Health care workers turn their focus to an overlooked patient population.
By the year 2030, every baby boomer in the U.S. will have reached age 65, and 1 in 5 of the country’s residents will be at or past retirement age. In Texas, people 65 and older already make up more than 12 percent of the population.
Few people are more concerned about this major demographic shift and its attendant demands on health care than Diane Hawley, associate professor of professional practice at TCU’s Harris College of Nursing & Health Sciences. She is leading an initiative to train professionals in a team-based approach to geriatric care.
The need for improved care for elderly patients is critical, and the stakes are personal for Hawley, who lost her mother in August 2018 following a fall.
“My mother had Alzheimer’s disease and was living in a memory-care facility,” Hawley said. “I really believe that the purpose of my journey with my mom since her diagnosis was, ultimately, to make me a better nurse and educator in understanding the fate of older persons.”
Hawley said medical schools and nursing programs tend to overlook glaring areas of concern in geriatric patient care. Among these are mobility and fall prevention, recognizing and addressing cognitive decline, and evaluating day-to-day function — whether patients are able to go grocery shopping, prepare meals and keep house.
“By and large, medical and health sciences students — and even a majority of providers currently in practice — aren’t thinking about this stuff,” Hawley said.
“Polypharmacy is another area of particular concern. Older adults are often dealing with multiple chronic conditions, so they’re visiting multiple specialists.
“It’s not unusual for elderly patients to be taking 20 or more drugs to treat chronic conditions: neurodegenerative diseases like Parkinson’s or Alzheimer’s, heart disease, depression, insomnia, incontinence.
“In addition to polypharmacy, health literacy is a big concern— so being able to understand what all the prescription bottles say, understanding the medical terminology their providers use and so forth. It’s all very challenging as you get older.”
Beyond confusing medical jargon, polypharmacy can turn fatal. Patients taking multiple daily medications may overdose, miss doses altogether or ingest medications that are harmful when taken together.
TRAINING LEADERS IN GERIATRICS
In an effort to make health care more effective for elderly patients in Tarrant County and neighboring rural counties, Hawley leads the Geriatric Practice Leadership Institute. The 10-month program assembles interprofessional teams from area health care organizations to address issues that affect this patient demographic.
The institute is one of the five components of Workforce Enhancement in Healthy Aging and Independent Living (known as WE HAIL), a collaboration among TCU’s Harris College of Nursing & Health Sciences, the University of North Texas Health Science Center, the Tarrant County Area Agency on Aging and John Peter Smith Health Network. The collaboration is funded with a $3.4 million federal grant from the Health Resources and Services Administration.
The institute operates much like a formal certification program. It is designed to strengthen the efficacy of interprofessional team-based care whereby physicians, nurses, physical therapists and even administrators collaborate to help patients get healthy and stay healthy.
When geriatric patients are being treated for specific health issues, their conditions can change rapidly. Well-oiled, interprofessional teams are better able to keep up.
“When an elderly patient visits the emergency room, they may be admitted to critical care, then move to palliative, or end-of-life, care, and then to home hospice. That’s a lot of change, and it can happen fast. So the handoffs from team to team are absolutely critical,” said Janice Knebl, principal investigator for WE HAIL and an endowed chair in clinical geriatrics at the University of North Texas Health Science Center.
Among the cohorts admitted to the institute was a team from John Peter Smith. The team included a physician, a pharmacist, a community outreach specialist and a geriatric service line administrator who oversees multiple health care professionals participating in the continuum of geriatric patient care. The team is one of 12 groups to graduate from the institute so far.
Instruction consists of all-day sessions monthly from August to December. From January to April, each team tackles a research project by collecting and analyzing data and preparing a presentation for the general public.
The projects are expected to yield measurable improvements in geriatric patient outcomes, Hawley said. The John Peter Smith team’s final project used visual illustrations — such as a sun and moon to indicate daytime or evening — to help patients better understand their medication dosing instructions. After leaving the clinic, fewer patients were calling back for clarification or returning to the clinic due to improper dosing.
Also among the institute’s graduates was a team from Brookdale Senior Living Solutions, the largest provider of senior housing in the nation, including 32 assisted living communities throughout the Dallas-Fort Worth area.
“We wanted to look at the relationship between loneliness and dementia symptoms or cognitive decline,” said Rebecca Potter, executive director of Brookdale Pecan Park in Arlington, Texas.
Potter’s team interviewed 24 senior residents who ranged in age from 78 to 96. The team used questionnaires, a loneliness scale, a mood scale and a brief cognitive test. Of those screened, 10 residents were identified as “at risk” and were subsequently engaged in socialization and one-on-one visits and were encouraged to participate in a structured activities program over a four-month period.
“It ended up that six residents [of the 10] had increased their scores on the cognitive assessment after four months, resulting in increased ability for word recall and recognition. We also found that five of those six residents increased their participation in community activities,” Potter said. “The success of our project gave us the opportunity to create a new loneliness program geared toward incoming residents.”
Michael Newberry participated in the institute with a team from MedStar Mobile Healthcare, the exclusive ambulance provider for 15 North Texas cities, including Fort Worth.
“When we applied to send a team to the institute, we knew we wanted to reduce the number of fall-related 911 calls while also improving the health, balance and overall safety of patients,” Newberry said.
A sizable percentage of MedStar clients “are ‘frequent fallers,’ so to speak,” Hawley said. “In other words, MedStar responders see these clients often and are going into their homes and connecting with these people.”
In treating elderly patients, MedStar emergency responders have long relied on a formal fall risk assessment known as STEADI — Stopping Elderly Accidents, Deaths & Injuries. But, Newberry said, preventing falls requires a more holistic inventory of the patient’s health, routine and environment.
“When we respond to a 911 call to treat a patient who has fallen or is complaining of complications following a fall … we also want to find out why they fell and how we can stop it from happening again,” Newberry said. “Was it a new medication? Are they on too many medications? Are they incontinent of the bowel and rushing to the bathroom, causing a fall? Are there trip hazards in the house? Do they need grab bars in their bathrooms and showers? Can we refer them to other organizations for help?”
As they return again and again to the same homes and patients, MedStar providers are well-positioned to address these areas of concern, so Newberry’s team created a more comprehensive fall risk assessment.
By tracking the efficacy of the revised assessment, the MedStar team was able to show a significant increase in referrals made to an educational and strength- training program called A Matter of Balance, as well as a decrease in the number of fall-related emergency calls in the region.
“They’ve seen something like a 70 percent decrease in falls since they put in these new screening protocols,” Hawley said. “The results were amazing, and they have now put that process in place as a matter of course, so people all over Tarrant County will benefit from this.”
Hawley and Knebl said the changes resulting from the teams’ projects are making a huge difference for elderly patients.
“Most of these projects are impressive, but they’re really not rocket science,” Knebl said. “They’re simplistic and yet very impactful, and they don’t cost the organization any more money.”
In the future, Hawley and Knebl hope to incorporate an online platform so that the institute can reach more health care providers and organizations, particularly in rural areas.
“The Health Resources and Services Administration is really concerned with how do we take care of rural America? Because that’s where many geriatric patients live,” Hawley said. “If we can offer the majority of this training through online modules, perhaps we could work with people in other states. Would that be a possibility? Would it be as effective? That would be an experiment for our next grant.”
BY JULIE ENGEBRETSON