Rally the Troops: Optimizing Teams for Care of Hospitalized Elders American Geriatrics Society Annual Meeting 2013 Grapevine, Texas

Jonathan F. Bean MD, MS, MPH Wanda Horn, MD Director, Geriatrics Inpatient Service Assistant Professor of Medicine Albert Einstein College of Medicine Joe Verghese, MBBS, MS Chief, Integrated Divisions Cognitive & Motor Aging and Geriatrics Professor of Neurology and Medicine Albert Einstein College of Medicine Sharon K. Inouye, MD, MPH Director, Aging Brain Center Hebrew SeniorLife Professor of Medicine Harvard Medical School Jonathan F. Bean MD, MS, MPH Medical Director, Spaulding Outpatient Center Associate Professor of PM&R Harvard Medical School

Objectives Develop partnerships with medical and surgical specialties Discuss the utility of cognitive and motor risk stratification and prediction tools Recognize and prevent neurogeriatric syndromes like delirium Team with rehabilitation medicine to set functional goals and improve outcomes

Geriatrics and Surgery: Are You Ready for a Partnership with a Surgical Team? Wanda Horn, MD Director Geriatrics Inpatient Service Assistant Professor of Medicine Albert Einstein College of Medicine

No financial disclosures

Objectives Define co-management Compare different co-management models Describe the Montefiore Model Discuss future developments in co-management models

Elements of Co-Management Team Group of professionals Interdependence Sharing authority Responsible for self-management Accountable Common goal Performance greater than the individual sum

Medical Co-Management as a Business Model Engagement of physicians to assist business in a hospital setting Joint effort to improve hospital practices Develop specialty-specific protocols Establish specific inpatient quality and efficiency objectives Erickson JC. Physicians Practice 2011

Hospitalist Co-Management Program Surveyed hospitalist programs over 1 year 2005-2006 85% co-managed patients Orthopedic DRGs most prevalent Performance measures LOS, mortality, readmissions, patient and provider satisfaction Few studies evaluating co-management programs Mixed results on clinical and economic outcomes SHM- Guide To Building a Co-Management Program 2012

Impact of Hospitalist Co-management Programs Mainstay of hospital medicine Fueled massive demand for hospitalists Manpower shortage Possible specialist disengagement and hospitalist career dissatisfaction and burnout Siegal EM. Journal of Hospital Medicine 2008

Co-Management Program Profiles Beds Community vs Academic Year MDs Specialties 1 120 Community 2006 10 Orthopedics Neurosurgery 2 500 2001 20 3 150 4 1000 Academic 60 5 600 2000 Hematology Oncology 6 1200 1997 35 7 550 Cardiology CT surgery No Geriatrics

Geriatrics Co-Management Effect of Geriatricians on Outcomes of Inpatient and Outpatient Care Impact of inpatient multidisciplinary teams that included geriatricians Cochrane 2011 - ACE units Systematic review - limited data 5 individual studies - lacked power Department of Veterans Affairs, Veteran Health Administration, Quality Enhancement Research Initiative 2012

Geriatrics Co-Management Hip Fracture Study Co-managed Geriatric Fracture Center (GFC), 2004 Highland Hospital, University of Rochester School of Medicine and Dentistry, NY 195 patients over a one year period Geriatrics and Orthopedics Friedman et al. JAGS 2008

Geriatrics Co-Management Hip Fracture Study Lower than predicted length of stay and readmission rates Short time to surgery Low complication rates and mortality

Geriatrics Co-Management Hip Fracture Program Principles Most patients benefit from surgical stabilization Short time to surgery, less iatrogenic illness Frequent communication avoids iatrogenesis Standardized protocols decrease unwarranted variability Discharge planning begins at admission Friedman et al. JAGS 2008

Montefiore Geriatrics Co-management Long history of consultative service Orthopedics General surgery Vascular surgery Neurosurgery Hip fracture service Co-management with orthopedics 2010

Fall Emergency Room Co-Management Admission Traditional Consult Service Co-Management Surgery Traditional Consult Service? Co-Management Hospital Discharge Co-Management Rehabilitation

Montefiore Geriatrics Co-Management 120 hip fracture admissions 2011 Usual care versus Geriatrics co-management Geriatrics cohort: Geriatrician + Orthopedics in the ED Outcomes Delirium Length of stay Perioperative complications Readmissions In-hospital deaths

W Horn, unpublished data GERIATRICS (n = 68) USUAL CARE (n = 52) P-value Age, years 85.2 ± 7.7 83.4 ± 7.8 0.22 Women, n (%) 50 (73%) 39 (75%) 0.99 Community residing, n (%) 49 (72%) 37 (71%) 0.53 Time to surgery, days 0.8 ± 0.8 1.1 ± 1.0 0.15 Risk category: Low, n 22 17 0.67 Risk category: Intermediate, n 38 31 Risk category: High, n 8 4 W Horn, unpublished data

W Horn, unpublished data GERIATRICS (N = 68) USUAL CARE (N = 52) P-value Perioperative Complications, n(%) 9 (13%) 7 (13%) 0.99 Delirium, n(%) 15 (22.0%) 2(3.8%) 0.007 Length of stay, day 4.9 ± 2.2 7.1 ±6.2 0.008 30 day readmission, n(%) 11(16%) 7(13%) 0.42 In-Hospital Deaths, n(%) 0 (0%) 2 (4%) 0.15 W Horn, unpublished data

Montefiore Geriatrics Co-Management Co-management works Increased efficiency Choose the right partner Tailored to service and institution Need for more studies

Future Directions Extend the model TAVR experience Barriers to overcome Personnel Clinical Risks Teaching Physician Satisfaction

Acknowledgements Division of Geriatrics Rubina Malik, MD, MSc Paul Cavaluzzi, MD- Geriatrics Fellow 2013 Department of Orthopaedic Surgery