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Health Care of Older Persons - Time to Think Different: A Podcast with David Reuben



On this week's podcast we have the honor of talking with David Reuben about health care for older adults and how it's time to think different.   It really is a smörgåsbord of topics, ranging from how to think about population health for older adults (and how we as individuals providers can provide at least some level of population health), the UCLA Alzheimer's and Dementia Care Program and its outcomes, Medicare Advantage for All, working with community partners through voucher systems, and tips for leading change.

Dr. Reuben is Director of the Multicampus Program in Geriatrics Medicine and Gerontology and Chief of the Division of Geriatrics at the University of California, Los Angeles (UCLA). He is also the Archstone Foundation Chair and Director of the UCLA Claude D. Pepper Older Americans Independence Center and the UCLA Alzheimer's and Dementia Care program.

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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 very exciting guest with us today.

Alex: We have an exciting guest today. We have Dr. David Reuben who is Archstone Professor of Geriatrics at the David Geffen School of Medicine at UCLA. Welcome to the GeriPal podcast David.

David: I'm delighted to be here. Thank you.

Eric: And we're going to be talking about kind of a big subject looking at population-based health for older adults. We actually have a title for this one, too, right?

Alex: Health Care of Older Persons: Time To Think Differently.

Alex: Time to think different.

Alex: Different is different from differently apparently. We're going to get into that distinction, critical distinction.

Eric: Before we do, do you have a song request for Alex, David?

David: I do. Here, There and Everywhere. It was a great song growing up as a child of the '60s and one of the best Beatles songs ever.

Eric: Great.

Alex: (Singing.)

Eric: Wonderful.

Alex: Someone is speaking, but she doesn't know he's there.

Eric: A little bit of a topic of cognitive impairment, which we will be talking about.

Alex: Cognitive impairment.

Eric: But Alex, do you want to try that title again?

Alex: I'll try it again.

Eric: What happened at the end? What's the difference?

Alex: Health care of older persons, time to think different, which is not the same as differently apparently.

Eric: Why is that?

David: So thinking differently is how you are thinking. Thinking different is what you see. So seeing a different future. The thinking differently is you might think about thinking optimistically or you might be thinking about something pessimistically. Those are thinking differently. Thinking about something that is different.

Eric: Okay. I think I get it.

David: If you get it, you can work for Apple.

Eric: I've got to use words like synergy and ...

Alex: Disruptive.

Eric: Disruptive. So tell us what is different? What kind of different thinking are you talking about here?

David: So when we think about caring for older people, each one of us has a vision of what an older person looks like. And most of us in healthcare, when we think about an older person, we think about frail older people. We think about people who may be quite impaired, either physically or cognitively. But in fact, the health care of older people is much broader than that. It turns out that a common vehicle for conceptualizing this is using a pyramid and the pyramid is by percentiles and it can be anything. It can be cost or utilization or disease severity or disability. But you'll have the top 1%, the 2-5%, the 6-20%, the 21-60% and the 61-100%. That's typically how they do it.

David: But you realize that the vast majority of these people, the 21-100%, are people who aren't impaired. So the people who are the most impaired are the ones who come to mind most easily, but they represent the minority. So when you think about caring for older people, you have to have this broader vision because the needs of the vast majority are not going to be the same as the top 1% or the top 5%, for example.

Alex: And when we're thinking about, let's say healthcare systems and populations, how should that change how we're thinking? Because from a healthcare system, the ones that we interact most with are those people higher up on that pyramid.

David: Correct. And if you have a health system that's a population-based health system and certainly the managed care population Medicare Advantages are, but more with the ACOs and other kinds of new payment mechanisms, as a health system, you're responsible for people so you have to have programs that meet the needs of the healthiest people and the sickest people. And the ultimate goal is to prevent the healthiest people from becoming the sickest people. They talk about something called rising risk and it's not really rising risk, but it is the risk of potential moving to one of the more severe categories.

Alex: Because our audience is comprised of primarily clinicians, geriatricians, palliative care clinicians, I wonder. Louise Aronson made a provocative argument in her recent book Elderhood that geriatrics has too long focused on the most frail, the oldest old, those with multiple comorbidities, serious illness and that we need to broaden the scope of what geriatrics is to include the healthy older adults, that we should be the pediatrics of older age.

Alex: And I know you're talking about health of populations, not necessarily the specific discipline or field of geriatrics, but I wonder what your reactions are to those sort of competing perceptions of what geriatrics is as a thought leader in the field.

Eric: Yeah, versus something like Mary Tinetti, where geriatricians are an elite workforce that should be focused on particular areas. Where do you fall with that?

David: Well it's actually a very good debate to have, but the reality of the situation is that there will never be enough geriatricians to care for that entire range and for the healthier older people. The field just isn't recruiting quickly enough. Roughly a couple hundred people a year go into geriatrics fellowships. So from an efficiency standpoint, it is much more efficient to focus on the frailer people for geriatricians. On the other hand, I think one of the things that geriatrics can do is it can design healthcare for the people who aren't as frail, that the vast majority who receive their care through general family internists and specialists.

Eric: Yeah. I think we hear similar arguments, too, in palliative care. There's never going to be enough palliative care specialists, so really thinking about both primary palliative care and also, this tertiary specialty palliative care and finding the right mix between the two. Can I ask another more naïve question?

David: Yes.

Eric: The title includes population, population health. What is population health? When I think about people talking about these terms, I have an idea, but I've never actually thought what's included under that?

David: It's like Goldilocks and The Three Bears. You want to make sure that everybody's getting the right care for their needs. And anything more than that would be excessive and wasteful and anything less than that would be omission. So if you are a health system and whether it be a managed care health system or whether it be an ACO health system or a population, just a general fee-for-service population, you want to be able to design interventions for people at all levels. So I'll give you an example.

David: One of the things we're working on at UCLA is population-based approach to dementia. So that top tier, that top 1%, these are people who are frequent fliers. They're often in nursing homes and they aspirate or they have urosepsis and come back in and out of the hospital. And one of the things that these folks should have are discussions with palliative care. They should have discussions about the quality of life versus the quantity of life. There is a population of people who have severe dementia and have some behavioral symptoms and they might benefit from psychiatry involvement or things such as UCLA Dementia Care Program. And then there are people who have less severe dementia who might benefit from less intensive programs such as the Care Ecosystem or an enhanced information referral system.

David: So that what we're trying to do at UCLA and we're well underway is actually to use machine learning and algorithms and our electronic health record to prompt physicians to refer appropriately based on things such as utilization, things such as medications, things such as clinical conditions to the appropriate type of services.

Alex: So it sounds like there's multiple components. A is having some types of tools that helps alert people that there are these potential resources. It also sounds like having these resources is another thing that's incredibly important. You've done a lot of work around this, too, including the development of, what's it called? The Dementia Care Program? Is that right?

David: Yeah. UCLA Alzheimer and Dementia Care Program. So this is something we started seven or eight years ago now and we were very fortunate to hit the lottery. We got one of the first CMMI Innovation Challenge awards, which allowed us to bring it up to 1000 people in the program and now we've cared for over 2800 people. But this is a very interesting program because it's aimed at helping primary care providers, particularly general internists and geriatricians to some extent to help them manage dementia with high quality. And the way it works, it's a co-management program so that dementia care specialists who are nurse practitioners manage all of the dementia aspects of the care in collaboration with the PCP and the PCP manages everything else.

David: So what really it's contingent upon is a good relationship between the PCP and the dementia care specialist, so there's a lot of communication, nothing gets done without the approval of the primary care provider and it works very well. The patients love it. It achieves a lot of good outcomes. The quality of care is very high. The patients have fewer behavioral symptoms and less depression. Their caregivers have less strain, depression and distress from behavioral symptoms and it saves Medicare money.

Eric: Yeah and you recently, I think last year you had a paper in JAMA Internal Medicine with Lee Jennings, who used to be Chief Resident here at UCSF.

Alex: She got away.

David: She left us, too.

Eric: I heard. And it also showed decreased nursing home use. Is that right?

David: It did. It decreased nursing home use by about 40%.

Alex: That's a huge deal, given the cost of nursing homes. Were you going to stay with that point?

Eric: I was just going to ask. I just want to know, where would you put this program in that pyramid? It seems to me like it's maybe upper-middle pyramid, not top, not bottom.

David: Yeah. So it's really for the top 20% and really, if you had to thread the needle, I would say it's probably at that 5-20% who it's most suited for. The people who are in that very top 1% are people who the best use is to try to reduce admissions by helping clarify goals of care and to try to prevent rehospitalization by things such as reducing aspiration risk and reducing recurrent urinary tract infections and reducing psych hospitalizations.

Eric: There's a lot that we did. We had a podcast about Care Ecosystem, which Alex mentioned a little bit earlier and you mentioned it, programs that are really focused on this particular population of individuals. How would you think about the differences between those two programs for the listeners who were listening to both podcasts?

David: The Care Ecosystems is a great intervention. It is staffed by care navigators who are not professional in terms of certification or receiving health training, whereas the UCLA Alzheimer's and Dementia Care Program, these are nurse practitioners. And these nurse practitioners have superb skills. They have good clinical skills. They have good communication skills. And they're also able to do the care coordination. Plus, they can hold their own with the docs. So I think the models are very different. My own sense is that for many people, a system like Care Ecosystem with care navigators is enough and it's really a good intervention. But I think that people who are more severe and need higher levels of clinician care would do better with the Alzheimer's and Dementia Care Program.

Alex: So that's what you mentioned before that the Care Ecosystem ... So if the UCLA Alzheimer and Dementia Care Program is targeted at that 5-20%, then the Care Ecosystem might be somewhat on the healthier spectrum.

David: Exactly. And so we haven't replicated the Care Ecosystem, but we have done something somewhat similar with a ... turns out she's a Master's level person who does information and referral system. It's not quite as intense as the Care Ecosystem, but it's certainly nowhere near as intense as the UCLA Alzheimer's and Dementia Care Program.

Alex: What is going to lead to ... oh, I'm interested to hear about next steps. CMMI is over. Is that right?

David: CMMI has been over for several years, yeah.

Alex: So what's happened? What's the continuation? What's the sustainability dissemination? How is it working when the funding goes away?

David: We were initially very fortunate to get some philanthropy to keep the program going for a bit. The institution has picked up a good bit of the cost at this point. We've done a lot to maximize revenues in terms of billing. But perhaps the most important thing is that we are working as this Care Ecosystem to try to get Medicare to cover these kind of services, probably through some of the alternative payment models that are emerging and will be implemented. We believe that people who have dementia and their caregivers are paying enough in terms of their personal costs and that these kind of healthcare costs should be covered.

Eric: We have said this many times in this podcast, but it bears repeating. If this intervention were a drug, then some pharmaceutical company would have taken it to market and made billions of dollars on it. What can we do to change the system to incentivize these nonpharmacologic interventions?

David: We actually did a calculation. It's not quite accurate anymore because a couple of the drugs have gone generic, but when we first started, the drugs weren't generic and the per-day costs of this program compared to the drugs was about a third of the cost. So Medicare covers the drugs, but they weren't covering the program. So I think that Medicare is a prudent buyer and I think you have to say that you're not just providing care that doesn't meet the triple aim. So I think that our experience with Medicare is they're very reasonable in many senses, but they want to be purchasing things that are of value and are efficient.

David: The whole triple aim of better quality, improved outcomes and lower costs, it's a tough bar to meet, but I think that some of these dementia care programs and Care Ecosystems, there is some evidence along these lines and UCLA Alzheimer's Dementia Care Program and the Ashkenazi program in Indiana all show that this can actually lower costs.

Eric: I'm actually just thinking there was a recent New England Journal article on hot spotting. Did you guys read that one?

David: Yeah.

Eric: It was this randomized control trial looking at the top 1%, the really high utilizers, randomized them to ...

David: Hot spots.

Eric: Yeah.

David: The Camden intervention.

Eric: The Camden intervention. And what they found was what Ken Covinsky loves to talk about regression to me. Both groups kind of improved, but there was no difference between the two groups, just reminding me how hard this is to actually figure out how to improve the population-based health for those individuals.

David: Yeah. They chose readmissions as the primary outcome and that is notoriously difficult to move because it involves both medical care and social care and I guess, Camden Health was trying to do that as much as possible. But there are a lot of idiosyncrasies in terms of rehospitalizations. It's a tough measure to move.

Eric: Yeah. What about the other population? What about all the way down the pyramid, that big, that 60% of the population that are healthier? How should we ...

David: Down the pyramid?

Eric: Down the pyramid. How should we think different about that population?

David: What's different about those people is they need to have somebody to reach out to. So once you've been established, have the diagnosis of dementia established, you are there by yourself. You're on your own. I remember Nancy Reagan being quoted when her husband announced that he had dementia, "We had questions. We had nobody to answer the questions." So for these people that have questions, somebody that can answer their questions and it's not just going on a website, it's somebody to talk to because every person with dementia's journey is different and unique.

Eric: Yeah. What about even healthier? I have maybe some blood pressure problems, maybe some diabetes. I'm 75 years old. I'm not in the middle, but I'm still playing some tennis out there occasionally. Should I think differently about ...

Alex: Think different.

Eric: Dang it! About that population?

David: Absolutely. So the example I gave you was simply about dementia, but you could think about anything. You could think about heart disease. You could think about COPD. You could think about diabetes and you're still going to have that pyramid. So once you start thinking in that population-based health, you think about each person or each strata of each tier is what's going to help them the most? So if you have hypertension and you have diabetes and you're in that bottom 60%, what's going to help you the most?

David: Things like exercise programs, things about controlling your weight, things about medication adherence, all of those kind of things. And that's ... to develop programs, many of those things are nonmedical. Many of those things are things that you don't go to your clinic to get. You don't go to your clinic to get an exercise program. It doesn't really help you.

Alex: And I think part of the key is something that come back to at the beginning is incentivizing these nonmedical, nonpharmacologic approaches to caring for populations and that is if we could refashion the system to be focused on populations rather than procedures, prescriptions, the health of the whole population may rise. We did a podcast with Vince Moore from Brown, who argued for Medicare Advantage for all. I'm interested in your thoughts on that as it pertains to population health.

David: For all Medicare beneficiaries or for all people of all ages?

Alex: He was ... I'm not sure. We were focused on older adults, so I would say for older adults. I don't want to extrapolate from what he said to all ages, but good question.

David: I think that's fair. I was hoping you were going to say that. So yeah. So the Medicare Advantage for all is kind of where the puck is going anyhow. Even though I think it's something around 40% now, Medicare Advantage, the alternative payment models and the bundled payment models and all of this are making things that once fee-for-service look more managed care-like. And so this is a trend that's increasing and you're going to see more of it. And I think there are many reasons for that. But one of the reasons is that if you're responsible for a population because you're a Medicare Advantage plan, you have to think about population health approach.

David: So it makes sense because the fee-for-service payment structure is about widgets. It's about units of service and that's almost diametrically opposed to a population-based approach.

Eric: All right. I've got a question. So let's say I have a primary care clinic or I do geriatric consults or palliative care consults. What's my role in population-based health? Should I be doing anything different now that I've learned this new term?

David: Yes. So I do think. I think that if you are at least even aware of a population-based approach, I don't know whether you guys do huddles, but I do huddles before I see patients every clinic session. And if you think about each one of those patients, about where they are on that pyramid is you say, "Jeez, my approach to that patient is really about trying to prevent them from moving to the next highest utilizer" or whatever measure of severity you want to use and say, "Am I dealing with somebody in that top 1%?" Your whole approach and your whole philosophy about what to do for that person is different, knowing where they are.

David: And you might be ambitious and you might be well-connected enough in your health system to say, "Jeez, we got something missing here. We don't have anything for that bottom 60% and maybe we could develop something or maybe we could partner with an organization that could do that."

Eric: I also noticed that in your Dementia Care Program and correct me if I'm wrong, that partnering thing was interesting because you actually had vouchers to pay for community-based organizations for some time-limited services.

David: Yes. We do.

Eric: Tell me about that.

David: So this is something that was a lesson that we learned. As part of the innovation challenge awards from CMMI, we needed to establish partnerships with community-based organizations. I think it was a requirement, but it turned out to be the best thing we ever did because it brought the health system in collaboration with community-based organizations because there's some services that they can do certainly less expensively. They're not dealing with unions that the hospital does or other kind of overhead costs and they can do it frequently better. I don't think any health systems are going to set up adult daycare programs and certain other kinds of counseling programs that can be done actually better outside of the health system.

David: So initially, we gave block grants to the community-based organizations and that just didn't work so well because there wasn't all this kind of accountability and things like that. So what we did was we created a voucher system and the voucher system works like this. The dementia care specialists talk and find out what the resources of the people are and what their needs are and sometimes they will find that something is missing and either the person can't afford it or maybe they're afraid to try it or reluctant to do so, so they can give limited-time vouchers for adult daycare, for counseling, for financial services, legal services, etc. And our program will pay for that on a short-term basis.

David: More recently, we got a grant to start doing that for respite care and I'll give you a great example of that was one of the patients I was caring for in the hospital who was part of our program. He presented with some delirium due to actually a flare of pseudogout. And we were ready to send him home, but it turned out that his wife had just had shoulder surgery a few days before and she couldn't handle it. So what we were able to do is to purchase some caregiver time so we could discharge the patient until the son could come from Hawaii and provide some additional care while his mother was recovering.

Eric: That's fabulous.

David: Yeah.

Eric: And I love the idea of partnering with community organizations. We often talk about limited resources out for dementia. There's also a lot of redundancy in the system as far resources. The Alzheimer's Association, hugely underutilized by patients and healthcare systems. Often people don't get referred to them when they get diagnosed, but it's a huge support system that's available that's really underutilized. So really thinking about our community partners, love that idea.

David: And that's something that both the UCLA Alzheimer's Dementia Care Program and the Care Ecosystem and virtually all of the dementia comprehensive care management programs do. They don't provide all the services themselves. They tap into existing services. And a lot of this is about knowledge. It's about knowledge and who to go to and who can be helpful and what the costs are and all of these kinds of things. So people like care navigators and dementia care specialists, they have this knowledge and much of it's local. It's not book knowledge, it's local wisdom.

Eric: Yeah. I've got another question. Is it okay if I switch topics just slightly?

David: Sure.

Eric: Or Alex, did you have a question?

Alex: My question was about where our listeners could go to find out more about these programs. Should we go there now? Is that all right?

David: Yeah. So I'm going to pull up the website which is the most important thing.

Alex: It's a beautiful website by the way. I was perusing around.

David: Yeah. It is. Let me pull it up. So it's the UCLA Alzheimer and Dementia Care website and the site is www.uclahealth.org\dementia\. And what's great about this website, not only do we boast about ourselves and have the publications, but the tools that we use can be found on the website. But perhaps the best part is the caregiver training videos. And we created about 16 caregiver training videos for common situations like repeated questioning, wandering, sundowning.

Alex: Oh, that's fabulous.

Eric: That's great.

David: Sexually inappropriate behavior. And they're all about two minutes long. They're not very long. They typically will have an example of how somebody is handling this poorly and then an expert will tell you tricks about how to handle it better and then there'll be an enactment of it being handled much better.

Eric: Oh, that's great. This is a valuable resource for our listeners who I'm sure are caring for patients and caregivers who are dealing with these issues, either to learn to teach them themselves or to give them the links to these videos to watch.

Eric: And we'll have a link on our GeriPal website to David's program and website. My last question is for a lot of us in geriatrics or doing palliative care, there's a lot of junior faculty members that are thrown into leadership positions and when we're thinking about population health, there's a lot of leadership needs with that. You have done so much in your career and have been a leader in healthcare. Do you have one or two key pointers as far as leadership lessons or skills that we should be thinking about? I know I'm putting you on the spot...

Alex: Yeah. That's what we do.

David: I think about this a lot. There are a couple of things. I meet with my boss fairly frequently and have a great deal of respect for him, just a tremendous amount of respect for him. And a couple of principles. Number one is I always try to be part of the solution rather than part of the problem. So most of the time at institutions, you're always asking for something or needing something and people who are at higher levels get tired of that because they hear it all the time. But being part of the solution is really valuable, being valuable. I don't ask very much, but when I do ask, it's generally for something important.

David: I think geriatricians and hopefully, some geriatricians will be tuning into this, have some really important assets. One of the assets, I was just teaching one of our Fellows yesterday about this, is that geriatricians know who belongs where. So who belongs in an acute care med/surgery hospital? Who belongs in a psychiatric hospital? Who belongs in a nursing home? Who belongs at home? Who belongs in assisted living? It turns out that's very important in health care. People who are in the wrong place, number one, they cost a lot. Number two is they don't get better.

David: We were talking about this in the context of a patient who was on the medical unit and then eventually wound up almost strangling somebody because they were on the wrong unit and was transferred over to the psychiatric unit and has been much more blissful. The thing that they did wrong on the inpatient unit was that they put him in restraints and he went nuts. So knowing where a person should be is a really important skill that a geriatrician has and that is part of being the solution.

Alex: That's terrific.

Eric: That's great. Thank you.

Eric: I said that was my last question, so I'm going to stick to that. Anything else Alex?

Alex: That's it for me. Anything else that you want to talk about David?

David: No. I think this is a great idea. I just hope that more people embrace geriatrics and palliative care because Lord knows we need it. So thank you guys. I'm very honored.

Alex: We're honored to have you as our guest, David. Thank you so much for joining us today.

Eric: And before we say goodbye, we always end with a little bit more of a song. Alex.

Alex: (Singing.)

David: Paul McCartney would be proud.

Alex: Yeah, right.

Eric: David, actually I'm going to ask you one more question. You wrote a musical, a musical or opera? I forget.

David: Yeah, a musical.

Eric: A musical.

Alex: Oh, we should have done a number from the musical. Next time we have you on.

David: Yeah. So the musical is a geriatric story.

Eric: Oh really?

David: Yeah. It's a great story if you have a second.

Eric: Yeah.

David: It is one of my patients was in his 90s and he had heard that I wrote. And he came up to me and he said, "I've written a few songs and I wonder if you'd write lyrics to them." And it turned out, he wasn't just any patient. He was a very famous studio musician and he played with everybody from Ella Fitzgerald and Frank Sinatra all the way through Donna Summer. And the songs were just great. They were just wonderful songs and he was 93 and had end-stage renal disease and I think he was the oldest person at the time to ever get a TAVR. He was quite frail and died on hospice. I spoke with him shortly before he died and then I had about 20 songs that I didn't have anything to do with them. So I wrote a libretto about a songwriting team of an elderly person and a middle aged person or young person and they had a songwriting team and what happened to them. So that's what the play is about.

Eric: Can we find it on YouTube? iTunes? Amazon Music?

David: Jeez. I don't have it on any of those things. I have digital files, but I don't have it on any media.

Eric: All right. Next time we have you on, Alex will do a little bit of ...

David: It sounds lovely, lovely.

Alex: Yeah. And maybe we can get the digital video and splice it into the YouTube video for our podcast.

David: Oh, that would be great.

Alex: That would be awesome.

David: I can send a few to you. Actually, one of them is about aging.

Eric: Great.

Alex: Terrific.

Eric: Well, with that, I want to thank all ... First, thank you, David, for joining us.

Alex: Thank you so much, David.

Eric: Thank all of our listeners for joining this podcast. If you have a second, please rate us on your favorite podcasting app.

Alex: Thank you to Archstone Foundation. By folks.

Eric: Goodbye. Good night.



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