Geriatrician Roles and the Value of Geriatrics in an Evolving Healthcare System
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UCSF Health Workforce Research Center on Long-Term Care Resear ch Repor t Geriatrician Roles and the Value of Geriatrics in an Evolving Healthcare System Tim othy Bates, MPP Aubri Kottek, MPH Joanne Spet z, PhD July 8, 2019 This report was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) as part of an award totaling $533,932.00, with 0% financed with non-governmental sources. The contents are those of the author[s] and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS, or the US Governm ent. Please cit e as: Bates, T., Kottek, A., Spetz, J. (2019). Geriatrician Roles and the Value of Geriatrics in an Evolving Healthcare System. San Francisco, CA: UCSF Health Workforce Research Center on Long- Term Care. UCSF Health Workforce Research Center on Long-Term Care, 3333 California Street, Suite 265, San Fr ancisco, CA, 94118 Copyright © 2019 The Regents of the University of California Cont act : Tim Bates, timothy.bates@ucsf.edu, (415) 502-1558 UCSF Health Workforce Research Center on Long-Term Care Research Report Geriatrician Roles and the Value of Geriatrics in an Evolving Healthcare System Table of Contents Table of Contents ........................................................................................... 2 Table of Tables .............................................................................................. 3 Execut ive Sum m ary ....................................................................................... 4 Background ................................................................................................... 7 Methods ........................................................................................................ 8 Recruit m ent ................................................................................................ 8 Profile of Interview Participants ..................................................................... 8 Interviews and Analysis ............................................................................... 9 Key Findings ................................................................................................ 10 Geriatrician Roles ...................................................................................... 10 Direct Patient Care Roles ......................................................................... 11 Consult ant Versus Co-management .......................................................... 13 Educator for Geriatricians and Non-geriatricians ......................................... 16 Leadership ............................................................................................. 18 Valuing Geriatric Care ................................................................................ 22 Valuing Geriatrics Effectively .................................................................... 22 Geriatrics as a Meta-discipline .................................................................. 25 Geriatrician Training .................................................................................. 28 Conclusion .................................................................................................. 30 Recom m endat ions ........................................................................................ 32 Relat ed Resources ........................................................................................ 34 References .................................................................................................. 35 2 UCSF Health Workforce Research Center on Long-Term Care Research Report Table of Tables Table 1. Interview participants’ occupations and types of organizations ................ 9 Table 2. Specific high-level interventions for the Age Friendly Health System 4 M Model ......................................................................................................... 20 3 UCSF Health Workforce Research Center on Long-Term Care Research Report Geriatrician Roles and the Value of Geriatrics in an Evolving Healthcare System Executive Summary I. Introduction There are insufficient numbers of practicing geriatricians to meet current demand for their services, and the shortage is projected to worsen in the coming decades as the number of older Americans rapidly increases. Understanding how to best leverage geriatricians as members of an overall care team is critical. This report is the second component of a two-stage project examining current and emerging roles of geriatricians as members of healthcare teams across different care settings. The first report, The Roles and Value of Geriatricians in Healthcare Teams: A Landscape Analysis, provided a comprehensive analysis of the current landscape, derived from scholarly work assessing how geriatricians are integrated into healthcare teams and how care is delivered to the geriatric population in different types of healthcare delivery systems. This study focuses on information solicited from leaders in geriatrics as to how different types of healthcare organizations utilize geriatricians and how geriatrician roles may evolve and new roles emerge as healthcare systems and organizations reorganize care in response to a changing environment. II. Methods Semi-structured qualitative interviews were conducted with field experts in geriatrics, including practicing geriatricians, academic researchers, clinician educators, healthcare philanthropists, and representatives from professional geriatric societies. III. Findings There were several common themes among key informants’ descriptions of geriatrician roles: (1) Geriatrics should be seen as a set of principles that can inform all care provided to older adults, by all types of providers; (2) Geriatricians are engaged in direct patient care activities as primary care providers, serve in consultative and care management roles, are clinician educators, conduct academic and policy research, are engaged in practice model redesign and implementation, 4 UCSF Health Workforce Research Center on Long-Term Care Research Report and hold positions in many types of healthcare organizations at the director or executive level; (3) Healthcare organizations, conscious that geriatricians are a scarce resource, are increasingly focused on utilizing them in roles that amplify their expertise; and (4) Healthcare organizations are adapting to the emerging value-based payment environment, with its focus on interdisciplinary team-based care, and implementing care models designed to provide higher quality lower cost care to older adults, as compared with the procedure-based fee-for-service system. IV. Conclusion Interviews suggest that healthcare systems and organizations are reorganizing the delivery of geriatric care in ways that acknowledge the persistent shortage of geriatrician specialist physicians and seek to utilize this scarce resource to both amplify geriatricians’ expertise and provide higher quality, lower cost care. Geriatricians continue to provide direct care to patients but increasingly do so as part of interdisciplinary teams, which facilitates integrated, comprehensive care. While the role of academic clinician educator will always be necessary and fundamental, it is clear that for healthcare systems and organizations to embrace the concept of geriatrics as meta-discipline – not a niche specialty, but rather a set of principles that informs all care provided to older adults – a key role for geriatricians will be to educate non-geriatrician providers in geriatrics principles. As value-based care continues to incentivize the adoption of innovative geriatric care models, organizations will rely on geriatricians to lead efforts to implement them. V. Policy I mplications The expectation that geriatricians will play a substantial leadership role in helping to transform the delivery of care to older adults raises questions about the content of fellowship training and need for other professional development opportunities. The experts interviewed suggested that fellowship programs could help prepare future leaders by incorporating experiences that allow fellows to deepen their knowledge of concepts such as population health, implementation science, healthcare financing, and practice model innovation. Programs should also offer mid-career professional development opportunities that utilize the executive MBA model to deliver content on these topics to practicing geriatricians and geriatrics fellowship- like content to non-geriatrician physicians. There is clear value in efforts to establish new billing codes within the fee-for-service system that reimburse for care activities geriatricians routinely provide, such as advance care planning, transitional care management, and chronic care management. The profession and policymakers should continue to advocate for expanding the number of geriatrics-relevant billing 5 UCSF Health Workforce Research Center on Long-Term Care Research Report codes, as well as refining the performance measures used by the Centers for Medicare & Medicaid Services (CMS), as part of the Merit-based Incentive Payment System (MIPS), to determine upward (or downward) adjustments to a geriatrician’s fee-for-service payment rates. 6 UCSF Health Workforce Research Center on Long-Term Care Research Report Geriatrician Roles and the Value of Geriatrics in an Evolving Healthcare System This report is the second component of a two-stage project in which we examined current and emerging roles of