Perspective: Transforming Chronic Care for Older Persons
Boult, Chad MD, MPH, MBA; Christmas, Colleen MD; Durso, Samuel C. MD, MBA; Leff, Bruce MD; Boult, Lisa B. MD, MPH, MA; Fried, Linda P. MD, MPH
Dr. C. Boult is director, Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Bloomberg School of Public Health, and professor of public health, with joint appointments in medicine and nursing, Johns Hopkins University, Baltimore, Maryland.
Dr. Christmas is director of residency education, Bayview Medical Center, and assistant professor of medicine, Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Dr. Durso is clinical director, Division of Geriatric Medicine and Gerontology, and associate professor of medicine, Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Dr. Leff is associate professor of medicine, Division of Geriatric Medicine and Gerontology, Department of Medicine, School of Medicine, with a joint appointment in the Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.
Dr. L. Boult is assistant professor of medicine, Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Dr. Fried is dean, Mailman School of Public Health, and De Lamar Professor of epidemiology, Columbia University, New York, New York.
Please see the end of this article for information about the authors.
Correspondence should be addressed to Dr. C. Boult, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Room 693, Baltimore, MD 21205; telephone: (410) 955-6546; fax: (410) 955-0470; e-mail: (firstname.lastname@example.org).
The size and impending morbidity of the aging baby boom generation could soon overwhelm the U.S. health care system. Transforming chronic care for older persons to avert this calamity will require rapid increases in the number of physicians who are skilled in providing chronic care and prompt adoption of new models for providing high-quality, cost-effective chronic care.
The authors propose a new approach for attaining these objectives, recommending that today’s leaders of academic medicine help transform geriatrics into a collaborative discipline of clinicians with advanced skills in leading educational, organizational, and research-related initiatives; that they support the collaboration of geriatrics with primary care and specialty disciplines in preparing physicians to practice effectively in new models of chronic care for older persons; and that they energetically promote rigorous training in chronic care at all levels of medical education.
Implementing this strategy would require firm commitment by the Association of American Medical Colleges, specialty boards, accrediting organizations, academic institutions, the Centers for Medicare and Medicaid Services, legislators, and business leaders. Although garnering such support would be challenging and controversial, this approach could leverage the expertise of geriatric educator–leaders to help transform chronic care in the United States and to make high-quality, cost-effective chronic care accessible to most chronically ill Americans within 20 years.
We propose an approach by which today’s leaders of academic medicine could help transform chronic care for older persons in the United States. At its core would be a cadre of educator–leader “change agents” who would infuse geriatrics expertise throughout medical education, health-care-delivery systems, and governmental agencies.
For 30 years, experts have warned that the United States’ health care system, which is focused primarily on acute care, is unprepared to provide adequate chronic care for the aging “baby boom” generation.1,2 Despite these admonitions, America’s health care policies and providers have not focused on chronic care. Its hospitals, nursing homes, outpatient clinics, and home care agencies still operate as uncoordinated “silos,”3 its physician workforce is inadequate,4 and the quality and efficiency of chronic care in America remain “far from optimal.”3–5
The cost of fragmented, inefficient chronic care is high. Medicare beneficiaries with four or more chronic conditions account for 80% of Medicare spending,6 which totaled $425 billion in 2007.7 Without prompt transformation, chronic care in America will soon become unsustainably expensive.
20th-century efforts to improve chronic care
Early in the 20th century, clinicians and scholars created the discipline of geriatrics to improve the care and well-being of older persons with chronic health conditions. Later, the Institute of Medicine (IOM),8 the National Institute on Aging,9 the RAND Corporation,10 and a national expert panel11 exhorted the nation to prepare more geriatricians to teach and conduct research. The IOM recommended that geriatrics develop “as an academic discipline,” but it advised against establishing a formal practice specialty in geriatrics.1
During the last 30 years, geriatrics has emerged as the discipline most focused on improving comprehensive care for older patients with multiple chronic conditions.12–23 Because the number of geriatricians grew slowly, in 1998 the American Boards of Internal Medicine and Family Practice reduced from two years to one the duration of the fellowship required for eligibility to sit for the qualifying examination for the Certificate of Added Qualification (CAQ) in Geriatric Medicine. This reduction resulted in the elimination of educational methods, research, and leadership from the training of most geriatrics fellows.24
Even with shorter fellowships, the number of fellowship-trained geriatricians (FTG) has grown slowly. In July 2007, the workforce of FTGs consisted of only 920 full-time equivalents (FTE) devoted to teaching,25–27 far fewer than the 1,400-plus needed to teach the medical students and primary care residents who will care for most older Americans during the coming decades.11 Consequently, 77% of medical schools do not require students to take any courses in geriatrics,27 residents in internal medicine and family medicine receive little training in the comprehensive management of patients with multimorbidity, and two thirds of America’s internists report being undertrained in chronic care.28 Despite the IOM’s 1993 recommendation that by 1999, primary care residency programs should include at least nine months of geriatrics,29 only 9% of internal medicine residencies require six or more weeks of geriatrics training, mostly in the form of block rotations through nongeriatrics clinics or assessment clinics during the second or third year of training.30 Only 26% of family medicine residencies require four or more weeks of geriatrics.31 Most general internal medicine (GIM) and family medicine faculty members have not been trained to practice or teach geriatrics, and GIM educators report discomfort with teaching geriatrics.32
Also undersized is the nation’s FTG workforce that provides clinical care (currently one FTE for every 10,350 Americans age 75 years or older),33 and recent trends suggest that interest in geriatrics fellowship training may have plateaued. The number of physicians in U.S. first-year fellowship positions, almost two thirds of whom are international medical graduates, has remained essentially unchanged, with 290 in 2003 and 287 in 2007.34 With limited federal funds for advanced training, the number of physicians in second- and third-year positions, during which most educational and research methods are learned, also stagnated, averaging only 48 per year for the entire United States.34 Clearly, the nation’s 20th-century strategy of training enough geriatricians to teach, conduct research, and provide chronic care for its aging population cannot succeed. Fortunately, however, new approaches have begun to emerge.
Recent interdisciplinary initiatives to improve chronic care
Philanthropic foundations, educational institutions, and professional organizations have recently launched interdisciplinary programs to improve the chronic-care expertise of the physicians who will be providing such care. The John A. Hartford Foundation (JAHF) has funded 40 medical schools to develop geriatrics in their undergraduate curricula, and it funded general internists to work with geriatricians to improve geriatric graduate education.35 The Donald W. Reynolds Foundation (DWRF) has funded 30 academic health centers to strengthen their geriatrics education for medical students, residents, and practicing physicians. Four universities affiliated with some of these academic health centers now offer one-year teaching fellowships and brief geriatrics “mini-fellowships” for nongeriatrician faculty members. The American Geriatrics Society (AGS) and several foundations have launched programs to improve the geriatrics training provided by medical and surgical postgraduate educational programs, 70% of which include no geriatrics in their curricula.36
The American Board of Internal Medicine (ABIM) recently upgraded geriatrics to a subspecialty and will stop issuing CAQs in Geriatric Medicine. Although this change will permit geriatric subspecialists to recertify only in geriatrics (without recertifying in internal medicine), it is unlikely to attract many additional physicians to geriatrics. The American Board of Family Medicine (ABFM) will continue to issue its CAQ in Geriatric Medicine.
A Strategy for the Next 20 Years
U.S. medicine stands at a worrisome crossroads as the first baby boomers near retirement age.37 Preparing a physician workforce capable of providing high-quality chronic care requires a new and realistic strategy soon.
Some have argued that we should give high priority to recruiting and training more one-year geriatricians.38 Though increasing the number of geriatricians would help, one year of clinical training does not equip geriatricians with skills in educational methods, organizational management, or research. Others have recommended reallocating resources from geriatrics to academic primary care programs so that they can train primary care physicians to provide and teach chronic care.39 Although it is true that internal medicine, family medicine, and many subspecialties have large workforces, these disciplines’ current lack of expertise in teaching chronic care threatens the feasibility of this approach.32
We believe that a better strategy would be to merge these two approaches, broadening the expertise of geriatricians to include leadership and educational skills and incorporating geriatricians into the educational programs of many disciplines. The success of this approach would require several simultaneous changes inside and outside academic medicine.
Changes in geriatrics
Geriatricians’ expertise in chronic care could be leveraged most productively if geriatricians were not only skilled clinicians but also effective leaders in medical education, health care delivery, or research. Acquiring these skills would require a physician to complete a year of clinical geriatrics and leadership training, followed by master-level training in educational methods, organizational management, or research. Those focusing on education would then collaborate with academic internists, family physicians, and subspecialists in leading programs to teach the principles and practice of chronic care at all levels of medical education. Those emphasizing organizational management would lead initiatives to improve chronic care in organizations that provide or purchase health care or in governmental agencies that monitor or regulate such care. Those conducting research would collaborate with interdisciplinary teams of scientists.
To prepare physicians for these leadership roles, the nation would need a network of academic centers equipped to provide rigorous training in clinical geriatrics, leadership, educational methods, organizational management, and research. Geriatrics centers of excellence, now supported by philanthropic organizations such as the JAHF and the DWRF, could become the foundation for such a network.
Adequate funding to support the training of these educator–leaders would be crucial for this approach to succeed. The Centers for Medicare and Medicaid Services (CMS) would need to continue and expand its support of one-year clinical geriatrics fellowships. Supplemental stipends for supporting the second and third years of training could be provided by the Health Resources Services Administration (for fellows focusing on educational methods), by private industry and philanthropic organizations (for fellows focusing on organizational management), and by the National Institute on Aging (for fellows pursuing research careers).
Changes in academic medicine
Leaders of academic geriatrics, internal medicine, and family medicine would need to conduct ambitious campaigns to elevate and enforce rigorous standards for teaching chronic care to health care professionals. To succeed, they would need to convince many influential organizations to require adherence to such standards at all levels of training—organizations such as the ABIM, the ABFM, other specialty and subspecialty boards, the CMS, the Association of American Medical Colleges (AAMC), the National Board of Medical Examiners, the Liaison Committee on Graduate Medical Education, and the Accreditation Council for Graduate Medical Education would have to enforce these educational standards through funding and accreditation incentives. To comply with these new educational requirements, academic institutions would need to invest substantial resources to upgrade the chronic care components of their educational programs. Internal medicine, family medicine, and other disciplines would need to incorporate geriatrics educator–leaders into their educational and clinical programs.
Changes in consumers, legislators, and business leaders
U.S. consumers would need to demand high-quality chronic care vigorously enough, perhaps through the lobbying efforts of the AARP and other champions, that politicians’ election (and reelection) to public office—and providers’ success in the marketplace—would be significantly influenced by their ability to make such care available and accessible. Leaders of government would need to respond to consumer demands by investing public funds in a national infrastructure capable of supporting such elements of good chronic care as interoperative electronic health information technology and powerful financial incentives for Medicare providers to deliver efficient, high-quality chronic care. Driven by consumer demand and government incentives, provider organizations would need to emphasize chronic care in their business plans for competing in the medical marketplace.
We recognize that the approach outlined above for improving chronic care in the United States by 2030 might provoke controversy in at least four areas.
* The need for educator–leaders. Some academic leaders may oppose subsidizing and collaborating with educator–leaders within their institutions. Lack of appreciation for the added value of geriatric educator–leaders and concerns about finances may underlie such opposition.
* The feasibility of having geriatrics reinvent itself. Each of the present options for the future growth of geriatrics carries significant risks. Redoubling its efforts to create a large workforce of geriatricians capable of teaching, conducting research, and providing care for a significant percentage of older Americans would likely fail. Continuing to train modest numbers of one-year clinical fellows in the hope that they would both care for large numbers of patients and revitalize other disciplines’ capacity for chronic care seems unrealistic. To reinvent itself (again), this time as a discipline of clinicians who are also educator–leaders, geriatrics would face new challenges in recruiting and training fellows, building academic credibility, and sustaining financial stability.
* The feasibility of expanding the duration and scope of geriatrics fellowship programs. Would requiring a minimum of two years of fellowship training and focusing geriatrics on education and leadership reduce the number of qualified applicants to its fellowship programs? The answer might depend on the degree to which public and private investment in improving chronic care could overcome the career obstacles that have thwarted recruitment into geriatrics in the past: ageism, scarcity of faculty role models,25,40 underfunded education and research programs, lack of curricular access to medical students and residents,39 trainees’ average debt load (>$113,000),41 unattractive practice image,42 relatively poor remuneration,41 and waning interest in careers in all primary care specialties.43 Medicare’s poor reimbursement for the time-consuming services needed by its beneficiaries with multiple chronic conditions discourages many physicians from focusing their practices on chronic care.44–46 Specific recommendations for actions to overcome these obstacles, such as training grants, career-development awards, loan forgiveness, secure jobs, and higher income, have been articulated by the AGS,38 but the authority to implement such recommendations is widely dispersed, and leaders in the executive and legislative branches of government are only beginning to formulate comprehensive plans to address the health-related challenges of the aging U.S. population.
* The feasibility of creating an adequate workforce of educator–leaders. A conservative 20-year workforce simulation (which was based on 75% of the current FTG workforce, a change to two-year fellowships in 2013, a pre-1998 rate of recruitment into two-year geriatrics fellowships thereafter—that is, 200 fellows per year—and an assumed 70% retention of graduates) projects that the workforce of educator–leaders would number 3,139 by the year 2027. Such a workforce could provide the 10 faculty members needed by every U.S. medical school,10,47 plus 2,000 more to guide chronic care development in the nation’s health care organizations and governmental agencies.
Improving chronic care must begin with careful consideration of the many pros and cons of each of the options. We encourage leaders of academic medicine, government, and business to debate these issues vigorously, to reach consensus soon, and to begin addressing the many pragmatic obstacles that have stymied us so far. The AAMC is well positioned to further stimulate and facilitate these debates and to champion this worthy cause among the many stakeholders in chronic care in the years ahead. Attaining excellence in chronic care will take decades, yet the baby boomers will begin to retire in 2011.
The authors acknowledge the valuable suggestions for revision of early drafts of this manuscript made by Dr. Donna Regenstreif.
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