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Becoming an Advocate for Older Adults: A Podcast with Joanne Lynn

Geriatricians in the 2030s may be able to prescribe very costly medications for older Medicare beneficiaries who cannot get supper. Most older Americans who live with disabilities will not be able to pay for adequate housing, food, medicine, and personal care. All who serve older adults must shoulder the responsibility to help avert this oncoming suffering and social disruption. The window of opportunity for effective change is already narrow; procrastinating for a decade will be too late.

These are the words of Joanne Lynn, a geriatrician and palliative care physician, who leads Altarum’s work on eldercare. She wrote a recent JAGS editorial titled The “Fierce Urgency of Now”: Geriatrics Professionals Speaking up for Older Adult Care in the United States” which is very much a call to action for those who care for older adults.  We talk with Joanne about this article and some meaningful things clinicians in both geriatrics and palliative care can do to be advocates for a growing population of older adults.

One way I would like to plug to better advocate for our patients is through our national societies. To learn more what both AAHPM and AGS are doing to improve care for older adults and those with serious illness, and to learn how you can help lead change, check out the following links:
So check out the podcast and pick one thing that you can do to better advocate for older adults or those living with serious illness.

Eric (@ewidera)



  


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Transcript

Eric: Welcome to the GeriPal PodCast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, somebody's in this room with us.

Alex: Ken Covinsky, introduce yourself.

Eric: Hi. I'm Ken Covinsky.

Alex: It's been a while since we've had Ken on. It's great to have you back, Ken.

Ken: Fun to be here.

Eric: And who is our very special guest today?

Alex: Today we have Joanne Lynn, who is the director of the program to improve elder care at Altarum, which is a non-profit research and consulting group that's dedicated to improving care for our most vulnerable of older people in the U.S. And she's a geriatrician and a palliative care physician. Welcome to the GeriPal PodCast, Joanne.

Joanne: Delighted to be here.

Eric: I'm super excited because you just published an article in JAGS titled The Fierce Urgency of Now: Geriatrics Professionals Speaking Up for Older Adult Care in the United States. We're hoping to talk to you about health policy. Why we should think about it-

Alex: Fiercely. Now. Urgently.

Eric: ... fiercely as physicians and healthcare providers. Urgently.

Joanne: No, no, no. Not just think about it, do something about it.

Alex: Do something.

Eric: Do something. Well, we'll talk about that. What's my role as a healthcare provider? Do I need to do something? But before we do, lots of topics to talk about. You have a song request for Alex?

Joanne: Sure. Caroline Cotter's A Midnight Escape.

Alex: Great. (singing).

Eric: I haven't heard of that song. How did you pick that song, Joanne?

Joanne: I know Caroline Cotter, and I've always been moved by that song. I hope Alex will do the second verse at the end. But, basically this is a demented lady whose husband is looking after her. It brings to bear that caregiving aspects and the tragedy of living with somebody whose mind has holes in it.

Alex: Wow.

Eric: So, we usually like to start off with how you got interested in this particular subject. I'm going to ask you, not particularly about dementia, but how did you get interested in health policy?

Joanne: I guess my life has spiraled from one-on-one, taking care of patients when I was first a doctor, to worrying about groups and organizations. And now we have sort of the structure of how we put together the society to make it possible for people to live reasonably well.

Joanne: It helps to be in Washington, where the policy ... both doesn't happen and sometimes does happen. And sometimes happens all wrong. But unless we buckle down and get things put together better, we are going to face real misery in about 12 or 15 years. A whole lot of people are not going to be able to afford food and housing.

Alex: That's great. Now you're getting into the "fierce urgency and now" bit. Can you tell us a little bit more about what you're concerned about over the next 10 to 15 years, as far as care of older adults? Particularly the frailest, oldest people living with disability and dementia in our communities.

Joanne: When I first started working in geriatrics, there were whole states where the average nursing home patient was tied down. Where whole states where the average nursing home patient was on major psychotropics.

Joanne: I came into one nursing home in Washington, D.C. as an emergency when a doctor got sick, and found that half of the patients had pressure ulcers. Not just surface pressure ulcers, I mean, these were full thickness. We don't see nursing homes that bad anymore. Or at least not very many of them. And it certainly isn't the standard.

Joanne: But we could lose all those gains, not just in nursing homes, but how people live, simply from the enormous poverty coming at us. People are going into old age without adequate resources. Geriatrician numbers are going down. The availability of disability-adapted housing is not present.

Joanne: Everywhere you look we are just not doing a good job in preparing for the arrival of large numbers of us who are going to be old and frail together. You just can't imagine a time when we will have 80– and 90-year-olds begging on the streets. And we will if we don't do something now.

Ken: Joanne, this is a beautiful essay and it's full of all these quotes that I underlined. It's wonderful and full of these really impressive, moving statements you had.

Ken: One of them that stood out for me, you said that in the coming years we will have a lot of seniors who are getting very expensive drugs but can't pay for dinner. Could you say a little bit more about that and why that's happening?

Joanne: That's already true. We have this commitment to this right to healthcare, but not to housing and food. On the hierarchy of needs, housing and food come first. The fact that we are just not arranging things in ways that make it possible for people to be able to take care of housing and food in old age.

Joanne: The Health Affairs article just a couple of months ago showed that just within a decade, the majority of people who lived in the middle class will be unable to afford housing in old age, when they're old. That should be stunning to us. As a culture, we should be shocked.

Joanne: There's a well-known study of Meals on Wheels that had no trouble recruiting eight cities with more than six-month waiting lists for home-delivered food. These are people who you know, need home-delivered food, and they're on a more than six-month waiting list? That should be outrageous to this country. And yet it doesn't even get a news report.

Joanne: Incidentally, in that study, they randomized a third of the people to not get any. Again, how could you do that? How could you run a study in which you randomize a third of people to not get food?

Eric: Joanne, when you get older in the U.S., there's Medicare, there's Social Security. Aren't we pretty well covered with both of those?

Joanne: Yeah, you know that isn't true [laughter]. Medicare does not cover anything in long-term care. I mean, only little dribs and drabs here and there. The point at which you need personal care, you are just up the creek.

Joanne: There is just ... Medicaid is there if you have nothing. I mean, you have to be really really poor. And then mostly, it's nursing home care, not support in the community. Most states have very long waiting lists for home– and community-based services.

Joanne: The recession back in 2008 really hit people 45 to 60. Their houses went underwater, they tried to rescue their kids and their grandkids, so we have a population coming into old age that is not even well situated to support themselves while they are healthy. And when they start not being able to function well and need more help, they have just enough income to not qualify for Medicaid. But way too little to qualify for the help they need.

Joanne: It used to be everybody lived on the farm, and somebody could take Grandma in and look after her, because there was always enough room on the farm. But that's no longer the case, and the number of family available to help has just crashed. In 1900 it was something like 60 people who had only one elderly woman to look after. Somebody could take her in.

Joanne: Now, if you count everybody in the society, you've only got six or seven people. And that's going down. Yeah, we've set up this perfect storm in which we are going to have very large numbers of people not able to get food and housing, much less medical care.

Ken: Joanne, the other day I was listening to a news show and I heard one of the congresspeople say, "We have the best healthcare system in the world." In the United States. I was wondering, surely if we're having a problem, maybe is all the world having a problem? Or are there other examples of countries that are doing this better than we are?

Joanne: I mean, no one's doing it perfectly yet, but other countries have done so much more. For example, almost all countries cover long-term services in their medical care system. So right off the bat, you do not have to be paying on your own for someone to give you a bed bath, or to spoon-feed you.

Joanne: There are countries like Japan that have seriously invested in the well-being of children, so that they are highly productive when they become young adults. We throw away huge numbers of our children so that we are guaranteeing a weak economy as they come into adulthood.

Joanne: It all comes together as a whole society. The long-term care supportive services in most European countries are so much better than ours. Even in Canada, they're so much better. Here it's up to you to take care of yourself in old age. Well, good luck with that.

Joanne: If you retire at 65 ... most people actually retire earlier ... but say you retire at 65, and have 20 years of relatively healthy retirement, and then three years of serious disability, you've barely made it through the retirement phase with what you've managed to save in Social Security. And now bad illness comes upon you.

Joanne: People don't yet realize that we have, on average, two years of self-care disability. People don't plan for that. So it's the only thing we can't really insure for. You can't buy long-term care insurance at any price that anybody can afford.

Joanne: Anyway, those are the kinds of things that come together to ... I mean, we're really up against it.

Eric: I also heard of the concept of compression of morbidity. I think those were ... I can't remember; those words came out of Ken's mouth. I can't remember if he was railing against it, or if he was for it. But is that a thing, where we're living healthier lives, we're smoking less, that 20 years from now, we'll have less frailty as we get older?

Ken: I did hear it the other day, Joanne.

Joanne: How do you choose to die?

Ken: That's funny. I think part of what ... Eric was noting that I mentioned that if we, like I heard Dr. Oz say the other day, that if we just eat blueberries and exercise more, we don't have to worry about old age. We'll be healthy all our lives.

Joanne: You still have to die.

Eric: ... successfully compressed morbidity.

Joanne: You still have to die.

Alex: Really?

Joanne: Which way will you choose? And you know, all the short-term ways of dying, we've really suppressed. You don't smoke, so we don't have as much lung cancer and we don't have much strokes, and we don't have as much heart attacks.

Joanne: What we're left with is dementia, frailty, Parkinson's; these are all long-term illnesses. The batter-up, the last batter standing is frailty. Yeah, having watched my mother die of frailty over six years, I'll take pancreatic cancer if I get my choice. I don't want it till I'm 90, but frailty's a tough way to go.

Joanne: Yeah, you can eat all the blueberries you want. You could exercise all you want, and maybe that gives you five or six extra years of good health. And you're still going to get something awful. It has to be some way off this mortal coil, and they all are bad.

Alex: Now you write quite a bit in this piece about the need to improve long-term supportive services, particularly basic needs, as you describe them like housing and food. But let me just play devil's advocate for a moment.

Alex: Okay, we're all physicians, right? We're just talking with each other, so can't we just acknowledge that this isn't really our domain? We're doctors, right? We don't deal with these housing and food issues. Right? You're pointing this out so somebody else can take care of it.

Eric: Unless there was a pill for housing, then we could prescribe it.

Alex: Right.

Joanne: Well, at some point, there's this old story in public health that there's a coroner who's supposed to drag the body out of the river and figure out what happened. And yeah, there's one or two bodies in the river every year.

Joanne: Then suddenly, there's a year in which there's a body every day. Well, at some point, you have the obligation to go upriver and figure out what in the heck's happening. Your role has changed; and I think the same thing happens to us. I'm not saying that we should become housing experts or food experts. But we do have to speak up on behalf of our patients.

Joanne: There's something really silly about treating somebody's lipids when they can't get supper. The person who is 86 and living in a car, and using the gas station for their hygiene, we need to speak up on behalf of that person, and on behalf of the many people who are going to end up in that spot.

Joanne: I'm not saying we should abandon our role as doctors, and we should still take care of people one at a time. But we also should get to know our senators and our congressmen and our city council members, and make sure they understand that there is this serious challenge coming, and that they better be really good at figuring out what it is that will help it.

Joanne: It's an ancillary duty because we see the effects. If you have a person coming to you for whatever; hypertension or dementia or whatever. And they simply can't get enough calories in the day, you've got to speak up on behalf of home-delivered food.

Joanne: We have a particular prominence in this society to speak up on these things; people hear us differently. If the doctors get together in some little town in Iowa, and say, "We really need to get rid of this waiting list for home-delivered food," the newsprint will carry that. The TV station will interview them.

Joanne: If their spouse says, "Hey, we're starving out here," people can ignore it. But doctors are listened to. So we should speak up. We have a responsibility to speak up. I only called for a couple hours every month, which you get to know your civic leaders and speak to them.

Eric: What does that actually look like? If I'm interested and motivated and trying to make a change, what does a couple of hours a month do? Where should I start?

Joanne: Oh, one of the easy things is to find out when your representatives are in home district time, and set an appointment. They almost will always meet with you. They'll give you 15 minutes, and you go in and you just really bludgeon them with facts.

Joanne: You make sure that you're on their Rolodex or their electronic Rolodex, so that when something comes up, they call you. And you really push them to say, "You've got to have an agenda for this."

Joanne: In your case, you've got a couple of people running for president. And you've got Governor Newsom saying he's going to build the plan for the future.

Joanne: You could make sure that these kind of people know the better plans; that they aren't just, "Well, let's institute GRACE or let's have an ACE unit in every hospital." They're much more fundamental, and we need to get them realizing that you can't take care of people and have them do well if they can't get supper.

Eric: I guess that's the question. We can go to their offices with facts. But it may feel overwhelming just to say, this terrible terrible thing is going to happen without any potential solutions. Just-

Joanne: Well-

Eric: ... you should think about that. Are there solutions to this?

Joanne: There are solutions. There are solutions. We need to develop ways in which people can save. I have one of them in the article, a very clever way of building a long-term care insurance plan, so people can reasonably save.

Eric: What does that look like? Can you tell me what that looks like?

Joanne: Yeah, this is a very clever plan put together under a contract to the Bipartisan Policy Center. Basically, it would have the federal government pick up the tail of long-term care.

Alex: What does "tail" mean? Tail of long-term care?

Eric: Something about wagging?

Joanne: When I first started working in a nursing home, I picked up a patient whose stroke was before I was born. That's the tail of long-term care. That's the people who had really lost in the gamble, and got 20 years or 10 years of long-term care. That's incredibly expensive. No one can save enough for that.

Joanne: And no long-term care insurance policy could take the gamble that they will end up with a substantial number of people who go 10 years.

Joanne: If the government picked up after, say, five or seven years for us, who have reasonably good incomes, and after just one or two years for low-income people, it turns out to be very inexpensive. Less than 1% on the Medicare tax would be added, and all of a sudden, we'd all be buying long-term care insurance. Because we'd know what we needed to cover.

Joanne: Right now, you don't know whether you're going to have a terrible stroke tomorrow and have 20 years of living in a nursing home. But, if the government was going to pick up after five or seven years, then you would buy a policy for those five or seven years.

Joanne: That effectively is savings. And it stimulates the economy because the insurance companies invest this money in capital investments. It's an economy stimulant and a savings mode for individuals. And really works well. It's a very clever scheme. So that's one we could push.

Ken: Interesting.

Joanne: We could also push all of our good geriatrics programs, all the things that never take off: PACE and GRACE and ACE and all these wonderful things that never go anywhere.

Joanne: There are 45,000 people in PACE in the country. There are 45,000 people who need PACE between Washington and Baltimore. Why are they not in PACE programs? We have not learned how to spread our very good things.

Joanne: I think we need a couple dozen communities that would set out to do this right, to drive down the per capita costs. We need to free them up to do it right, and do the Toyota Revolution in long-term care. Figure out how to have a better product at a lower price that everybody will want. Then the political pressure will be huge.

Joanne: I think it's easy to find the things to push. But they can't be just these surface things. It can't just be an ACE unit; it can't just be, "Train a few more geriatricians." It's got to be much more fundamental.

Eric: Well, I feel like for most physician lobbying, it's around things that are around reimbursement for physicians, or lobbying for specific programs. I do both palliative care and geriatrics, lobbying for both geriatrics and palliative care, workload, PCHETA for palliative care, so training bills for palliative care. Same thing for geriatrics.

Eric: It sounds like you're also advocating to expand our horizons a little bit beyond those things that have to do with directly our workforce, either payment for our workforce or growing our workforce? Is that right?

Joanne: For sure. The sessions that are public at our professional meetings that focus on things like PCHETA just drive me crazy. Here we are looking at serving a population that is going to be too poor to eat, and we're talking about our incomes.

Joanne: Sure, we should have to worry about our incomes. And we should worry about our workload. But surely we can find room to speak up on behalf of our very vulnerable population. We have to ... otherwise, we're going to be in the terrible position of, as you quoted at the beginning, I said in the editorial, "We are going to be prescribing thousand-dollar drugs for people who can't get supper." That should really worry us.

Joanne: So we have to also speak up for that population. And we need to find allies. We need to get the AARP involved, and the Alzheimer's Association, and the American College of Physicians and others that could carry the banner with us.

Joanne: And it is outside of our comfort zone. It's very much easier for me to go in and talk to some congressperson about the wonderful things that happen with palliative care. It is much harder to say, "We've really got to buckle down and figure out how we're going to feed our population."

Joanne: That's out of my comfort zone. But no one else is doing it, so let's do it ... How is it that we have these debates among these Democrat candidates, that don't ever address the issue of how we're going to take care of one another in the coming rise in the number of old people?

Eric: You know we just had the Democratic candidate debate. I'm wondering, was there anything out of that debate; I didn't listen to it; I heard something about everybody getting a thousand, or 10 families getting $1,000. But is there anything from that debate that stood out to you? Or was it just lacking in any discussion about these issues?

Joanne: Every time they talk about Medicare for All, I put an asterisk that say, "Except for those that was originally designed for." Medicare for All is fine; I mean, at least as an argument for you and me. But our 90-year-old patients with six illnesses and ADLs that are three dependent ADLs, Medicare is the wrong thing for them.

Joanne: I often ask audiences, "If we had a dozen 90-year-old ladies living in second-floor walkups design Medicare, what would they have had as priorities to cover?" And out of the first 10 things that the audience comes up with, there are only two or three that are actually covered. The rest aren't.

Joanne: Eyes, ears, teeth, they aren't covered. Then you get into food and housing, and they aren't covered. Yes, you can get your hips and your cataracts, and those are always on the list. But where is comprehensive care? Where is continuity care? Where is the availability of home-delivered food?

Joanne: Medicare was designed by men in suits who were running Blue Cross plans, and they designed one heck of a good Blue Cross plan for 68-year-olds. They did not design a program for people who were living with serious disabling illnesses in the shadow of death. And we need to re-design that.

Joanne: So every time they say "Medicare for All," stick in the asterisk and say, "Fine, that's good for the rest of the population, or it might be good for the rest of the population. But for the population that geriatricians deal with, and the palliative care physicians deal with, it's the wrong plan."

Ken: Wow, that's ... Joanne, you just ... That was very interesting. You made me think, the interesting thing about Medicare for All is that the people we're talking about extending it to, middle-aged people, Medicare's perfect for. And the only problem is, Medicare's terrible for people need Medicare. Who are old. Which is a very fascinating irony.

Ken: I wanted to-

Joanne: But that's the kind of thing you could say to your congressman, and he or she will remember it.

Ken: Wow. Wow. One thing that comes out just listening to you, and I've heard you talk before. You just have so much passion when you speak. Your passion also comes out in this commentary. But it's a passion that also ... There seems to be a not ... I don't want to use the term "anger," because it's not that type of anger.

Ken: It's maybe ... It is maybe the kind. that the anger of the fierce urgency of now, the sort of sense of ... You don't quite say this, but you really seem to be exhorting our profession to do better and to kind of chide us for not doing what we should be doing, and not being effective advocates.

Ken: I mean, am I picking up an emotion here, or am I picking up, are you trying to kick us and shock us into doing something differently and changing the way we behave?

Joanne: I don't think that I'm generally angry or chiding. I think more, calling on us to be the leaders we could be. It would have been better for the society to make plans 10 years ago; it would have been better, I suppose, for us to speak then. But now, the issue is really urgent.

Joanne: We are going to have nearly twice as many frail and disabled elderly people in the mid-2030s as we had just a few years ago. And we are making, as a society, no plans.

Joanne: We're in the position to see that. It is shocking to me that the palliative care meetings do not have any sessions on dementia. They do not have any sessions on nursing home care. It's enough, it seems, for palliative care to have outpatient clinics and hospital-based services. But the people who need it are in their homes, in their nursing homes, in their assisted living centers. We aren't speaking up on behalf of them.

Joanne: We're pushing PCHETA, but we're not pushing the Older Americans Act. The Older Americans Act comes up for a vote before the end of this month. And there are not physician professional groups advocating for the Older Americans Act, except I suppose a little bit on behalf of the American Geriatric Society.

Joanne: But what if all the geriatricians wrote a letter to every newspaper in the country this week, pushing the Older Americans Act? It would probably fly through.

Joanne: They're proposing, I think, a 6 or 7% increase in the Older Americans Act? It's already more than 50% behind where it was just 15 years ago? We won't be falling farther behind, but we're already so behind, that we have these huge waiting lists for home-delivered food.

Joanne: I mean, I'm a palliative care physician at heart. I work with whatever the world throws at me. I don't bother being angry that the person has a fatal disease. I work with whatever it is they've got. And I see our culture that way. We've brewed up this bad illness.

Ken: Yeah.

Joanne: Now we have to work with it.

Ken: It so happens I'm going to my geriatrics clinic right after this. I actually have the capacity in the next couple of hours to spend unlimited sums of money. I have tons of resources at my disposal.

Ken: I can order really expensive drugs and I can order scans, and I can send my patient to the hospital. I can just spend tons of money, and the VA will pay for everything I request and order.

Ken: But-

Joanne: Isn't that shocking that you can do that?

Ken: Yeah. But I can't-

Joanne: But they can't be sure that person has clothing, food, and shelter?

Ken: Well yeah, or if I see the caregiver; I'll have a teary-eyed caregiver next to the patient, and I can't tell the VA to give that caregiver one week of paid vacation, so they could take care of their loved one. Or to even have paid for time off for them to bring them to their appointment with me.

Ken: I guess I can't send them home; I can't prescribe supper, you're right. I mean, should I leave a little angrier? Channeled anger can sometimes be a good thing.

Joanne: Yeah, promise me, Ken, at the end of your session today, you'll look up the number for your congressperson and the email, or even the Twitter feed. They all have Twitter feeds now.

Joanne: You can tweet them and say, "I'm frustrated as hell. I've just spent all day taking care of very sick elderly people who do not have these things that they desperately need. Where's the leadership in Congress to do something good about this?"

Joanne: There is now a caregiver caucus in Congress. It's pretty timid so far. We have to make it safe for politicians to lead. They don't ever lead way out in front. They lead when they feel that there's a groundswell. So sure, leave a little angrier and yeah, tell me what you've done.

Joanne: Hey, write a letter in to JAGS about what you were moved to do, so that more people could pick it up and do things. It's awkward at first; it's uncomfortable. But yeah, somebody's got to do it.

Eric: Well, I guess that somebody's got to do it. Joanne, I read your article, you have thought about this a lot. You are shockingly smarter than me. You have connections, you're in D.C.

Eric: Do I really need to do anything? Because we've got Joanne on our side. And she's going to fight. And there's things like the Alzheimer's Institute that's working on this. What's little old me going to be able to do?

Joanne: It depends on a whole of little old me's. You've got to get that caregiver, that teary-eyed caregiver beside Ken's patient, got to get that person calling her congressperson. Calling her senator, talking to Governor Newsom and his plan for aging in California. California could be the model for the rest of the country with Newsom's leadership. He's been willing to stick his neck out.

Joanne: There are two Democratic candidates that have put forward a long-term care plan. They both are completely unworkable, and do not get to the right level. But at least they've said something. Klobuchar and Booker.

Joanne: It's interesting that the others haven't really come out with ... I mean, Bernie's plan says something about long-term care, but doesn't really say what it's going to cover.

Joanne: So let's push these people, and make it ... but again, you have to make it safe for them to do that. I think that we have to get a lot of caregiver groups really activated. Caregiver groups have been willing to sweep up the crumbs from the table.

Joanne: They need, as Ken was saying, they need to have paid respite. They need to have the opportunity to take some time off. And most countries give the family caregiver access to healthcare, for example.

Joanne: The 55-year-old woman who takes off time to take care of her mother and ends up spending three years unemployed, tries to come back in to the workforce and can't get a job, because now she's got hypertension and diabetes, and nobody will take her.

Joanne: We need to be protecting people from these kinds of outcomes. So we need to build the voice that ... One little you is enough.

Eric: Yeah, and I think I said that, obviously, a little facetiously. But I think it applies too when we think about our academy, AAHPM, or AGS, or whatever organization we belong to and work in is that ... conferences, the things that pop up as sessions and symposiums are the things that we individually submit.

Eric: If there's nothing on dementia, it's that most likely, people aren't submitting stuff. People aren't submitting stuff on how to do these consults in LTACs or SNFs. We'll be having an upcoming podcast on palliative care LTACs. Great article that just came out, Joanne; palliative care doesn't happen or any of those folks.

Eric: And how do we actually improve it? It takes that one person. It takes that one person to submit. It takes that one person who's interested in this to actually play a role in the academy's policy. It's made up of individuals, and we often think about it as, "this organization." But it's really an organization made up of individuals.

Eric: So another callout there for everybody listening to this is, take an active role in your organization. Whatever organization that be; if you're interested in this, they're always looking for people who want to play a role in policy, who are interested in it, and actually grow that segment of the organization.

Joanne: Yep. And we can't just hide behind research. We can't just say, "Oh, it isn't really a session unless it has a control group and a statistical test." Nothing in my editorial relied on a statistical test; it was more, "Here's where we're headed. We don't want to be there. Let's take a different route. Let's find a different outcome."

Joanne: We need to make room for some of those sorts of things. We did a little study once on the care of patients after heart failure hospitalization, and found some 30 articles on randomized control trials of care after hospitalization for heart failure. And every doggone one of them said, "More research is needed."

Joanne: I mean, when you get the 30 articles showing that people some followup, you don't need another research. You need to figure out how to get this out there and being done. We all too often hide behind this claim of research, and we ... At this point, we need direct action.

Joanne: We need a whole lot of people to call their congressperson or call their senator. Call their city council member and say, "We really need help here. We need people thinking hard on how we're going to take care of one another when we have very large numbers of very old people.

Joanne: "And if we don't do that, we are going to have campouts of 88-year-olds who don't have better than a tent. We should not deliberately end up there. We've got to end up in a better place."

Joanne: I hope that a few people out there who listen to your podcast will take it up. You'll say, "Yes, one voice counts."

Eric: That's great.

Joanne: For sure, the absence of one voice is not going to count.

Eric: Yeah.

Joanne: You've got to get this on the table.

Eric: Well, Joanne, I really do appreciate you joining us for this podcast. I encourage all of our readers to check out the JAGS article that Joanne wrote called The Fierce Urgency of Now. We will have a link to it on our GeriPal Show Notes on our blog.

Alex: And commit to one action. We should all commit now. I'm going to commit to contacting my representative ... Do you think it's better to contact the representative or the senator? Probably representative.

Joanne: Oh, do one and then you'll have such fun with it, you'll do another.

Alex: Do the other, right. Representative and senator. To raise the issue, the need for leadership on the issue of housing and food insecurity in the elderly.

Joanne: Go for it.

Alex: Yeah.

Ken: I'm going to contact my congresswoman, too. Something I think we also need to do, we need to contact our society.

Ken: It's occurred to me as we were suggesting this, Joanne, that I've been with various advocacy groups outside of medicine, where a big part of advocacy is they train you on how to talk to your congressperson and senator.

Ken: I've been in meetings in Washington where they corral like a thousand people at once to descend on Capitol Hill. The insurance companies and HMOs are all doing this. So if we're not getting ourself out there, we need to learn how to train each other to do this.

Joanne: Well, how about the three of you try that, and then write a letter to JAGS about your experience? You'll teach a whole lot of people. And put it on your blog.

Eric: Yeah, I think, Ken, that's a great point. Both AGS and AAHPM and other organizations have some tools that you could actually use around health policy, getting it out there.

Eric: I do, I know we've mentioned PCHETA. I still think it's a very important part as far as workforce in palliative care. Just like we have that for geriatrics.

Eric: Committing myself to making sure that my voice is out there also for PCHETA, but also expanding beyond just the palliative care part, but thinking about also where are we going, or our patients themselves. Food insecurity, that's another thing I'm going to be advocating for.

Ken: Thank you, Joanne, just for writing such an inspirational essay.

Joanne: Thanks for putting it out for others to hear.

Eric: And teaching me about a new song; I'm wondering, Alex, would you mind before we close up with Lynn?

Alex: Second verse. (singing).

Eric: That was wonderful. Joanne, thank you again for joining us. To all of our listeners, thank you for listening. And, one more commitment that we're going to ask of you: share this podcast with one other person, or on one social media site. We certainly would appreciate it. Thank you, everyone.

Alex: Thanks, folks. Bye.



Comments

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