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

2. 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

3. 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

4. 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

5. No financial disclosures

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

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

8. 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

9. Hospitalist Co-Management Program
Surveyed hospitalist programs over 1 year
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

10. 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

11. 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

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

13. 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

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

15. 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

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

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

18. 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

19. 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

20. 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

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

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

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