

“It’s the answer to all the burnout stuff we’re reading about,” Glaseroff declares.

For Lindsay, it’s also more fun.

A higher percentage of her time was spent on “intellectually stimulating and emotionally satisfying work,” she says. That meant less was spent on the “mess of things we weren’t particularly trained to do or that seemed like a waste of our life.”

Building A Care Coordinator Workforce

Lindsay is now developing a health workforce program in Humboldt County that aims to bring the model of medical assistant-as-care-coordinator to the county’s community clinics.

This is for the community at large, but Lindsay has big plans for care coordinators as part of a senior independent living and memory care community modeled on the SCC approach.

Because Humboldt is an isolated community, densely forested and mountainous, older adults who need more care than the community can support will have to come down off the mountain.

“They are going to need help scheduling the appointments, getting there, perhaps making housing arrangements,” she says. The provider off the mountain, meanwhile, will need paperwork and records, and the local provider will need to know the results of that appointment and what follow-up information is required.

All this will be the purview of medical assistants. In exchange, Lindsay plans to raise their pay, but that’s the crux of the problem: The kind of care that Lindsay wants for seniors in her community, and that seniors will require more and more, can’t work in a fee-for-service world. So again, she’s looking to other payment programs.

Although there are accountable care organizations, and the Centers for Medicare and Medicaid Services recently added codes meant to support complex care, there’s also the Program of All-Inclusive Care for the Elderly (PACE), a Medicaid program that covers interdisciplinary team care and wrap-around services for older, frail adults still living at home, when they qualify for both Medicaid and Medicare. Medicare Advantage “gives systems flexibility in how to design care to meet seniors’ needs,” Lindsay says.

The Importance of Geriatric Training

When Patricia Curtin, MD, does rounds at the two Acute Care for the Elderly (ACE) units that are part of her ChristianaCare’s Wilmington, Delaware, health system, her eyes scan the white board in patients’ rooms. On each of them is jotted “What Matters Most?” and the answer for that particular patient.

Curtin, ChristianaCare’s chief of geriatric medicine and ACE unit medical director, implemented the change after 20 years of working to adapt her system’s approach to be ready for the influx of seniors. Now that it’s here, she says they are always learning. But for years, team care — even team care led by non-physicians — has been part of that work.

Twenty years ago, Curtin first attended a training on Nurses Improving Care for Healthsystem Elders (NICHE), a nurse-led team-care approach that’s become the foundation of senior care for 710 health systems in five countries, and that has trained 56,000 providers.

Over the years, Curtin has sent 2,500 of those providers to NICHE, but they aren’t just nurses or geriatricians.

“There are many older patients throughout our health system,” Curtin points out, “so pharmacy and the physicians and the patient care techs and therapists, and everybody who touches our patients should really have the training in geriatrics.”

NICHE is where they get it — though it’s now called WISH: We Improve Senior Health.

In recent years, Curtin has led the system into another approach to senior care. The Age-Friendly Health System initiative from the Institute for Healthcare Improvement calls on health systems to implement research into treating and preventing geriatric syndrome: pressure ulcers, falls, incontinence, functional decline, and delirium. The initiative focuses on creating team approaches to memory and mental health, mobility, and medication, all under the guidance of what matters to the patient. These are the four Ms of Age-Friendly Health Systems, and they are the reason patients’ white boards keep the patients’ goals top of mind.

Age-Friendly Health Systems’ approach does something that all the training in the world can’t do, according to Ellen Flaherty, PhD, APRN, past president of the American Geriatrics Society and director of the Dartmouth Centers for Health and Aging at Dartmouth University’s Geisel School of Medicine.

“You can train people all you want, and unless you create a system whereby you are systematically screening older adults for fall risks, for instance, and then are able to refer them through a process to an evidence-based falls prevention program, you’re not going to reduce the amount of falls,” she states. “But changing that system is difficult.”

At ChristianaCare they started small, at the system’s two ACE units, where a team of social workers, nurses, health techs, and doctors work in concert to identify and align medication, mentation, and mobility interventions with what matters to the patient.

It was so successful that they are now rolling it out to every department, starting with internal medicine. And, they’ve found the approach so valuable for bringing evidence-based care to patients that they are now expanding it beyond seniors.

“We want to know what matters most to the 45-year-old,” Curtin says, “as much as we do the 85-year-old.”

Leading by Learning

Today, the gerontology fellows at Rush University Medical Center are as likely to be preparing for careers as cardiologists or rheumatologists as they are to be training to be geriatricians, according to Magdalena Bednarczyk, MD, chief of geriatric medicine at Rush University Medical System in Chicago.

At first, that seemed strange to Bednarczyk, and she mourned the loss of providers who focused only on older adults. But now it seems right. Like Curtin at ChristianaCare, Bednarczyk thinks geriatric training is a good idea for all providers. “It’s complex, evidence-based, patient-centered and safe,” she says.

Bednarczyk, however, goes further: She is training the next generation of physicians to be part of a team. Like Stanford Coordinated Care, Rush practices a team model with advance-practice nurses, physician assistants, social workers, and others, and it’s all led by someone who has an LCSW, not an MD.

When she arrived at Rush 15 years ago, Robyn Golden, LCSW, Rush’s associate vice president of population health and aging, says that leadership “barely knew what social work was.” They thought she’d just do the discharge planning and that would be that.

Instead, Golden has led the hospital system into innovative programs like their Bridge Program, which has social workers following up after patients leave the hospital to make sure they are settled and won’t end up back in the emergency department. This programming took place years before CMS instituted readmission standards.

Social workers also step in where older patients and their caregivers often struggle — with health literacy or follow-through by a family member, for instance, as well as mental health counseling.

Now Golden is working on assessing and getting care for caregivers as well.

“We literally have a button that a physician or a primary care provider can push if he or she believes the patient needs more of a self-management program,” she says. “A physician can also push a button and have a social worker involved.”

Today, the hospital has a not-quite-senior center on site, where older adults take Zumba, where physicians give presentations on medical conditions and answer questions, and where chronic illness self-management courses take place.

Meanwhile, nurses and social workers do care management for patients, freeing physicians to do more complex care. To Rush’s Rothschild, the approach makes so much more sense.

“The reality is, if you have me seeing you for a cough or a cold, you’re going to wait longer to see me than a nurse practitioner, and it’s not a good use of my brain cells,” he explains. Likewise, systemic change means that people like Rothschild can do joint injections, freeing up specialists for more complicated care.

“Working to the top of license moves all the way up the system,” he adds. “Everybody is addicted to the low-hanging fruit, but we can’t do that anymore.”

For Bednarczyk, being part of Golden’s team has been a highlight of her career. She considers Golden not just a leader, but her mentor and sponsor. While she leads her department, she loves the team approach that Golden has developed.

“You don’t have to be a physician to be a leader,” she states. “This healthcare system is so complicated; we’d be foolish not to take advantage of other people’s knowledge. It means being part of a team of people who are equally as passionate as you.”