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  1. University of Arkansas for Medical Sciences
  2. Arkansas Geriatric Education Collaborative
  3. Author: Chadley Uekman

Chadley Uekman

Meet Our 2020 Geriatric Fellows

UAMS AGEC 2020 Geriatric Fellows

Robin McAtee, PhD, RN, FACHE, Director and Ronni Chernoff, PhD, FAND, FASPEN, AGEC Associate Director are pleased to announce awardees for the 2020 Junior Faculty Fellowships in geriatrics at the Donald W. Reynolds Institute on Aging at UAMS. Obioma Nwaiwu, MD, PhD and Stephanie Trotter, PhD, RN were notified of the decision in June 2020. The fellowship program objective is to support the career development of professionals who want to specialize in academic and clinical geriatrics. The award includes $30,000 in salary support and supported attendance for each at (1) national geriatric conference.

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Obioma Nwaiwu, MD, PhD

Obioma Nwaiwu, MD, PhD obtained his medical degree from University of Ibadan, Nigeria, a PhD in Health Services Research from Texas A&M Health Science Center, and completed his family medicine residency at the University of Arkansas for Medical Sciences.  He was accepted into the geriatric fellowship program at UAMS in 2019 and has now joined the Department of Geriatrics as an assistant professor.  His passion for improving access to care and reducing disparity for vulnerable older adults started prior to his medical education. Over the past few years, he has been involved in multiple projects aimed at improving access and care for vulnerable older adults and he has collaborated with the community leaders in this effort. He is very interested in helping older adults to reduce their fall risk and partnered with Area Agencies on Aging in Texas to implement and evaluate falls reduction programs.  He is also an Aging Research in Criminal Justice & Health Network Scholars Awardee where he plans to evaluate the need, capacity, and interest in improving access to care of incarcerated older adults in Arkansas through provision of geriatric consultation services.​

 

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Stephanie Trotter, PhD, RN

Stephanie Trotter, PhD, RN began a second career in 2010, when she chose nursing as a second career path.  She completed her baccalaureate nursing degree in 2012 and a PhD in nursing in 2017 both at UAMS.  She loves the diversity and limitless opportunities available in this healthcare field.  While obtaining her undergraduate degree, she was selected for the Hartford Center for Geriatric Nursing Excellence externship.  During this experience, she developed a passion for the health and well-being of Arkansas’ geriatric population and this is where her teaching and research has since focused.  Her dissertation work focused on age-specific differences in time perspectives, health beliefs, and behaviors of hypertensive adults.  Dr. Trotter is a faculty member of UAMS’ College of Nursing where she strives to cultivate respect and passion for the geriatric population in undergraduate nursing students.  She feels that as a nurse educator, it is her calling to prepare the next generation of nurses to care for older adults.  In her free time, she enjoys family time, including her four-legged family members, and home improvement projects. ​

Filed Under: AGEC, UAMS

From The Director’s Desk

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By Robin McAtee, PhD, RN, FACHE, Director, Arkansas Geriatric Education Collaborative (AGEC), a Geriatric Workforce Enhancement Program (GWEP) at the University of Arkansas for Medical Sciences (UAMS) Donald W. Reynolds Institute on Aging (DWR IOA)

Spring 2020

Is this a new AGEC era?

What a difference a few weeks make.  Last time I wrote this newsletter, we at the AGEC were preparing for a very busy end of winter and early spring with several exciting programs and activities scheduled!  We were all really looking forward to better weather and traveling the state to conduct programs and see our community-based and academic partners in action.  And now…. we are still very busy, but differently.

As most people, we have started working part-time at home and part-time on campus. We have also greatly changed the way we are delivering programs and activities.  We have had to spend time learning new systems and thinking about how to do things differently – while socially distancing ourselves!  Below are a few examples of how we are adapting and changing.

We are converting community programs into virtual forums:

  • Dementia Friendly Business – Converting in-person coaching to virtual/online program
  • Converted our popular community forum “Understanding Dementia & Alzheimer’s Disease” to an online program via BlackBoard Collaborate
  • Converted Lunch & Learn series with Alzheimer’s’ AR and Community Based Organizations from in-person to online.
  • With our AR-IMPACT partner, we have completed four on-line programs: Alternative Pain Relief and Self-management amidst the Opioid Crisis; Tips for the Busy Clinician; Opioids and Falls; and Recognizing and Responding to Suffering
  • Transforming community programs (some educational and some exercise programs) to on-line versions while encouraging our older adults to participate online.  For example: Presenting Ageless Grace online (via Facebook) and to date, along with our partners in this venture we have had over 5000 hits!
  • Working with our clinical partner with QI activities via phone conferences

As we learn new ways of delivering our programs and grant activities, we want you to stay connected with us. If you have unique ideas about how to reach and connect with health professionals who specialized in geriatrics or the older adults themselves and/or their caregivers, or the general community, please share them with us!  We are all in this together and are striving to meet the needs of older Arkansans while improving their health and wellbeing!

Filed Under: AGEC, Newsletter, UAMS

Polypharmacy: Definition, Causes, and Solutions

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By Lisa C. Hutchison, PharmD, MPH, BCPS, BCGP
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

 

Definitions

Polypharmacy may be defined as a number of medications, ranging from as few as two to as many as 21.  The most common numerical threshold for polypharmacy is 5-6 or more medications.  However, a patient with diabetes, chronic kidney disease, hypertension and heart failure is easily prescribed more than 6 medications if treated according to accepted guidelines making them all potentially appropriate for the individual.  Polypharmacy may be defined as use of potentially inappropriate medications as identified by a set of criteria such as the AGS 2019 Beers Criteria.(1)  These criteria list medications whose risk usually outweighs potential benefit when used in older adults.  Yet another definition of polypharmacy is limited to the presence of medications in the patient’s list that are unnecessary, which is defined as medications that are not indicated, dosed in excess, continued beyond an adequate duration, duplications, or causing adverse events.  The most stringent definition of polypharmacy involves evaluation of each medication a patient receives according to 10 questions which comprise the Medication Appropriateness Index.(2)

  • Is there an indication for the drug?
  • Is the medication effective for the condition?
  • Is the dosage correct?
  • Are the directions correct?
  • Are the directions practical?
  • Are there clinically significant drug-drug interactions?
  • Are there clinically significant drug-disease/condition interactions?
  • Is there unnecessary duplication with other drugs(s)?
  • Is the duration of therapy acceptable?
  • Is this drug the least expensive alternative compared to others of equal utility?

If any of the questions receives a negative response, the drug use is not appropriate and polypharmacy is present.  In research applications, the first three questions are given more weight in the assessment.  This helps the clinician know to focus on indication, effectiveness, and dosage.

Causes

The causes of polypharmacy are many, but include the patient’s use of multiple physicians and pharmacies, disease state guidelines recommendations for multiple medications, prescribing cascades, and direct-to-consumer advertising.  When a patient sees multiple physicians, communication between providers is necessary to prevent prescription of duplicate medications.  In addition, prescribing cascades may result when one prescriber is unaware of the therapy recommended or prescribed by a previous prescriber. Additional medications to be considered are over-the counter medications and supplements that the patient consumes without the knowledge of the provider. This results in a further increase in drug interactions and adverse drug events.  If a patient uses different pharmacies, assessment of important drug-drug interactions may be lacking as each pharmacy will likely only have a partial list of medications.(3, 4)

The prescribing cascade is defined as when a new medication is prescribed for a symptom that is misinterpreted as a new medical condition when it is actually an adverse drug reaction or side effect.  An example is shown in Figure 1.

Prevention and Intervention

The first step in prevention of inappropriate polypharmacy is to perform a medication regimen review whenever a new medication is being considered for prescription.  An adverse drug effect may be the cause of a symptom and require adjustment or discontinuation of a currently prescribed agent instead of addition of a new one.  Non-pharmacological interventions are preferred for many chronic illnesses and should be promoted to older adults.

Secondly, the clinician can identify inappropriate polypharmacy exists for an older adult through use of various tools that can aid in identifying medications that may be unnecessary.  Annual or more frequent review of the medication regimen is recommended.(5) Taking the time to carefully consider each medication and its risk/benefit in light of a patient’s circumstances is important, especially as a patient becomes frail with an increased susceptibility to adverse effects.

 

 

References:

  1. American Geriatrics Society 2019 Beers Criteria® Update Expert Panel. 2019 updated Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019; 67:674-94 DOI: 10.1111/jgs.13702
  2. Hanlon JT, Schmader KE, Samsa GP, Weinberger M, Uttech KM, Lewis IK, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45:1045–51.
  3. Rochon PA, Gurwitz JH. Optimising drug treatment for elderly people: the prescribing cascade.  1997;315:1096-9.
  4. Scott IA, Gray LC, Martin JH,Mitchell CA. Minimizing inappropriate medictions in older populations: a 10-step conceptual framework.  Am J Med. 2012;125:529-37.
  5. Choosing Wisely. An initiative of the ABIM Foundation. https://www.choosingwisely.org/societies/american-geriatrics-society/ Accessed 30 April 2020.

 

Figure 1

Filed Under: Newsletter, UAMS

Age-Friendly Healthcare in Rural Arkansas

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By Leah Tobey, MBA, PT, DPT
Clinical Coordinator
UAMS Arkansas Geriatric Education Collaborative

 

My name is Dr. Leah Tobey and I am the clinical coordinator for the AGEC team. As part of our HRSA Geriatric Workforce Enhancement Program, we have goals to improve clinical health outcomes of older adults in the primary care setting. Our partnered clinics are with ARcare, a federally qualified healthcare clinic network. Specifically, the two clinics where we partner with to improve outcomes for older adults are ARcare England and ARcare Augusta. I help provide up-to-date and evidenced-based trainings to clinicians, particularly focused on age-friendly work practices, tests and measures to enhance patient experiences and improve outcomes of older adults in these rural areas.

As a member of the 2020 Institute for Healthcare Improvement (IHI) Age-Friendly cohort, we at AGEC have requested the ARcare clinics to implement the 4Ms framework to optimize the care of older adults. This framework is not a program, but rather a shift in how care is provided.  The 4Ms framework consists of: What Matters to the older adult, high-risk Medication review, cognitive and Mentation screens, and Mobility tests for fall prevention. Through a variety of geriatric-focused trainings, including the 4Ms framework, our first goal was to improve the clinician’s knowledge of best practices of caring for older adults. We then collected baseline data of common health related indicators for older adults, such as uncontrolled hypertension, diabetes, number of patients prescribed high-risk medications like opioids and older adults who experience frequent falls. The 4Ms framework for age-friendly care has been well-received and AGEC is continuing to monitor how and when this framework is being implemented into primary care, including Medicare annual wellness visits.

We know the population of older adults, specifically the Baby Boomer population, continues to increase, and we expect the 4Ms framework will be a helpful guide to ensure that older adults are delivered safe, age-friendly healthcare. This framework helps to ensure patients move safely every day in order to maintain function and do what Matters​ most to them (ihi.org). We have seen promising results in several areas, for example, assessing Mobility​ with fall screens has improved over 50% in one year in the ARcare England clinic. ARcare England also had a 30% increase in annual wellness visits for Medicare patients in one year. We continue to address areas of improvement, using the 4Ms framework as a helpful guide to care. As I mentioned above, the 4Ms framework includes Mentation screens specifically for the presence of the 3D’s: Dementia, Delirium and Depression. Early, accurate screening procedures will allow the clinicians to prevent, identify, treat, and manage cognitive changes noted in an older adult patient. When cases of depression or dementia are caught early, we want the ARcare clinicians to have the knowledge to treat with age-friendly care and also provide helpful community resources for patients and their families. This goal coincides with the healthy aging programs the AGEC brings to Arkansans across our state.

Despite difficult times recently, we at AGEC have been busy creating and providing clinical trainings to continue building upon the early, positive results within ARcare. I’m happy to report as of March 2020 ARcare England and Augusta have been awarded the certification of being “Age-Friendly Healthcare Systems” by the Institute for Healthcare Improvement. We are looking forward to continued improvements in health-related indicators for older adults in our rural ARcare communities and to making them more age-friendly.

Filed Under: AGEC, Newsletter, UAMS

Does Age-Related Hearing Loss Worsen Cognitive Decline?

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By Natalie Benafield, Au.D., CCC-A
Communication Sciences and Disorders
University of Central Arkansas

 

Most of us associate aging with a decline in hearing acuity, with good reason. Two-thirds of individuals over 70 years of age have a loss in hearing that would be considered clinically significant. Communication obviously suffers, causing frustration for both the person with the hearing loss and their family members. However, it is estimated that less than one-quarter of individuals with age-related hearing loss seek treatment. Evidence is mounting that ignoring hearing as you age can have detrimental effects that go beyond difficulty communicating with others.

As far back as 1989, scientists have suggested that age-related hearing loss may contribute to cognitive decline in seniors. A pivotal study published in the Journal of the American Medical Association (Uhlmann, et.al.,1989) suggested that hearing loss in older adults was associated with a higher risk of dementia. For the past several years, other researchers have been conducting research in this area and have come to similar conclusions. Dr. Frank Lin, at Johns Hopkins University, and his team followed 639 individuals from the ages of 36-90 for twelve years to investigate the link between hearing loss and dementia. After adjustment for other factors including age, gender, educational level, diabetes, smoking and hypertension, their research suggested that those with hearing loss experiences a 30-40% accelerated rate of cognitive decline (Lin, et al., 2013). More recently a large-scale review of epidemiologic studies of age-related hearing loss and cognitive function from twelve countries was conducted. The researchers found that age-related hearing loss was significantly association with a decline in all main cognitive domains, except for Alzheimer’s disease and vascular dementia. They concluded that hearing loss related to aging is a modifiable risk factor for cognitive decline and dementia in seniors (Loughrey, et al., 2018).

While the exact mechanism underlying the relationship between age-related hearing loss and cognitive decline has not been identified, there are several theories. Some have suggested that hearing loss and cognitive decline may be caused by the same general neurodegenerative process (Stahl, 2017). Neuroimaging studies have suggested that similar changes in the temporal regions of the brain have been noted in individuals with hearing loss and with cognitive decline (Lin, et al., 2014). Other researchers suggest that hearing loss (i.e., the lack of sensory input) causes individuals to use additional cognitive resources to process auditory input, resulting in chronic cognitive “multitasking” and overload. (Tun, McCoy, & Wingfield, 2009). Exacerbating the condition may be that untreated hearing loss often leads to social isolation and even depression, which in turn leads to reduced cortical input over time, hastening atrophy in certain regions of the brain.

Will hearing aid use slow cognitive decline? It makes sense that the use of hearing devices such as hearing aids could increase auditory input, lessen cognitive load, and decrease social isolation, thereby slowing cognitive decline (Sarampalis, et al., 2009). However, we need more large-scale, longitudinal studies before being confident of that claim. Current studies have failed to show a robust protective relationship between hearing aid use and cognitive function. One recent small-scale study found that individuals with evidence of auditory- to- visual cross-modal reorganization in the brain showed evidence of reversal of the re-organization in the auditory cortex, with additional gains in speech perception and cognitive performance (Glick & Sharma, 2020).

What does this mean for current clinical care of older adults? Health care providers often see hearing loss as normal part of aging as they must focus on the numerous urgent medical needs of older adults. This research suggests that clinicians should take a proactive, rather than reactive approach to hearing health in the aging population. Rather than waiting until a patient complains of difficulty hearing, encourage early hearing screening, evaluation, and treatment for those 60 and older. Most patients will not understand the importance of their hearing to brain health. While we lack the evidence to suggest that hearing aids can reduce cognitive decline, we have plenty of evidence to say that hearing loss is not good for the brain. Early hearing evaluation and treatment is risk-free, and evidence is mounting that appropriate treatment of age-related hearing loss could have a positive impact on cognitive decline.

 

References

Glick, H. A., & Sharma, A. (2020). Cortical Neuroplasticity and Cognitive Function in Early-Stage, Mild-Moderate Hearing Loss: Evidence of Neurocognitive Benefit From Hearing Aid Use. Frontiers in Neuroscience, 1.

Lin, F. R., Yaffe, K., Xia, J., Xue, Q.-L., Harris, T. B., Purchase-Helzner, E., Satterfield, S., Ayonayon, H. N., Ferrucci, L., & Simonsick, E. M. (2013). Hearing loss and cognitive decline in older adults. JAMA Internal Medicine, 173(4), 293–299. https://doi.org/10.1001/jamainternmed.2013.1868

Lin, F. R., & Albert, M. (2014). Hearing loss and dementia – who is listening? Aging & Mental Health, 18(6), 671–673. https://doi.org/10.1080/13607863.2014.915924

Loughrey, D. G., Kelly, M. E., Kelley, G. A., Brennan, S., & Lawlor, B. A. (2018). Association of Age-Related Hearing Loss With Cognitive Function, Cognitive Impairment, and Dementia: A Systematic Review and Meta-analysis. JAMA Otolaryngology– Head & Neck Surgery, 144(2), 115–126. https://doi-org.ucark.idm.oclc.org/10.1001/jamaoto.2017.2513

Sarampalis A, Kalluri S, Edwards B, & Hafter E. (2009). Objective measures of listening effort: effects of background noise and noise reduction. Journal of Speech, Language & Hearing Research, 52(5), 1230–1240. https://doi.org/1092-4388(2009/08-0111)

Tun PA, McCoy S, Wingfield A, Tun, P. A., McCoy, S., & Wingfield, A. (2009). Aging, hearing acuity, and the attentional costs of effortful listening. Psychology & Aging, 24(3), 761–766. https://doi.org/10.1037/a0014802

Uhlmann, R.F., Larson, E.B., Rees, R.S., Koepsell, T.D., Duckert, L.G. (1989). Relationship of hearing impairment to dementia and cognitive dysfunction in older adults. Journal of the American Medical Association 261(13), 1816-1919.

Weinstein, B.E., (2018). A primer on dementia and hearing loss. Perspectives of the ASHA Special Interest Groups, 3(6), 18-27.

 

Filed Under: AGEC, Newsletter, University of Central Arkansas

Hospice: A Transition of Care to End of Life

Arkansas State University

By Dr. Angela Schmidt, Professor Emeritus
College of Nursing and Health Professions
Arkansas State University

 

Transitioning from one care setting to another in the United States Healthcare system, has become complex and problematic, especially for  older adults and other vulnerable populations.

Included in these transitions is hospice care, provided at home, in a hospital, a nursing home, or in a facility specifically designated for hospice care delivery.  This care delivery is holistic and is delivered by an interdisciplinary team of physicians, nurses, social workers, therapists, clergy, and often volunteers. It is available to any person regardless of age, race, or illness. The goal of hospice is comfort instead of cure, to be pain free with aggressive methods as necessary. The philosophy of hospice is to provide supportive care for the patient’s emotional, social, and spiritual needs, as well as these medical symptoms, as part of holistic care delivery.

Services provided in hospice care include prescribing drugs to control pain and manage other symptoms; physical, occupational, and speech therapy; medical supplies and equipment; medical social services; dietary and other counseling; continuous home care at times of crisis if home setting; and bereavement services. Although hospice care does not aim for cure of the terminal illness, it may treat potentially curable conditions such pneumonia and bladder infections, with brief hospital stays if necessary. Hospice programs also may offer respite care workers, people who are usually trained volunteers, who take over the patient’s care so that the family or other primary caregivers can leave the house for a few hours. Some facilities where hospice care is provided also include volunteer caregivers as a part of the hospice philosophy.

In the mid-1970s when hospice came to the U.S., most hospice patients had cancer. Today, more than half of hospice patients have other illnesses for which they are medically eligible for hospice services, such as late-stage heart, lung or kidney disease, and advanced Alzheimer’s disease or dementia. Hospice also once was exclusively for adults, especially elderly people, but today many hospice programs accept infants, children and adolescents

In a significant research study, published by The Journal of American Geriatric Society (Amann & LeBlanc, 2014), researchers found that cancer and advanced dementia were the conditions that most often resulted in being admitted for hospice care. The duration of hospice care was less than 13 days for half of these study participants. The short duration of hospice suggested that healthcare providers might need to consider discussing referrals to hospice sooner with people who are approaching the end of their lives.

Further, the study revealed that older adults who were frail were least likely to be admitted for hospice. However, the most common condition leading to death was frailty (syndrome of physiologic decline in later life), followed by organ failure, advanced dementia, and then cancer.  The researchers suggested that referral to hospice at the end of life should be based on an older adult’s burden of pain and other distressing symptoms including frailty, as well as consideration of earlier hospice referrals. (Amann & LeBlanc, 2014)

A National Hospice Foundation Survey noted that 90% of Americans were unaware that hospice care is a covered Medicare service. To be  eligible to receive hospice services, a hospice physician and a second physician (often the individual’s attending physician or specialist) must certify that the patient meets specific medical eligibility criteria; generally, the patient’s life expectancy is 6 months or less if the illness, disease or condition runs its typical course. However, if the individual lives longer than six months and the condition continues to decline,  recertification by a physician or nurse practitioner for additional time in hospice care. Similarly, if a hospice patient’s condition improves, the individual may be discharged from hospice care. The patient is eligible for hospice again if his or her condition begins to decline.  The decision to consider hospice services, as recommended by the Hospice Foundation of America, should include: 6 months or less to live, according to a physician; rapidly declining despite medical treatment (weight loss, mental status decline, inability to perform activities of daily living); and  readiness to live more comfortably and forego treatments aimed at prolonging life. Many health care service options for transitions of care are determined by financial considerations.  The type of insurance coverage the patient has determines of-of-pocket payments for hospice care.  Hospice services usually follow Medicare requirements to provide the following:

  • Time and services of the care team, including visits to the patient’s location by the hospice physician, nurse, medical social worker, home-health aide and chaplain/spiritual adviser;
  • Medication for symptom control and/or pain relief;
  • Medical equipment, such as wheelchairs or walkers and medical supplies like bandages and catheters;
  • Physical, occupational, and speech therapy if needed;
  • Dietary counseling;
  • Any other Medicare-covered services needed to manage pain and other symptoms related to the terminal illness;
  • Short-term inpatient care if in home setting and pain and/or symptom management cannot be achieved;
  • Short-term respite care if temporary relief from caregiving is needed to avoid or address “caregiver burnout”; and
  • Grief and loss counseling for patient and loved ones.

However, not all services provided to patients enrolled in hospice care are covered by the Medicare Hospice Benefit. The hospice benefit will not pay for:

  • Treatment intended to cure your terminal illness or unrelated to that illness;
  • Prescription drugs to cure your illness or unrelated to that illness;
  • Room and board in a nursing home or hospice residential facility; and
  • Care in an emergency room, inpatient facility care or ambulance transportation, unless it is either arranged by the hospice team or is unrelated to the terminal illness.

(see https://hospicefoundation.org/Hospice-Care/Hospice-Services )

 

Note that not covered is “room and board” which is misunderstood by consumers when most resources state, “Medicare covers hospice care”.  Even care received in a hospice facility can charge the patient for room and board daily not covered by Medicare, although the above allowed services may be covered.  Six months or 180 days at 140-$200 per day (totaling $25,000-$36,000) for room and board, may be an out of pocket personal expense.  In addition, some medications are not included. For example, some intravenous (IV) medications that are not related to the terminal illness are not covered by hospice. Even dehydration occurring as a natural process in a terminal illness does not allow IV fluids.  Further, most antibiotics are not covered by hospice unless they are for palliative needs only.  What lacks clarification is that the patient can have these treatments/services but the patient would be responsible for payment.   Even though there are many exceptions to coverage, Medicare Part A supplies items such as diapers, medications, and equipment related to the terminal illness, while Medicare Part B covers physician charges.  The patient is responsible for any deductible amounts and for any charges not covered as described.

Most hospice patients, especially elderly ones, are eligible for Medicare, which covers most aspects of hospice care and services as long as it is related to the terminal illness. There is no deductible for hospice services although there may be a very small co-payment for prescriptions and for respite care. In most states, Medicaid offers similar coverage.  Medicare coverage also includes Medicare Advantage Plans. Many private health insurance plans offer hospice benefits but the extent to which they cover hospice care and services may differ from Medicare as well as from one another.  Military families have hospice coverage through Tricare. Most hospices will accept private payment, or “self-pay.”  Some hospices have mechanisms by which they can provide services to people who are medically eligible but have neither insurance nor the resources to pay for their care.

Hospice care is given in benefit periods. You can get hospice care for two 90‑day periods followed by an unlimited number of 60‑day periods. Although medical eligibility generally relies on the physician’s opinion that the patient’s life expectancy is 6 months or less, neither the patient nor the physician is penalized if the patient lives longer than 6 months. The patient can be re-certified for as long as he/she continues to be medically eligible.  It is also possible with hospice care that a patient’s condition stabilizes and may even improve sufficiently so they no longer meet medical eligibility for hospice services. At that time, the patient is “discharged” from the hospice program and their Medicare benefits revert to the coverage they had before electing hospice care.
(see https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice )

Hospice patients may choose to pursue curative therapies such as entering a clinical study for a new medication or procedure. In order to do so, the patient must withdraw their selection of hospice care, called “revocation.”  Patients who are discharged as well as any who choose to leave hospice care can re-enroll at a later date without penalty at any time they meet the medical eligibility criteria.

To ensure health care providers, facilities, and consumers are aware of hospice service benefits, CMS announced a “Value-Based Medicare Advantage Model” in 2019.  This initiative is intended to accelerate the development and testing of new payment and service delivery models for hospice.  In October 2019, President Trump issued an Executive Order on “Protecting and Improving Medicare” for our nation’s seniors to include this hospice delivery model. Through both this announcement and a separate RFA that CMS released in January 2020 for other components of the VBID model, CMS is implementing key provisions of the President’s Executive Order. Medicare Advantage (MA) organizations will finalize their VBID plan designs for all components of VBID by the 2021 bid deadline of June 1, 2020.

“Hospice patients find themselves in a particularly vulnerable and difficult time, and the Trump Administration wants to make every provision possible to allow them to focus on their loved ones and their care, rather than government bureaucracy…….This Model is a vital element of that effort. By expanding benefits and coverage and igniting greater coordination, it promises to improve quality of care and quality of life for our nation’s seniors. The result of our efforts has been a dramatic increase of participation in the VBID Model and the value-based, coordinated care it can provide.”
(see press release https://www.cms.gov/newsroom/press-releases/cms-announces-strong-participation-value-based-medicare-advantage-model-cy-2020-and-new )

By reducing fragmentation and increasing financial accountability, CMS is enabling organizations to better coordinate palliative and hospice care for beneficiaries that choose Medicare Advantage.

Arkansans need to improve our knowledge and use of hospice care to ensure that all those who will benefit from hospice care earlier in the course of a serious illness have access to compassionate, high-quality care that proves to be an appropriate transition of care.  This needed resource for many elderly people is often overlooked and underused.   In 2018, the proportion of Medicare decedents enrolled in hospice at the time of death varied from a low of 13% (other) to a high of 59.4% (UT) with AR ranking 21st at 50%.  More facts and figures for hospice care in the United States and Arkansas and the use of hospice services are available from, The National Hospice and Palliative Care Organization (NHPCO),  https://www.nhpco.org/wpcontent/uploads/2019/07/2018_NHPCO_Facts_Figures.pdf,  in their facts and figures report.

Filed Under: AGEC, ASU, Newsletter

Latest News from AGEC

First Responder Online Dementia Training

KARK Channel 4 (NBC) recently featured the UAMS Arkansas Geriatric Education Collaborative in a video story about our recently-launched Online First Responder Dementia Training. You can check out KARK’s story about our online training, featuring interviews from UAMS Police Chief Barrentine and AGEC’s Laura Spradley, by clicking here.

To learn more information or to register for our free Online First Responder Dementia Training, click here.

 

 

 

UAMS Arkansas Geriatric Education Collaborative Awarded $3.7 Million by Health Resources and Services Administration

UAMS Arkansas Geriatric Education Collaborative, Clinton School Address Opioid Crisis

KATV News Story: https://katv.com/news/local/town-hall-medical-professionals-address-opioid-use-for-chronic-pain

Arkansas Democrat-Gazette News Story : https://www.arkansasonline.com/news/2019/apr/13/opioid-struggles-focus-of-forum-2019041/

Facebook: https://www.facebook.com/UAMShealth/videos/380861315843726/

Twitter: https://twitter.com/ProgramsUACS/status/1117867656990744576

 

Filed Under: Uncategorized

Online Dementia Training for UAMS First Responders

AGEC In the News

 

KARK Channel 4 (NBC) recently featured the UAMS Arkansas Geriatric Education Collaborative in a video story about our recently-launched Online First Responder Dementia Training. You can check out KARK’s story about our online training, featuring interviews from UAMS Police Chief Barrentine and AGEC’s Laura Spradley, by clicking here.

To learn more information or to register for our free Online First Responder Dementia Training, click here.

 

The UAMS Arkansas Geriatric Education Collaborative (AGEC) is funded by the Health Resources and Services Administration’s Geriatric Workforce Enhancement Program under grant #U1QHP28723.
The AGEC is a program of the UAMS Reynolds Institute on Aging. 

Filed Under: AGEC

From The Director’s Desk

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By Robin McAtee, PhD, RN, FACHE, Director, Arkansas Geriatric Education Collaborative (AGEC), a Geriatric Workforce Enhancement Program (GWEP) at the University of Arkansas for Medical Sciences (UAMS) Donald W. Reynolds Institute on Aging (DWR IOA)

Winter 2020

Happy New Year and Happy New Decade from all of us at the Arkansas Geriatric Education Collaborative!  I am excited to be writing to you as we begin a brand new decade!  Here at the AGEC we have an exciting year planned as we being programs for healthcare professionals and students, community members, caregivers, and older adults.

Reflecting back on the last 3 months of 2019, we had several very successful programs.  These included:  a 2 day train-the-trainer program where six individuals were recertified in Ageless Grace and 32 individuals were certified to be lay leaders.  They can now go to their perspective audiences all over Arkansas and conduct Ageless Grace classes. We also hosted our fall webinar which featured Dr. Masil George who presented on Palliative Care for People with Dementia. Attendance was great with 78 attendees.   Another exciting event was National Family Caregiver Month in November where we brought in Mr. Don Guess (an advocate of older adults from the Arkansas Farm Bureau) to conduct an interview that was shown on Facebook as a video.  It has had over 6,400 views!  We also launched a Caregiving Tips video series that will continue throughout 2020.  The AGEC also launched our First Responder Dementia and Elder Justice Online Training and have had over 70 completers to date!

As we look to the first few months of 2020, we will sponsor Geriatric Grand Rounds January 28th with Margaret Pauly, MS, RD, LD and Stephan Dehmel, MD whose program will be titled Gut Check:  Are you prescribing the right foods for your elderly patients?.  We will also be working closely with our clinical partner ARcare in England, AR.  We will be learning with them as we endeavor to help them become the first Age-Friendly Health System in AR.  “Age-Friendly Health Systems” is an initiative of the John A. Hartford foundation and the Institute for Healthcare Improvement.  The initiative’s goal is to rapidly spread the 4Ms Framework (Medication, Mentation, Mobility, and what Matters to the older adult) to 20% of the US hospitals and medical practices by the end of 2020.  We are excited about this challenge as is ARcare!

Our academic partners completed another great semester of training the next generation of healthcare providers and our five Geriatric Student Scholars began their work with the AGEC.

Thank you for all you do for older adults in Arkansas and we look forward to continuing to partner with many of you to expand and improve services and programs.

Filed Under: AGEC, Newsletter, UAMS

Integrated Care: The Role of Mental Health Practitioners on the Primary Health Care Team

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By Kevin Rowell, PhD
Department of Psychology and Counseling
University of Central Arkansas

 

As with the implementation of the Affordable Care Act in 2017, U.S. health care continues to develop the patient-centered medical home model as a way of efficiently coordinating health care delivery. Especially for older patients where complexity of health care is the norm, the weight of responsibility in providing effective, safe, and lower cost interventions rests squarely on the primary care practitioner (PCP).  Now that baby boomers have reached late life, it is estimated that approximately one-fourth of patients seen in primary care clinics are over age 65. Although most are in good health, the natural decline in health with aging results in a greater presence of physical illness and dysfunction such that most older adults have at least two chronic conditions, as well as developing acute illnesses at prevalence rates similar to younger adults (CDC, 2013, as cited in Hunter et al, 2017).

While the public clearly understands that primary care is designed to be the first line of help in the case of medical illness and that most treatment is rendered therein, the majority of people do not realize that primary care practitioners are very often the first line of treatment for mental health issues as well (O’Donohue et al, 2005). People struggling with common disorders involving depression, anxiety, and substance abuse will more likely seek help from their PCP before considering intervention from a psychiatrist, psychologist, counselor, or clinical social worker. In fact, roughly one-third of the visits to PCPs is due to a mental health concern, and another one-third of visits involve a medical diagnosis that has a significant mental health component (Blount, 2003). The reasons are attributed to familiarity with the PCP, greater access to a PCP as compared to specialists (especially in rural areas), and fear of stigmatization in visiting a mental health clinic (Hunter, et al, 2017).

Research has shown that the most prevalent mental disorders are major depression, generalized anxiety, somatization, and substance abuse. Other common mental health issues include relationship conflict, stress, sleep disturbance, and fatigue. Not surprisingly, women are much more likely than men to report issues with mental health, which is a very consistent trend across most health care settings. Regarding patients over 65, other mental health issues involve cognitive decline, sexual dysfunction, grief/loss, isolation/loneliness, and lower motivation in managing chronic diseases (Hunter et al, 2007).

Whereas the PCP is able to provide appropriate intervention for many of these issues, usually through medication and perhaps brief consultation, a myriad of factors limits the effectiveness of the PCP in addressing primary mental health disorders and secondary mental health issues in chronic disease management. For example, diagnosing some mental disorders usually necessitates somewhat lengthy interviews and often a screening test, yet the high volume of patients scheduled daily in primary care clinics limits the time a PCP can spend with an individual patient. Furthermore, 60-85 percent of PCPs reported being under-trained in diagnosis and treatment of mental disorders. Additionally, when PCPs decide for a referral to a mental health specialist such as a psychiatrist or psychologist, wait times for appointments can be weeks and the likelihood of the patient following through with the appointment is less than 25 percent. Finally as previously mentioned, many people, especially older adults, with mental health concerns feel stigmatized in visiting a mental health clinic and will often refuse to seek help rather than potentially feel embarrassed or shameful (Blount, 2003, Hunter et al., 2017).

To address these issues, the fully integrated behavioral health model calls for the placement of a full-time behavioral health clinician (BHC) to be employed in primary care. Typically the BHC is a licensed psychologist, professional counselor, or clinical social worker who has received special training in integrated care behavioral health. Advantages of the behavioral health clinician are many. Of utmost importance is the presence of a mental health expert in primary care whose function is to identify primary and secondary mental health issues in patients and then to collaborate with the PCP and other staff in providing effective evidence-based interventions for patients. Through research backed behavioral interventions, BHCs can address stress reduction, mindfulness, sleep hygiene, maladaptive thoughts, as well as adaptive, healthy life style changes like exercise, relaxation, diet changes, smoking cessation, and decreased alcohol/substance use, all of which directly improve mental health and chronic disease management (Hunter et al, 2017). For the older patient, BHCs can conduct screenings for dementia and other cognitive problems, address social isolation, and help with sexual dysfunction.

Research indicates that when a full-time BHC is employed in primary care, treatment effectiveness increases, patient and staff satisfaction increase, and treatment and medication costs decrease (Blount, 2003; Ogbeide, Stermensky II, & Rolin, 2016). For example, one consistent finding is that patients with mood (depression) and anxiety disorders show significant improvement, often without medication, when they work closely with a BHC. Furthermore, when a referral to a mental health specialist is necessary, patients are much more likely to meet the appointment, particularly if the BHC can meet briefly with them during the wait time before the first appointment. The BHC is also freed from the standard 8-10 minute PCP appointment duration to better gather interview information, discuss treatment goals, and even implement brief 15-20 minute follow up appointments to reinforce interventions that are working and to make adjustments where needed.

Older adult patients should be encouraged by the addition of a BHC member to the PCP staff. Such a health care provider is able to better address so many more issues than one’s PCP, and the fact that the BHC has been called in to meet with the older patient in no implies that the patient should be embarrassed or stigmatized. It simply means that he or she will be receiving optimal holistic care that has been shown to have significant benefits.

 

 

References:

Blount, A. (2003). Integrated primary care: Organizing the evidence. Families, Systems, and Health, 21, 121-134.

Centers for Disease Control and Prevention (2013). The stage of aging and health in America 2013. Retrieved from http://www.cdc.gov/health/state_of_aging_and_health_in_America_2013.pdf.

Hunter, C. L., Goodie, J. L., Oordt, M. S., & Dobmeyer, A. C. (2017). Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention (2nd ed.). Washington DC, American Psychological Association: Washington, D.C.

O’Donohue, W. T., Byrd, M. R., Cummings, N. A., & Henderson, D. A. (2005). Behavioral integrative care: Treatments that work in the primary care setting. New York: Brunner-Rutledge.

Ogbeide, S., Stermensky II, G. & Rolin, S. (2016). Integrated primary care behavioral health for the rural older adult. Practice Innovations, 1, 145-153.

Filed Under: AGEC, Newsletter, University of Central Arkansas

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