Dear Friends,


When the Affordable Care Act was passed in 2011 the focus of health care was intended to shift to health promotion and wellness. Primary care is an important component of this shift. Good primary care helps not only to manage chronic disease, but prevent it as well. Primary care is not the same for every stage of life. Older adults need primary care that is age friendly and recognizes the uniqueness of caring for an older adult. This month HIGN is proud to announce that our Primary Care for Older Adult series for providers (PCOA-PCP) has been updated with the latest evidence-based practice and rebuilt with the newest digital technology. Support for this work was from the legacy gift to HIGN by Mr. Jay Paul. This work ensures the best educational resources are available for healthcare professionals to deliver age-friendly primary health care. Our guest column this month provides a view of some of the complexities of providing that kind of primary care to an older home-bound patient.


I hope you have a wonderful start to the fall season.


Best Wishes,

Tara A. Cortes, PhD, RN, FAAN

Meeting the Complex Needs of Older Adults in Primary Care


Mary Jo Vetter, AGPCNP-BC, FAANP

Clinical Associate Professor at NYU Meyers

Program Director, DNP


Mr. G was hospitalized for five days due to an ischemic stroke related to chronic, uncontrolled hypertension. He was subsequently transferred to a post-acute rehabilitation facility due to left sided weakness, mild aphasia, and general malaise. As discharge plans were being formulated, it became apparent that Mr. G would have difficulty accessing primary care in an office setting for several months as travel would take considerable effort and be taxing on him and his wife. Luckily, his established primary care providers offered home-based services. As his nurse practitioner, I communicated with a facility-based provider to coordinate his transition home, ordered certified home health care, and visited him within two days of discharge to ensure continuity of care and early detection of conditions that would warrant immediate intervention. My orders for home care included skilled nursing, physical therapy, occupational therapy, and speech language pathology to facilitate progress towards the best attainable health outcomes. Mr. G arrived home via ambulette to a fully equipped environment that included a hospital bed and raised toilet seat based on his current functional level. During my initial visit, a comprehensive evaluation uncovered continued elevated blood pressure despite his prescribed medication regimen which had been effective while he was in the facility. I collaborated with the home care RN to initiate remote physiologic monitoring at home and used the trended vital sign reports to safely and effectively titrate the medication dose to control his blood pressure. Mr. G made significant progress over the next two months and was discharged from home care with near normal ambulation, dexterity, speech, cognition, and activity endurance. He continued outpatient therapy for several months and followed up in the primary care office regularly.


Mr. G was very motivated to adopt and maintain healthy habits yet he was fearful that another stroke could occur in the future. He and his wife had never discussed his wishes in the event he could not make decisions for himself. Over a period of time, we discussed issues related to advance care planning. He worked with an elder care attorney to establish a power of attorney and health care proxy and was able to articulate his preferences for care in a variety of clinical circumstances. With these safeguards in place, Mr. G and his wife felt comfortable that there would be guidance available in the event of an unexpected health event. At each follow up visit, it was obvious that Mr. G regained a sense of normalcy. During his annual wellness visit, he disclosed that he had recently experienced a fall but didn’t think it was a serious event as he had no injuries. He was again referred for outpatient physical therapy to improve his balance and muscular strength in an effort to prevent future falls. To date, Mr. G is living a vibrant and full life feeling confident in his health and continually working to remain well.


This case illustrates the importance of primary care, especially in the older adult population. With continued emphasis on insurance reimbursement for services that minimize unnecessary hospitalization and Emergency Department use, an improved quality of life is attainable. Primary care practices are incentivized to provide care that is interprofessional, coordinated and preventive in nature. In this case, additional practice revenue was obtained by billing for transitional care management, home care plan oversight, advance care planning, and the annual wellness visit. More importantly, the health outcomes achieved enabled Mr. G to live a robust and satisfying life.

Primary Care of Older Adults Series for PCPs

HIGN has revamped our Primary Care of Older Adults Series to include the most up-to-date evidence and state-of-the-art instructional design with support from the J. Paul Legacy Fund. This series was developed to increase primary care professionals' age-sensitive healthcare knowledge and skills. Each course promotes team-based, coordinated, patient-centered, evidence-based care that is responsive to the particular needs of older adults. 


Courses:


Annual Wellness Visit

Screening and Disease Management for Older Adults 

Cancer Screening for Older Adults 

Presentation of Illness in Older Adults 

Dementia in Primary Care 

Advance Directives 

Palliative and Hospice Care

Management of Multiple Chronic Conditions

Chronic Pain in Older Adults 

Medication Management in Older Adults 

Reducing Linda’s Medications: Case Study

Practical Guide to Health Care Financing 

Pain, Opioids, and Older Adults 


Click here to learn more.

From Talk to Action: Moving Forward

with Nursing Home Quality Improvement


Prof. Jasmine Travers co-authored an article in McKnight's Long-Term Care News with Isaac Longobardi, Director of the Moving Forward Nursing Home Quality Coalition, and Alice Bonner, Chair of the Moving Forward Nursing Home Quality Coalition and Senior Advisor for Aging at the Institute for Healthcare Improvement. This May, the Senate Special Committee on Aging released a report, Uninspected and Neglected, on the state of nursing homes in America.


In response, the Moving Forward Nursing Home Quality Coalition developed nine action plans: 


  • Addressing Residents Goals' Preferences and Priorities
  • Strengthening Resident Councils
  • Improving Certified Nursing Assistant Wages and Support
  • Expanding Certified Nursing Assistant Career Pathways
  • Enhancing Surveyor Training on Person-Centered Care
  • Designing a Targeted Nursing Home Recertification Process
  • Increasing Transparency & Accountability of Ownership Data
  • Developing a Nursing Home Health Information Technology Readiness Guide
  • Financing Household Models and Physical Plant Improvements


Click here to read the article.

HIGN Scholars Program: Fall 2023


Please join us in welcoming our new HIGN Scholars: Alicia Chen, Xiaohe Chen (Jennie), Daniela Marcano, Emily Rae Vicente and Alejandra Molina! The HIGN Scholars program engages and develops baccalaureate students interested in specializing in the care of the older adult through mentorship and additional training.

HIGN Highlights


The Aliviado Health program of HIGN was highlighted as an exemplar neuropalliative care program in a recent perspective in the New England Journal of Medicine.



Prof. Fidel Lim published an essay entitled On Leaving and Loving Nursing in the ANA's American Nurse Journal.



Shin-Yin Lin, Senior Research Scientist, received a pilot award through the NIDUS network. Read the announcement here.


Xiang Qi was invited to be a guest speaker for a GSA iSession: Latest Perspectives and Future Directions: Effects of Loneliness and Social Isolation on Cognitive Health.



Prof. Tina Sadarangani authored an article We can't ignore our parents getting older for Insider.



Prof. Jasmine Travers was interviewed by CRAIN'S New York on CMS's proposed nursing home staffing rule.



Publications:


Lassell, R., Lin, S.Y., Convery, K., Fletcher, J., Chippendale, T., Jones, T., Durga, A., Galvin, J.E., Ruppper, R., Brody, A.A. (In Press). Neuropsychiatric symptoms in people living with dementia receiving home health services. Journal of the American Geriatrics Society. DOI: 10.1111/jgs.18548



Mao, W., Qi, X., Chi, I., Wichinsky, L., & Wu, B. (2023). Technology-Based Interventions to Address Social Isolation and Loneliness Among Informal Dementia Caregivers: A Scoping Review. Journal of the American Medical Directors Association. https://doi.org/10.1016/j.jamda.2023.08.005

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