1. Status of Geriatric Medicine in the United States Daniel Swagerty, MD, MPH Professor of Family Medicine and Internal Medicine Associate Chair for Geriatrics and Palliative Care, Department of Family Medicine Associate Director, Landon Center on Aging University of Kansas School of Medicine Kansas City, Kansas USA

3. Objectives Understand the following about Geriatric Medicine in the United States (U.S.):  Challenges of Caring for Older Adults  How Geriatric Medicine Differs as a U.S. Medical Specialty  Geriatric Medicine Training for Medical Students, Resident Physicians and Fellows

4. Challenges of Caring for Older Adults

6. World’s Population is Aging  2 Billion Adults over 60 years by 2050  1 out of every 5 People  Outnumber Children Worldwide  Fastest –Growing Segment will be over 80 years  People over 100 years will increase by a factor of 14 to 4 million by 2050 United Nations Program on Aging, Online

7. Challenges of Caring for Older Adults Current Training of U.S. Geriatricians  Too Few Geriatricians Produced – 7500 Geriatricians, but 17,000 currently needed to care for the frailest 30 % of Older Adults – 30,000 Geriatricians needed by 2030 – Rural Areas in Greatest Need Institutes of Medicine and Alliance for Aging Research, Online

8. Challenges of Caring for Older Adults Current Training of U.S. Geriatricians  St udents and Resident Physicians Lack Interest in Geriatrics – Underestimate the magnitude of need in coming decades Only 2/3 of Family Medicine Residents expect Geriatrics to be major part of their practice (Helton and Pathman,2008) rather than the reality that most of their patients will be elderly – Low Compensation Debt load of > $ 200,000 (200 Million W) Geriatricians make less than Family Physicians and General Internists, even with extra training

9. Challenges of Caring for Older Adults Current Training of U.S. Geriatricians  Students and Resident Physicians Lack Interest in Geriatrics – Negative Attitudes towards Older Adult Patients Too Complex Medical/Psychosocial Problems – Overwhelming Too Few Cures - Depressing Too Much Time - Demanding Too “Low Tech” – Unscientific – Training Experiences focused too much on the Frailest Older Adults

10. How Geriatric Medicine Differs as a U.S. Medical Specialty

11. Geriatric Medicine in the U.S.  Deals with the Process of Aging through a Scientific Background in the Changes of Physiologic, Physical, Psychological, and Social Function  Focuses on the Whole Patient, with Function and Quality of Life the Primary Concern  Specific Organ Based Diseases Less Important than Geriatric Syndromes and Conditions * Highest Ranked Specialty for Professional Satisfaction

12. How Geriatric Medicine Differs as a U.S. Medical Specialty Geriatric Medicine in the U.S.  Regarded as both primary care physicians and specialists for older adults  Comprehensive care and assessment  Continuity of care  Care across many sites  Hospitals  Clinics  Post-acute and Long Term Care Facilities  Home  Hospice

13. How Geriatric Medicine Differs as a U.S. Medical Specialty Geriatric Medicine in the U.S.  Regarded as both primary care physicians and specialists for older adults  Adult Medicine – Family Physician/Internist  Psychiatry  Physical Medicine and Rehabilitation  Neurology  Palliative Care and Hospice  Post-acute and Long Term Care Medicine

14. How Geriatric Medicine Differs as a U.S. Medical Specialty Value of Geriatric Medicine in the U.S.  Comprehensive and continuous care of older adults across many sites  Transitions of Care  Person Centered Approach  Coordination of Care  Focus on maintaining Functional Independence and Quality of Life

15. How Geriatric Medicine Differs as a U.S. Medical Specialty Value of Geriatric Medicine in the U.S.  Cost Savings  Hospitals  Health Systems  Government  Private Insurers  Patient Safety

16. How Geriatric Medicine Differs as a U.S. Medical Specialty Geriatric Medicine Training in the U.S.  All Schools of Medicine (4 Years) have some training in Geriatrics for their medical students, but only 27 % have a required separate rotation  All Family Medicine and Internal Medicine Residencies (3 Years) have required training in Geriatrics, with 95 % FM programs and 91 % of IM programs have 2 weeks or more of a separate rotation

17. How Geriatric Medicine Differs as a U.S. Medical Specialty Geriatric Medicine Training in the U.S.  Fellowship Training (1 Year) – 200 U.S. Programs  Required to be a Geriatrician  Follows either Family or Internal Medicine Residency Training  Provided by either Departments of Family or Internal Medicine  Family Physicians or Internists can train in either departmental program  Before 1992, a Board Certified Family Physician or Internist could take a test to be a certified as a Geriatrician

19. Minimum Geriatric Competencies for U.S. Medical Students

20. Minimum Geriatric Competencies for Graduating U.S. Medical Students  Set of 26 Minimum Competencies to Assure Competent Care of Older Adults by all First Year Residents, regardless of specialty choice  Focus on Issues that Impact Health Outcomes and Safety for Older Adults  Similar to Quality Indicators  Minimum Expected Behaviors  Taught and Evaluated by Any Medical School, with Approach Varied between Medical Schools  8 Primary Domains

21. Minimum Geriatric Competencies for Graduating U.S. Medical Students 8 Primary Domains  Cognitive and Behavioral Disorders  Medication Management  Self-Care Capacity  Falls, Balance, and Gait Disorders  Atypical Presentation of Disease  Palliative Care  Hospital Care for Elders  Health Care Planning and Promotion

23. Minimum Geriatric Competencies for U.S. Internal Medicine and Family Medicine Residents

24. Purposes are to Define What is :  Unique to the Care of Older Adults  Feasible within the Structure of Current Residency Programs  The Minimum, but Uniform Expectations for all Graduating Residents  Measure Behavior and Specific to Enable Assessments  Approved and Accepted by Key Stakeholder Organizations and Residency Program Directors

25. Minimum Geriatric Competencies for U.S. Internal Medicine and Family Medicine Residents Competencies  Based on the 26 Minimum Competencies for Medical Students  7 Domains – Transitions of Care – Hospital Patient Safety – Cognitive, Affective, and Behavioral Health – Complex or Chronic Illnesses – Medication Management – Ambulatory Care – Palliative and End of Life Care

27. Curricular Milestones for Graduating U.S. Geriatric Medicine Fellows

28. Curricular Milestones  What every graduating fellow should be able to demonstrate  Ensure that they can effectively and safely practice  All care settings  With all different older adult populations  3 Major Domains  Caring for the Elderly Patient  Systems-Based Care for Elderly Patients  Geriatric Syndromes  76 Total Milestones

29. Curricular Milestones for Graduating U.S. Geriatric Medicine Fellows Caring for the Elderly Patient Domain (Milestones)  Communication (7)  Gerontology (2)  Medication Management (4)  Functional Impairment and Rehabilitation (3)  Diseases in Older Adults (4)  Complex Illness(es) and Frailty in Older Adults (6)  Palliative and End-of-Life Care (2)

30. Curricular Milestones for Graduating U.S. Geriatric Medicine Fellows Systems-Based Care for Elderly Patients Domain (Milestones)  General (13)  Hospital Care (3)  Ambulatory Care (2)  Home Care (2)  Long-Term Care and Nursing Home Care (3)

31. Curricular Milestones for Graduating U.S. Geriatric Medicine Fellows Geriatric Syndromes Domain (Milestones)  Falls and Dizziness (3)  Cognitive, Affective, and Behavioral Health (8)  Pressure Ulcers (3)  Sleep Disorders (1)  Hearing and Vision Disorders (2)  Urinary Incontinence (3)  Weight Loss and Nutritional Issues (3)  Constipation and Fecal Incontinence (2)

33. End-of-Training Entrustable Professional Activities for Geriatric Medicine

34. End-of-Training Entrustable Professional Activities (EPAs) for Geriatric Medicine  Core Work that Constitutes a Discipline’s Specific Expertise – 12 EPAs  Framework for Faculty to Perform Meaniful Assessment of U.S. Geriatric Medicine Fellows  Describes a Geriatrician’s Fundamental Expertise  Describes How Geriatricians differ from General Internists and Family Physicians who Care for Older Adults

35. End-of-Training Entrustable Professional Activities (EPAs) for Geriatric Medicine U.S. Geriatricians entering into practice, in all care settings, are able to:  Provide Patient-Centered Care that Optimizes Function and/or Well-Being  Prioritizes and Manages the Care of Older Patients by Integrating the Patient’s Goals and Values, Co-Morbidities, and Prognosis into the Practice of Evidenced-Based Medicine  Assist Patients and Families in Clarifying Goals of Care and Making Care Decisions  Prevent, Diagnosis, and Manage Geriatric Syndromes

36. End-of-Training Entrustable Professional Activities (EPAs) for Geriatric Medicine U.S. Geriatricians entering into practice, in all care settings, are able to:  Provide Comprehensive Medication Review to Maximize Benefit and Minimize Number of Medications and Adverse Events  Provide Palliative and End-of-Life Care for Older Adults  Coordinate Health Care and Healthcare Transitions for Older Adults with Multiple Chronic Conditions and Multiple Providers  Provide Geriatrics Consultation and Co-management

37. End-of-Training Entrustable Professional Activities (EPAs) for Geriatric Medicine U.S. Geriatricians entering into practice, in all care settings, are able to:  Skillfully Facilitate a Family Meeting  Collaborate and Work Effectively as a Leader or Member of an Interprofessional Healthcare Team  Teach the Principles of Geriatric Care and Aging-Related Healthcare Issues to Professionals, Patients, Families, Healthcare Providers, and Others in the Community  Collaborate and Work Effectively in Quality Improvement and Other Systems-Based Initiatives to Assure Patient Safety and Improve Outcomes for Older Adults

38. Summary Geriatric Medicine Needs: More physicians world-wide with requisite skills, training and experience to care for an increasingly frail older adult population Specific set of physician competencies, curriculum and training through Geriatric Medicine fellowships More certified Geriatricians since credibility predicated on specialization

39. Questions and Comments

41. The Family Medicine Geriatrics in the United States

42. Objectives Understand the following about Family Medicine Geriatrics in the United States (U.S.):  Challenges of Training our Family Medicine Resident Physicians to Care for Older Adults  How Care Differs between Family Medicine (FM) Geriatricians and Family Physicians  Why Family Medicine is Excellent Training for Geriatrics

43. Challenges of Training our Family Medicine Resident Physicians to Care for Older Adults Attitudes and Future Plans of U.S. Family Medicine Resident Physicians in Geriatric Care  Attitudes  Generally, positive attitudes towards/interest in older adults  Some decline over the 3 years of residency  Only 68 % think that older adults will compromise a significant percentage of their practice  Less positive attitudes towards/interest in nursing home residents  Less professionally and financially satisfying

44. Challenges of Training our Family Medicine Resident Physicians to Care for Older Adults Attitudes and Future Plans of U.S. Family Medicine Resident Physicians in Geriatric Care  Plans – 92 % plan to provide ambulatory care to older adults – 26 % plan to provide nursing home care  Obstacles to Nursing Home Care – Time constraints and financial concerns

45. Challenges of Training our Family Medicine Resident Physicians to Care for Older Adults Too Few U.S. Faculty Geriatricians in Family Medicine Residencies  500 Accredited Family Medicine Residencies  1100 Faculty Geriatricians, with many residencies without one  Many faculty have heavy clinical loads and too little time for teaching  Many faculty aging themselves and will retire * Institutes of Medicine and Alliance for Aging Research, Online

47. How Care of Older Adults Differs between Family Medicine (FM) Geriatricians and Family Physicians

48. How Care of Older Adults Differs between FM Geriatricians and Family Physicians Family Medicine (FM) Geriatricians in the U.S.  About 3 % (2000) of all Family Physicians (75,000)  100 new FM Geriatricians each year  300 FM Geriatricians recertify each year  40 % of FM Geriatricians spend > 80 % of their time devoted to Geriatrics, with another 20 % spend 60 – 80 % of their time

49. How Care of Older Adults Differs between FM Geriatricians and Family Physicians Family Medicine (FM) Geriatricians in the U.S.  Versatile Professional Opportunities  Private Practice  Academic Medicine  Clinical Care  Education  Research  Government  Private Industry

50. How Care of Older Adults Differs between FM Geriatricians and Family Physicians Family Medicine (FM) Geriatricians in the U.S.  Leading FM Departments for Geriatric Medicine  Jefferson Medical College  University of Arizona  University of California – Irvine  University of East Carolina  University of Iowa  University of Kansas  University of Missouri  University of North Carolina – Chapel Hill  University of South Dakota  University of Texas – San Antonio

51. How Care of Older Adults Differs between FM Geriatricians and Family Physicians Family Medicine Geriatricians in the U.S.  Fundamentals of FM practiced as a Geriatrician – Continuity of Care – Family as a Unit of Care – Community –Based Thinking – Psychosocial Approach  Additional Emphasis on Older Adults – Whole Person Approach – Functional Abilities and Quality of Life are Highest Priorities

52. How Care of Older Adults Differs between FM Geriatricians and Family Physicians Value of FM Geriatricians in the U.S.  Comprehensive and continuous care of older adults across many sites  Transitions of Care  Person Centered Approach  Coordination of Care  Focus on maintaining Functional Independence and Quality of Life

53. How Care of Older Adults Differs between FM Geriatricians and Family Physicians Value of FM Geriatricians in the U.S.  Cost Savings  Hospitals  Health Systems  Government  Private Insurers  Patient Safety

54. How Care of Older Adults Differs between FM Geriatricians and Family Physicians Majority of Care of U.S. Older Adults by Generalists (Family Physicians and Internists)  Growing Numbers of Older Adults  Increased Pressure on Generalists to Provide More Outpatient and Post-Acute/Long Term Care  Increased Pressure to Provide Effective Care of General Medical (Organ Specific) and Geriatric Conditions (Syndromes)  Higher Quality Care for General Medical and Geriatric Conditions Associated with Better Outcomes for Older Adults

55. How Care of Older Adults Differs between FM Geriatricians and Family Physicians Majority of Care of U.S. Older Adults by Generalists (Family Physicians and Internists)  Fundamentals of Geriatric Care – Care Continuity and Coordination Across the Continuum of Care – Pharmacologic Management – Assessment and Management of Geriatric Syndromes Dementia, Delirium, Depression Gait Ataxia and Falls Incontinence and Constipation Pressure Ulcers Nutritional Compromise Dysphagia

56. How Care of Older Adults Differs between FM Geriatricians and Family Physicians Majority of Care of U.S. Older Adults by Generalists (Family Physicians and Internists)  Generalist Challenges in Care of Older Adults – Mental Status Recognition of Dementia in Ambulatory Care – 40 % patients missed over repeated visits (Chodash & Petitti, JAGS 2004;52:1051-9) Recognition of Delirium in Post-Acute/LTC - 25 % of patients missed at admission (Marcantonio & Simon, JAGS 2003; 51:4-9)

57. How Care of Older Adults Differs between FM Geriatricians and Family Physicians Majority of Care of U.S. Older Adults by Generalists (Family Physicians and Internists)  Generalist Challenges in Care of Older Adults – Medication Management Inappropriate Prescribing of Type and Number of Medications - 40 % in Post-Acute/LTC residents -21 % in Ambulatory Care Adverse Medication Reactions resulting in preventable hospital admissions (30 %) and preventable problems, such as falls and confusion

58. How Care of Older Adults Differs between FM Geriatricians and Family Physicians Majority of Care of U.S. Older Adults by Generalists (Family Physicians and Internists)  Generalist Challenges in Care of Older Adults – Care of Geriatric Syndromes – Inadequate Recognition of Conditions – Inadequate Knowledge of Management – Inadequate Recognition of Poor Patient Adherence of Recommendations – Inadequate Follow-up of Conditions  Generalists Lack Recognition of Geriatric Conditions – Multi-factorial Etiologies with Common Symptom Pathways – Occurs across organ systems

59. How Care of Older Adults Differs between FM Geriatricians and Family Physicians Majority of Care of U.S. Older Adults by Generalists (Family Physicians and Internists)  Generalist’s Detection and Care of Geriatric Syndromes Less Optimal than Care for General Medical Conditions  Higher Quality of Care by Geriatricians (with fellowship training) vs Care by Generalists ( without fellowship training) – Medication Management – Assessment and Management of Geriatric Conditions – Assessment and Management of Functional Status – Care Continuity and Coordination Across the Continuum of Care Phelan & Genshaft, JAGS 2008 Oct 56(10) 1807-1811

60. Summary Family Medicine Residencies are the best preparation for Geriatric Medicine Fellowships  Fundamentals of Family Medicine practiced as a Geriatrician – Continuity of Care – Family as a Unit of Care – Community–Based Thinking – Psychosocial Approach – Whole Person Approach – Functional Abilities and Quality of Life Highest Priorities – Coordination Across the Continuum of Care

61. Questions and Comments