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Patient Priorities Care: Podcast with Mary Tinetti



We have had some amazing guests on our Podcast.  True luminaries in geriatrics and palliative care. This week we are fortunate to be joined by none other than Mary Tinetti, MD, to talk about her recent JAMA Internal Medicine trial of Patient Priorities Care.

In this study of older adults with multiple chronic conditions, patients are guided through a process of identifying their health priorities and objectives, and this information is communicated to their primary care physicians.  The trail resulted in more medications discontinued, fewer self-managment and diagnostic tests, and less report of treatment burden.  This podcast builds on our prior podcast on this topic with Aanand Naik (awesome song choice, Lumineers' Gun Song).

We talk with Mary Tinetti about what exactly Patient Priorities Care is, how it differs from geriatrics and palliative care (or does it?), and how to disseminate this program widely (hint: start by going to their amazing website).

And...ah...Mary made me sing Joni Mitchell's Ladies of the Canyon.  My deepest apologies to fans of Joni Mitchell...

by: @AlexSmithMD

GeriPal is funded by Archstone FoundationArchstone Foundation is a private grantmaking foundation whose mission is to prepare society in meeting the needs of an aging population.




  


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TRANSCRIPT

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

Alex: This is Alex Smith.

Eric: And Alex, we have a special guest today on the line.

Alex: We have an extra special guest on the line today. We have Mary Tinetti who is a geriatrician at Yale, famous researcher, mentor to legions, a mover and shaker in the field. Thank you so much for joining us, Mary. Welcome to GeriPal Podcast.

Mary: I couldn't be happier. The only thing that's sad is that I wasn't the 100th broadcast.

Eric: You can come back for that one.

Mary: All right.

Eric: So we're going to be talking about your recent publication in JAMA Internal Medicine. The title was Association of Patient Priorities- Aligned Decision Making With Patient Outcomes and Ambulatory Healthcare Burden Among Older Adults With Multiple Chronic Conditions. That's a long title, but we're going to break that one down. But before we do, we always ask the guests, do you have a song request for Alex?

Mary: I do, and I'm so happy that Alex knows it. My very favorite artist is Joni Mitchell, and he's going to do for us Ladies of the Canyon.

Alex: Ladies of the Canyon in a very deep voice. Here we go. (singing)

Eric: Very nice.

Mary: That was great. Brought me right back to my youth. I love it.

Alex: Mary, can I ask you why you chose that song?

Mary: Well, I think she's just the best singer, songwriter. I'm an old folky and she, I think is really the spirit of that age. And I like that one because ... that's probably one of her higher octave ones that I wanted to hear Alex sing, and he did it well.

Alex: I did it more like Eddie Vedder meets Joni Mitchell.

Eric: I heard Eddie Vedder there. So we're going to be talking about your JAMA Internal Medicine article. You've had such an amazing career ranging from a lot of different topics, really well known for things like, falls and balance and gait assessment. How did you get interested in this particular subject about identifying and asking about patient priorities?

Mary: Yeah, thanks for the great question. So my first, as you said, my early work was on falls and balance and I absolutely loved it and I felt I'd taken that topic as far as it could be taken. It was time for other people who had other skillsets to get it more broadly disseminated into practice. And so I was ready to move on to something else probably about 10 years ago now. And just like my work with falls that came out of my seeing patients every single day, you as a geriatrician know as well as I do, you look at somebody's electronic health record and you see a problem list of 10, 15, 20, you see a medication list of that, and just what are we doing here? I just kept saying is, just like everybody who takes care of these older adults, what are we going to do about this? Everybody recognized the problem and I just felt, let's try to tackle it and see what happens.

Eric: Hmm. Terrific. How did you come to formulate, or how did you and your team come to formulate this notion of patient priorities care, and what is it?

Mary: Yeah, so that's another good question. In terms of how we got there, is I was learning from other people who were doing research at the time and trying to take it away from the very constrained randomized trial where the, quotes, 'expert investigators and clinicians' decide what to test and how to test it. It was this new world of implementation science that was happening in the real world. One of the things that you hear over and over again, you have to get all the stakeholders, and it's a term I hate, I hate the word stakeholder, but I can't come up with a better term. So if you got a better one, guys, I'd love to hear it.

Mary: But we needed to hear what was important to patients, to their caregivers, to the primary clinicians, to the specialty clinicians, payers, everybody who were either taking care of people with chronic conditions or had chronic conditions, what did they identify as the problem?

Mary: And so we got people together all over the country by webinars and in person, started in Dallas. Everything starts in Dallas, right? And over a year or so, they came up with three things that really were the issues that they felt we needed to grapple if we were going to get better care for older adults with multiple conditions. And one of them is we're focused on diseases and not on patient outcomes. And if you've got multiple diseases, how do you decide, in fact, I actually, believe it or not, did this in one of my studies. Would you rather not have a hip fracture or would you rather not have a stroke? Stupid question. So when you've got multiple diseases, disease outcomes don't work.

Mary: The second problem is that nobody was asking people what mattered most to them. And the more diseases you have and the more life you have, the more variable you are on what matters most to you. The third thing was nobody is in charge. Everybody does their own little piece of the elephant. The cardiologist does this, the endocrinologist does that. A social worker does that. We couldn't take on the last ones, we took on the first two, trying to focus on patient outcomes rather than disease outcomes and find out what mattered in the face of tradeoffs and that's what led to Patient Priorities Care.

Eric: What's the nuts and bolts of Patient Priorities Care? And I wonder if you could distinguish it from just thinking in my mind, within geriatrics for example, attempts to geriatricize primary care docs within palliative care, they talk about primary palliative care and training, primary care docs and expert communication and goals of care discussions. How does Patient Priorities Care fit in with those movements?

Mary: Yeah. First of all, I really don't feel like it's a movement. Second of all, I hate the name Patient Priorities Care, but we couldn't come up with anything better. And just like everybody does in 2019, we had a branding firm and that's what got voted on. So it was the least offensive. So we don't think it's a model. It's not a structure. It really is the content of decision making and communication between patients and their clinicians. It works in palliative care, it works in geriatric care, it works in specialty care, it works everywhere. It's just a way to make the decisions when you're faced with multiple different tradeoffs and multiple things that you can do and people vary in what matters.

Mary: Ad in many ways as a geriatrician, Alex, as you know, is I think a lot of this is really taking the black box out of what we do as geriatricians. How do we make decisions with people who have multiple things happening simultaneously? And we try to give words to it. We try to provide steps both for the patient part of the equation and for the clinician part of the equation. And I will tell you, we borrowed shamelessly from palliative care in terms of the communication part of it, but I think that's okay because I think palliative care has borrowed shamelessly from geriatrics in getting started, so trying to even the playing field.

Eric: If I had to visualize, can you tell me like a story of what actually is Patient Priorities Care?

Mary: Sure.

Eric: Is it just the goals of care discussion? Tell me about what's important to you.

Mary: It's really more than that. Because again, well, you could call it goals of care. I never know what goals of care is because it's one of those terms that, yeah, if you have a little bubble, everybody says the same thing, but in their brain there's 20 different things that flash up in their brain when they use that term. So we try to avoid that term for that reason. So it basically starts, okay, if you want to make the decision based on people's priorities, the first thing you need to know is what are those priorities? And you need to know them in a way that's systematic and reliable and actionable that it can inform decision making.

Mary: So the first step is identify people's priorities, and those are really two parts to it. One is the outcomes they want from their healthcare. They don't want their blood pressure under control because they like the number 120 better than they'd like the number 210. They want their blood pressure under control because they don't want to have a stroke so that they can continue to go bowling or babysit or whatever they do. So what's the outcomes they want from their healthcare? But the-

Eric: Yeah. It's sounds really important too. It sounds like you have to push it. The outcome isn't, I don't want to have a stroke. The outcome that's meaningful, I don't want a stroke because I want to continue bowling. I want to be mentally aware so I can participate with my family, do crossword puzzles, go shopping, be independent, all those other outcomes. Is that right? Like you actually have to drill down a little bit.

Mary: You do have to drill down. And that's exactly right because otherwise they're going to say what comes out of the top of their head and it's going to change from day to day. So you have to drill down. And that's the other reason is because, well, maybe it's the stroke that is not the thing that's going to keep them from doing what they want most. So when you got a lot of things going on, you've got to drill down so it's specific enough and reliable enough. Exactly right. And you do that by starting with their values, which are value based, people tell us. Those are the core values that people have throughout their life, their goals, the way they live. Those values may change, but the values stay constant. And that's where we start the drilling.

Eric: And how do you ask about values?

Mary: It looks like it comes under four areas. Aanand Naik, I know has done your podcast in the past and his group went along with Lilian Dindo at Baylor, were the ones that really took the lead on this. I learned a tremendous amount from them. Most values come under four simple categories. It's functioning and autonomy. It's relationships and community. Number two, it's managing your health. And number three, it's meaningful things in your life, productivity. And basically if you start with those four areas, you give people examples and we trained people to do this, to give people prompts to come up with three key values that they really think define their values.

Mary: I was quite skeptical and we've now done it in several hundred people and it works. The whole process to get to the actionable goals and preferences takes about 20 minutes. It's really doable.

Eric: That's terrific. So who does this? In your study that we're going to discuss today, you had trained facilitators. Is that the broader vision of having facilitators or is it to train primary care clinicians to do this eventually? Or what's the ideal vision of how this is disseminated?

Mary: The ideal vision is whoever the hell wants to do it and can do it and has the time to do it. That's the only way you're going to get anything through the tough clinical workflow we have. In our particular study, right, we had an advanced practice nurse and a care manager who worked for the primary care group where we did our pilot who were trained to do this. Basically anybody who has some interviewing skills, particularly motivational interviewing skills and are willing to go through the training are able to do it. Patients, interestingly enough, when we first talked to them about this, they said, "Well, doctors probably weren't the best people to do this."

Eric: Interesting.

Mary: And rather than being offended by that, although I completely agreed with them, they said it was probably just because doctors were too busy to do it. I think they had other reasons as well, but that was part of the reasons. But in truth, anybody can do this. The medical assistants can do it, social worker, nurses, physicians can do it. We are all also now developing a way, in fact, that's what I was working on when you called me a few minutes ago, making this self-directed so patients and caregivers can already do this. And I'll tell you, I'm shamelessly borrowing from the way Prepare for Their Care has set up their website. So I shout out to Rebecca Sudore on that.

Eric: And to our listeners, if you want to listen to more about Prepare for Your Care, we've had two podcasts with Rebecca and we have Aanand, we'll have another podcast with him. We'll link that to our show notes. So you can just go to the GeriPal website.

Alex: Terrific. I want to move into talking about this trial now.

Mary: Well, Alex, that's only half the equation. Can I just very briefly tell you the other half of the equation?

Alex: Please. Yeah.

Mary: Because this is sometimes what it's a little bit different than a lot of the other communication skills, which is sort of one directed. It's directed at patients either talking to the clinicians or clinicians talking to patients. We really feel we needed to get at both sides of the equation. So we also have a way to get people to identify what parts of their current care they think is working and doable and what part they think is just too hard for them and they really don't think is helpful, they'd like to get rid of. But we also have prepared clinicians to take this information and develop strategies. A few simple strategies for translating what is their current way they approach decision making, which is based on disease is to translate that into decisions based on patient's priorities.

Mary: So if we have time, I can tell you what those strategies are, but I just want to make sure both of those is patient priorities care.

Eric: I think we should talk about that because that's such a critical step. I mean, so many clinicians have been told, you know what you needed to do, goal aligned treatment. And they're like, "Okay," they ask about some goals and then they're like, "I don't know what to do with that. I've not been trained. I went to medical school, we talked about how to treat diseases, not how to treat goals. So it'd be really interesting to hear some examples of how these strategies play out.

Mary: Sure. And to be perfectly honest, I didn't have a clue either. That's why I had to get a lot more smart people around the table to help us figure this out. We always talk about this project as sort of flying the plane as we're building it. We never know what the next step is going to be. So what we did, using the actual patients that are part of the trial, we'll talk about it in a minute. We got the primary care clinicians and the cardiologists because those were two groups we worked with.

Mary: We got them on the phone with Daisy Smith who is a general internist, the vice president of clinical activities in clinical training at American College of Physicians. And Lillan Dindo who is a behavioral expert who works with Aanand Naik at Baylor, got them on the phone as coaches to have us actually work through actual, patients were part of this, and through that we recorded these, they listened to them, and I will tell you, it was unbelievable. It was just organically, the whole group together was figuring out what they were going to do once they were faced with people's goals and preferences and knowing their health conditions. And from that, we came up with a few strategies.

Mary: I'll tell you very briefly what those are. It's number one, and again, this is not rocket science. Number one, start with one thing. Start with the thing that patients care most about. Die. If you've got a thousand things and you don't know a right answer, why not start with what matters most to them. This became what we call a specific ask. And I can tell you more about that. The second thing is serial trials. It's what we do anyways, right? If we don't know what the hell we're doing, let's try A, let's try B. But we turned that around from being a limitation to being a strength particularly when we had to let people know there was a lot of uncertainty.

Mary: So we're going to start with this because it's what matters most to you. But if this doesn't work, don't worry, then we could go on to this and we can go on to that. Set it up right from the beginning of serial trials. Third is always use their own outcomes and preferences, their own priorities rather than their diseases in decision making and communication both with the patients and other clinicians. This worked particularly well between the primary providers and the clinicians because it got them all on the same page. So they were thinking about the same thing.

Mary: The final thing was, and this came right from the pain world, is don't try to get rid of all their symptoms. It's impossible much of the time when there's a lot of things going on, focus on the activity that this symptom is keeping them from doing. Use that in your communication and use that in seeing if whatever is working is working.

Eric: That's wonderful. I love that last thing about not focusing on the number on their pain scale, but what does that mean as far as their function. I'm also wondering if we can maybe just make a case out of it. Let's say I'm a 72 year old with COPD, CHF, some moderate AS, AFib.

Alex: We'll give you mild cognitive impairment.

Eric: So mild cognitive impairment. What matters to me is be with my family, my grandchildren, being able to garden still outside, and I just hate checking my weights everyday. They tell me to do that, I never do it. And I would love coming to the doctor, but I really want more time to be with my grandchildren, see how they do over the course of the next couple of years. What else do you want to know about me, Mary?

Mary: So you say it's important for you to be with your family, with your grandchildren. Tell me what you do, Eric, that honors that value of you. What makes you feel like I've really been with my grandchildren? What are the activities that you want to do?

Eric: Yeah. I go over there on the weekends. I help parents out. We play games together, those types of things, yeah, it's nothing specific. It's just being with them and sharing their lives.

Mary: Okay. So being with them, getting to their place and being with them and play. Let's talk about playing games with them because that's what grandkids love to do. I'm hoping someday to be able to do that. So we would talk about that and we would get it to being specific enough. People with a lot more talent at this than I will get you to get very specific in the activities, how often you do it.

Eric: Great.

Mary: Then we'll talk about, okay, what's keeping you from doing that right now? What is the thing that's keeping you from doing that?

Eric: Okay. Let's say, I get a little bit short of breath. I love taking my grandkids to baseball games, but it's getting a little bit harder to drive around. And when I'm walking I just can't walk as far. So I have to stop a lot and I worry that they don't want grandpa around as much because I'm slowing them down.

Mary: Okay. So then we would work either if there was something about your health, whether it's changing your inhalers or doing pulmonary rehabilitation that would help you so that you could do that particular activity better and keep up with the grandkids. Or they would say depending upon what your health trajectory is and that it is possible to talk about other activities that you could share with your grandkids that they would still love to spend time with you, at least till adolescence because then they never want to spend time with anybody. But up until that time, so it would either be changing your healthcare to get rid of that impediment or change the activity to match up with what you're able to do.

Eric: And are these discussions being documented in the EHR? Because I imagine that this is really important stuff for future decision making knowing how people currently make decisions, and does it link it all to advanced care planning?

Mary: Let me answer that last question first. I think it links directly to advanced care planning. Caroline Blaum, my partner in crime, a geriatrician at NYU who I'm sure many of you know very well, came up with the term current care planning. It's great to talk about what you want five years from now or even five minutes from now. But let's talk about what you want right now. If you start doing it now, then there will never be such a thing as advanced care planning because you're going to get it into your head right from the very beginning that you always talk about what your goals are now and how are you going to live out those goals and how your healthcare is going to help you. So it definitely aligns with advanced care planning and compliments it very well.

Mary: In terms of how we documented it, the bane of everybody's existence is electronic health records. The only thing worse than having to use the electronic health records is not having it to be able to track what's going on. So we came up again, with the input from the clinicians who are part of our work and with the patients. What is the core? What is absolutely necessary information to really align care with people's outcome goals given the care they're willing and able to do and what can we jettison? And it could never be more than one page. So we have a one page template that includes a very crude definition of their current functioning and support, what their perception of their health trajectory, how they think things are going to go over the next couple of years.

Mary: Because clinicians told us that people having unrealistic trajectory, idea of their trajectory made it difficult in decision making. Then they come up with, I mentioned those values, they articulate two or three values that matter most to them. And from that they have up to three SMART goals, specific, measurable, actionable, realistic, achievable goals. Three parts of their healthcare they think are helpful and doable. Three parts of their healthcare that they think are just too hard or not helpful. And then ends up with this thing, the specific ask, that brings it all together. And that is the one health symptom where probably they think is most getting in the way of doing the activity that they think is most important. And this is the particular health problem they think is causing it that they'd like you to address.

Mary: One page in the EHR we worked with, we had to do a work around, because we couldn't directly enter their EHR. Eventually the goal is it could be adapted to every EHR. And so it lives someplace in the EHR. Hopefully it will replace that advanced care planning tab with current care planning tab.

Eric: So you do a trial on this. You're looking at whether or not there's patient priorities... I'm blanking on the name-

Alex: Care.

Eric: Patients Priorities Care, PPC, identifying health priorities, like specific healthcare goals, healthcare preferences, and then aligning decision making to achieve those priorities. Was that better than usual care?

Mary: Yeah, so thanks for that. So we did this in, I said a primary care practice, along with the cardiology group that worked with them in here in Connecticut. And this was a very large practice. And so there was an office that we trained with patient priority decision making and an office that remained usual care and-

Eric: And how long was the training again?

Mary: The training takes four... Well, there's the training for their facilitators that takes about an hour or two to begin with and then some feedback sessions afterwards. For the clinicians, it was a couple of hours of face to face and then we did phone calls that were about 20 minutes for a few months afterwards. So we're still-

Eric: Pretty short training.

Mary: Well, they all thought it was too much, of course. And there's only so many bagels that you can bring to them. But we are definitely trying to get this as succinct as possible. That doesn't get you proficient, but I think it gets you started to doing it.

Eric: And can you take this training online? Are the materials free? Could any clinician out there who's listening, for example, go to a website and be trained themselves?

Mary: Well, I didn't even feed you that question, but thank you for asking it. You can get it in one of two ways. We did this along with the online curriculum for both identifying the priorities and doing priorities line decision making for clinicians. You can get it through the American College of Physicians website. It's one of the product that is free of charge. You can get CME credit or MOC credit, whichever you desire. You can also go to our website, patientprioritiescare.org and you could access it through that as well.

Eric: Terrific. And we'll put the links for that in the blog post associated with this podcast.

Alex: By the way, I still don't know, did it work? Should I even do it?

Mary: Well you keep interrupting me, so let me tell you [laughter]. No, you promised me you wouldn't be interrupting, and thank you for doing that. So the simple answer is yes, we think it worked. And obviously one study, all the limitations all of us nerdy researchers do to our work. But the bottom line is yes, it worked. People that got patient priorities care, they perceived greater decrease in their perception of the burden of their treatment compared to those who got usual care. And they have less what's called unwanted care. When we started doing this, both clinicians and patients were worried, well, wait a second, this is just rationing, you're going to keep stuff from us. So we really wanted to make sure any care that didn't happen was perceived as unwanted.

Mary: And I can tell you how we define that if you'd like, but more medications were stopped and the people got patient priorities care, particularly cardiovascular medications. They got fewer self-management tasks piled on because we're asking people to do more and more, weigh themselves, do this diet, do this exercise, check your feet five times a day, do dah, dah, dah, dah. So less of that. And also had to go to get fewer lab tests and diagnostic tests such as x-rays.

Eric: That's terrific.

Mary: Didn't see much change in whether or not they thought their care was more goal oriented. But I'm not sure they necessarily understood that concept.

Eric: This is tremendously exciting. That first primary outcome that you mentioned, feeling like they're total, let me see, it's treatment burden. The treatment burden questionnaire score improved for those in the Patient Priorities Care group compared to the usual care group. What are the components of that score? What does that mean and what's it evaluating?

Mary: Yeah. Thank you for that. So this was developed by Victor Montori's group. He is an endocrinologist who has been very interested in the burdens of care for a very long time with some of his UK colleagues. He's at Mayo. So it includes this kind of things that you think about that we ask people to do. It talks about whether their medications are giving them adverse effects or costing too much or too hard to remember to take, or there's just too many of them. It's, do they spend too much of their time going to health visits including the transportation and the time involved with all their health visits? Are they being asked to do too many things in terms those self-management tasks I mentioned, getting weighed, etc, etc?

Mary: So it reflects the actual activities that we ask people to do to take care of their chronic conditions. And it asks them, on a scale, I believe it's from one to 10, but I could be wrong, how burdensome they felt it. So it's not just what we ask them to do, it's how much burden they felt it caused them.

Eric: That's terrific. And we should mention that Victor Montori and a colleague wrote a terrific invited commentary that is also in JAMA Internal Medicine.

Eric: All right, Mary, I've got a question. So let's say, I'm going to take this out of the medical sphere for a second. Let's say I go to my dentist. She does patient priorities care.

Eric: I say, I hate flossing, and she says, "Oh, don't floss that. Knock yourself out." Is this what we're seeing here? We're seeing less meds, less burdensome care, but maybe it's like those things that may give them, going back 10 years instead of measuring what's important to people, like measuring survival.

Alex: Flossing is not keeping you alive.

Eric: Flossing is killing my teeth, man. May not be a priority now, but when I got no teeth... [laughter]

Mary: So great, there's about 10 different concepts in there. So let me disimpact it a little bit, which is-

Eric: You're going to tell me to floss just like my dentist.

Mary: No. I'm not going to tell you to floss. This is all about trade offs, right? We all want to live to 100 and not have to do anything to get there. I always say my major goal is I really want to be able to run a marathon, but I don't want to exercise. And so it's all about the trade-off. So that's why we ask them about the outcomes and the care that they're willing and able to do and not willing and able to do. Because that's what sets up the dialogue between the clinicians and the patients. Right? Well, I see here that it's really a priority for you to be able to keep your teeth as you age, Eric. And I also see that you don't want to floss, none of us like to floss.

Mary: My question to you is, which is more important to you, to keep your teeth or to not floss?

Eric: So it's almost like a little motivational interviewing.

Eric: It's trying to get me to say and think, oh yeah, this is something that's important to me and this is something, instead of having like the hygienist repeat the same thing over to me, "You need to floss."

Mary: Exactly. And it ties into what matters to them. What happens a lot with CPAP, I don't know if your listeners understand it. Those horrible masks if you have sleep apnea, people hate them. But if you just ask them, "Wear your CPAP because it's going to give you a high blood pressure if you don't." I'm tied into the activity they want and it actually happened. One of the persons, he was too tired in the afternoon to walk his dog. So we said, "Well, would you try the mask for a week to see if you're able to walk your dog?" That's the kind of thing. So yeah, it's not saying, "Okay, you don't want to do this, don't do it." It's saying, "Given this trade-off, what matters most to you?"

Mary: But you also do find stuff that we're asking people to do that once you hear it's too difficult for them and it doesn't really help them do what they want, then you say, well, maybe you don't really need to do that. So it works for clinicians and patients to think differently.

Alex: Right. And it's important to say, as you just noted, that this isn't all about taking people off of things, off of medication, stopping them weighing themselves, checking their feet, etc. It's also about, at its core, it's aligning the treatments they receive with their priorities. And sometimes that means they do more like go on the CPAP so you can meet your goal of walking your dog and sometimes it means you do less. Well, that isn't helping you meet your priority. So maybe we will stop the checking of the feet, etc. It's just on average, your study shows that it resulted in fewer tests, fewer self-management tasks, and fewer medications.

Mary: Correct. Nicely said.

Alex: And I wonder, you said earlier, I heard you refer to this study as a pilot, was that correct?

Mary: Right. This was our first venture. Again, it is we were building out the components of it, building out the workflow of it as we were doing it. So this was just trying to figure it out and we need to try it out in other places with other people.

Alex: So what's the next step here? Are you going to try a larger multi-site study? Are there lessons learned from this that you're going to tweak as you go forward?

Mary: Well, I'm going to do a GoFundMe page and anybody who wants to contribute to it to help our dissemination efforts would be well appreciated. We're going about this in several different ways, Alex. The first thing that we are doing... And this was really wonderful. I like the idea of passive dissemination because I don't want to have to do a lot of the heavy lifting to be perfectly honest with you. So what happened was when we started talking about it, people came to us and said, "Well, maybe we would like to try it." And that was fatal on their part because if they even showed any sort of interest, we just globed right onto them. And so we were lucky enough, Crystal Wiley Cene is a general internist at University of North Carolina, primary care provider who works with the rural clinics affiliated with University of North Carolina.

Mary: She was interested in doing something patient priorities care. And after talking with her back and forth, so we said, "Why don't you just try this?" So she has gotten funded from the National Institute on Aging to do a replication of this in the rural clinics in North Carolina with a very much more diverse and socioeconomically challenged population than we were able to do. We've just started working on that. So I'm really, really excited about that. We've taken little pieces of doing this in little bites. The emergency medicine people are interested in the specific ask piece of it. What's the outcome you really want from this visit? What are your fears and hopes and just to focus the ED visit.

Mary: Also, working with some chronic pain people to see if it works for people with chronic pain to get them off of opioids. So we're doing in multiple different ways.

Eric: That's wonderful. That's terrific. What I love about this is this is quality care that every person would want, right? The care that is aligned with your priorities. So it's the right thing to do. That said, it will not-

Mary: I knew there was a but coming there.

Eric: You knew there was a but. Right. That said, in order to really disseminate it, health systems, primary care practices, emergency practices, etc, will be most interested in it if it somehow aligns with decreasing costs, aligning with value propositions, shifting landscape of healthcare and health law and bundled payments, etc. Do you have some efforts going forward? I mean, at face value you'd think that with fewer medications and lab tests, this is likely cost savings, but are there demonstrations to actually tabulate up the cost of the intervention and the potential savings?

Mary: Yeah. So I think your point there is extremely well taken. What needs to be done is pretty straight forward, and who's against it? Right? When I did fall prevention, we used to wear these little badges with somebody falling down the stairs and that little X, like don't do it. And somebody said, "Well, who is for old people falling?" Right? This is the right thing to do, but how do you get them to do it? So there's a couple of things we're doing in that direction. We're waiting for funding from a foundation to work with the primary care people at Cleveland Clinic to actually do a cost effectiveness value-based study of the value of this work. And we'll hear about that soon. So that's one direction we're going in.

Mary: But we also realize there're so many different incentives and disincentives to do anything. So we're trying to build the business case, if you will. And it depends upon your payment model. If you're in an integrated, capitated or risk sharing environment, then decreasing a little bit of utilization is going to be good for you because the cost of actually doing this is not very much. If you are in a fee for service world, then what's the incentives for doing this? And there's still incentives because if you've got an office that's filled with people who don't necessarily need to be seen there, you don't have openings for people who probably have a better insurance than Medicare patients simply put. And using some of the current CMS codes can help be a revenue generator.

Mary: So we're doing all of those types of things. And we're trying to get this as simple as possible too so that more health systems are willing to do it. You just have to develop new skills and these are skills that none of us that started doing this work have, and we're learning them as we go. Anybody on the call who are listening to this has any interest in working with us on it, let me know.

Eric: And I can imagine also, this is my last question. I can imagine there're some disincentives to do this if a lot of quality measures around what percentage of your patients have you done something to, like what percent are taking beta blockers for X? Or are in blood pressures meeting goals? Or on specific medications for heart failure? I can imagine if we're aligning with patient's goals, what's important to them, their values, that you actually sometimes may do worse on some of those measures.

Mary: Yeah, that's a great question and that gets raised by a lot of the people we've talked to about this. A couple of answers to that questions. Number one, chances are pretty darn good that this approach to decision making will improve those metrics because right now there's a lot of non adherence because we're asking people to do stuff they just can't do. If you really get it aligned with what they're willing to do, I think their blood pressure and a lot of these other things are actually going to be better. And we plan to look at that, haven't done that yet.

Mary: Number two is we're working to get, as you know, a lot of this population is no longer in those metrics. After the age of 75, the blood pressure metrics are no longer there. The hemoglobin metrics are not. The problem is health systems don't want to have different set of metrics for different patient populations. That's the problem. And there's a lot of people working towards developing patient-focused metrics and we're hoping that those will be coming down the pike soon and be an incentive for this. But yes, right now there is at least a perceived disincentives of disease metrics for this work, which I don't think is really accurate.

Eric: Well, Mary, I want to thank you for joining us today. I learned a ton. Can you repeat the website again?

Mary: I thought you were going to ask me to repeat the name of the name of the work.

Eric: I think I have it down now. Patient priorities care, PPC.

Mary: I've got people to forget the term and do the approach. It's patientprioritiescare.org

Alex: Great. Thank you so much, Mary.

Eric: Great, patientprioritiescare.org. Mary, thank you very much. Before we leave, Alex, can you give us a little bit more?

Alex: A little bit more Ladies of the Canyon. (singing)

Eric: And with that, Mary, a very big thank you for joining us on this GeriPal Podcast.

Alex: Thank you Mary.

Eric: And thank you to all our listeners for joining us as well. We really love word of mouth. So if you can spread the good news about the GeriPal Podcast amongst your colleagues on social media or review us on your favorite podcasting app today, that would be absolutely wonderful.

Alex: See you next week. Thank you.



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