Summary: The Practice Change Leaders for Aging and Health program has given many frontline clinicians, including physicians, nurses, and social workers, the training and mentoring they need to transform care for older Americans. The program, which emphasizes the importance of building a business case for change, has led to several innovative models of care.
By Martha Hostetter and Sarah Klein
Older Americans, who are among the U.S. health care system's most vulnerable and frequent users, are arguably the most affected by its dysfunction. The system's failure to coordinate care between inpatient and outpatient settings, lack of attention to the social impediments to health, and inadequate focus on behavioral health all contribute to poorer physical health and quality of life.
The challenge of redesigning care models around the needs of the elderly is not for lack of ideas. Some of the more creative strategies for addressing these problems have emerged from frontline providers, who experience the dysfunction firsthand. It was a geriatrician at Johns Hopkins Medicine, Bruce Leff, M.D., who launched an ambitious program to help elderly patients avoid hospital-acquired infections and delirium by obtaining acute-care services at home.1 Another geriatrician, Eric Coleman, M.D., associate professor of medicine at the University of Colorado, came up with a national program for improving transitions in care that is helping to reduce readmissions and complications by fostering partnerships between the community-based organizations that provide elder services and the hospitals, nursing homes, and rehab facilities that need their help.2
A greater problem, Coleman and others believe, is that those with a vision for transforming geriatric care often lack the experience and training they need to overcome the financial, cultural, and organizational barriers they are likely to encounter as they attempt to change systems of care. "Building the core skills needed to make change happen—business case development, conflict negotiation, leading cultural change—these things are paramount," says Coleman, who received a "genius grant" from the MacArthur Foundation in 2012 for his work on care transitions.
To help them, Coleman created a program to provide physicians, nurses, social workers, and others with the leadership skills required to transform geriatric care. Founded in 2007 with funding from the Atlantic Philanthropies and John A. Hartford Foundation, the Practice Change Leaders for Aging and Health program provides training and mentoring to 10 professionals each year.3 It differs from programs that seek to train clinicians in particular quality improvement approaches, such as use of iterative quality improvement strategies and techniques from the manufacturing industry, because of its focus on leadership skills, policy, and personal development.4 Participants take part in peer-to-peer exchanges and problem-solving sessions, and receive mentoring from leaders in the field while they develop a particular improvement project (see exhibit). For example, James Campbell, M.D., director of geriatric health at Cleveland's MetroHealth, used the experience to help him launch a standalone medical center to provide older adults with a single point of access to all of their specialists, as well as to social workers and nutritionists.
To win support, “you have to think of the project outside of yourself,” Campbell says. “What does it look like to the mayor, to the city councilman, to the foundation director, as well as to the CFO, the CEO, and the chief nursing officer? They all see things differently.” Eventually, Campbell secured $32 million in funding for the center, which included support from the county and private philanthropies, in part by making the case that it would have a positive impact on the larger community. In fact, in the year after the center opened in a building that had sat empty since a hospital's closing, the crime rate within a 1.5 mile radius dropped by 26.5 percent.
Jennifer DeCubellis, assistant county administrator for health for Minnesota's Hennepin County and part of this year's cohort, took a similar approach in her efforts to enlist law enforcement, housing agencies, and other community partners in her efforts to improve care for Medicaid beneficiaries (see Q&A.)
Cross-Disciplinary Approach
The Practice Change Leaders program also gives participants the opportunity to interact with experts in medicine, public health, and the social service sectors, creating a microcosm of the care communities in which they function. For Lisa Ferretti, a social worker based at the University of Albany and a participant in the first cohort, this kind of interdisciplinary exchange was eye-opening. "I learned a lot about how the health care financing system works—where there is money in the system to help with public health projects to create mutually beneficial relationships," she says. Ferretti used the experience to develop a program to engage residents of a low-income neighborhood in Albany in efforts to lose weight, offering free health screenings and incentives to exercise and choose healthy foods. The popular program, know as the Biggest Winner, led to a state grant to build indoor exercise spaces and the city's creation of urban walking paths.
In turn, Ferretti felt like she brought an important on-the-ground perspective to the discussions. "Sometimes, health care pathologizes people's inability to make changes—we need to understand the incredible challenges faced by patients. It's hard to tell someone to walk 30 minutes a day if there are no safe places to walk in their neighborhood."
Making the Business Case
Another central focus of the Practice Change Leaders program is learning how to build a business case for improvement efforts. Each participant has to make a 10-minute pitch to a panel of seasoned health care executives about how their proposed project will not just improve care for seniors but also bring a return on investment—an approach that is similar to the format of the television show “Shark Tank.” This requires them to fine-tune their message and bring hard data as evidence, as Audrey Chun, M.D., learned in 2009 when she pitched her idea for establishing geriatric patient-centered medical homes in New York's Mount Sinai health system. This would require hiring team members who wouldn't bring in revenue for her employer.
“They asked, 'How are you different from every other administrator coming into my office asking for money for their program?'” Chun recalls. Noting that federal penalties for avoidable readmissions were on the horizon, Chun pitched the geriatric medical home as a way for the hospital to avoid losing money in the future. She ultimately secured support, and readmissions among the medical home's patients decreased over a 30-month period from about 25 percent to 14 percent.
Making the Case for Quality
Lee Greer, M.D., who joined the program in 2007, wanted to create "heart failure days," during which care teams, including himself (a geriatrician), an echocardiogram technician, outcomes manager, and pharmacist, would visit high-risk heart failure patients in the many small, rural clinics that are part of the North Mississippi Health System. The teams would review patients' medications, identify gaps in care, and make recommendations to their 'primary care physicians. But this model didn't have immediate appeal for leaders at the health system, which depended on revenue from fee-for-service payments. “We had not yet experienced HMOs, capitation, or other payment methods that were commonplace in other parts of country. Explaining why we needed to move to this model was a huge barrier," Greer says.
He was ultimately persuasive with the argument that better and more proactive primary care would enable the health system to get ahead of trends in payment and delivery reform. His project did in fact lead to better-quality care: patients who received team visits had reduced emergency department and hospital use, and higher rates of ACE inhibitor use, beta blocker use, pneumonia vaccinations, and echocardiograms. A few years later, North Mississippi Health System created "diabetes days" along the same model and last year, the health system received the Baldrige Award, in part because of its work in improving diabetes management and outcomes.
“What I gleaned from the program was the essentials of leadership, collaborations, influence," says Greer, "and how providers and people who have passion for change can have a profound influence on others around them.”
Influencing Policymaking
The Practice Change Leaders program has an explicit goal of encouraging leaders to influence change not just within their own professional spheres or local context, but also at the level of policymaking. Advisers will often push leaders to think bigger—and make introductions to help them take a broader approach. For example, Christian Furman, M.D., a geriatrician with Kentucky's University of Louisville and a 2013 Practice Change Leader, was interested in influencing how advanced care discussions take place in nursing homes, including the one for which she is the medical director.
"We said, ''Christian, this is important work, and have you considered extending your reach as part of the national POLST [Physician Orders for Life-Sustaining Treatment] movement?'" says Nancy Wilson, a gerontological social worker from the Baylor College of Medicine and one of the program's advisers. "We said, 'Instead of influencing just a few nursing homes you could potentially influence the whole state.'" Furman is now working with a University of Louisville team to promote POLST legislation that will be coming up in the Kentucky statehouse this January.
Leaders also discuss their projects with representatives from the Centers for Medicare and Medicaid Services and other agencies. "What we really want to do is help them realize they are part of the policymaking process—meeting with policymakers is a big identity boost," says Coleman. "We also want to build a feedback loop to the Center for Medicare and Medicaid Innovation, Congress, and elsewhere in government to provide on-the-ground views from people who want to improve practice."
The insight these sorts of conversations provide is essential to formulating a vision that others will be willing to follow, says Marjie Harbrecht, M.D., of HealthTeamWorks, a Colorado-based nonprofit that helps organizations redesign care models. That's because the future design of the health care system and the incentives underlying it are very uncertain, which creates resistance and skepticism. “You are going a bit without a roadmap,” she says.
Impact and Spread
One of the key benefits of the Practice Change Leaders program is "validation," says another of its advisers, Christine Fordyce, M.D., a family medicine clinician and geriatrician at Group Health."[People in geriatric care] are often working in isolation, and don't have an organizational directive to think about what good clinical care might be."
Andrew Garman, CEO of the National Center for Healthcare Leadership, agrees that external relationships can be crucial, especially when a person is going up against a system. “The system can try to make the person believe they are crazy. And to hear other people say, 'No, you are not crazy. You are getting out of the system the reaction people get when they try to change the system' can really help.”
And though the program supports only a small number of people—10 per year—there is evidence it has had ripple effects. Many of the leaders serve as mentors within their organizations and have been sought out by others working to improve care for seniors.
The experience led Campbell to apply for and win a $1.2 million grant from the Bureau of Health Professions to teach faculty members how to provide "systems-based medicine," with a focus on serving the whole patient and preserving their quality of life and care.
For Randi Berkowitz, M.D., medical director for care system improvement and care delivery innovation at Massachusetts' Commonwealth Care Alliance, the program is helping to spread a proven model of reducing hospitalizations. About five years ago, Berkowitz developed a program to reduce transfers from skilled nursing facilities (SNFs) to hospitals through automatic palliative care consults for all high-risk patients; standardized assessments by physicians at the time of admission, including discussion of the goals of care; and team improvement for patients and safety (TIPS) conferences to understand and address shortcomings in care for patients transferred to the hospital. This intervention led to a 20 percent reduction in hospitalizations among patients of Hebrew SeniorLife nursing home residences, where she then worked. Now at Commonwealth Care Alliance, a nonprofit special needs plan covering 5,000 of the state's "dual eligibles" (beneficiaries of both Medicare and Medicaid), Berkowitz is using her 2013 Practice Change Leader experience to create a strategy to scale and spread her intervention to dual eligibles across the state.
This model of care has received national attention. "I have been called by people from all over the country who are interested in doing TIPS conferences and bringing the patient and family voice into improving care," says Berkowitz.
1 S. Klein, "'Hospital at Home'" Programs Improve Outcomes, Lower Costs But Face Resistance from Providers," Quality Matters, August/September 2011, The Commonwealth Fund.
2 M. Hostetter and S. Klein, "Avoiding Preventable Hospital Readmissions by Filling in Gaps in Care: The Community-Based Care Transitions Program," Quality Matters, August/September 2012, The Commonwealth Fund.
3 Leaders receive $45,000, with the requirement that their organizations make in-kind contributions of about $20,000 in the form of employee time, staff to collect data, hardware, or other equipment. The Practice Change Leaders program was the model for the Centers for Medicare and Medicaid Service's short-lived Innovation Advisors Program. The program was originally two years, but it is now one year long.
4 A sister program, Health and Aging Policy Fellows program, also funded by Atlantic Philanthropies, provides support for practitioners to learn firsthand about federal and state policymaking processes.