Geriatrics Recruitment Resources

5. Big Picture Perspectives on Expanding Geriatrics Programs

The challenge: To incorporate big picture trends into strategies for academic geriatrics programmatic growth and development

Summary

Leaders are challenged not only to improve core training, research, and clinical services, but also to think and act strategically regarding big picture trends that are likely to shape the future of academic geriatrics. “If you stay the same you fall behind — everybody has to compete just to maintain and to compete at every level,” stressed one geriatrics leader. Getting ahead of the curve requires building on program strengths, and being aware of how to align national trends with your institutional mission and locale. While no one can predict which trends will emerge as the most important in the field of aging and geriatrics, several physicians, whose careers in academic geriatrics have led to leadership roles at national organizations and major programs, urge an activist role for academic geriatrics in the following areas:

• The growing quality care movement
• Engagement with policymakers regarding key issues, such as “medical home” legislation, increased funding for training, and enhanced reimbursement based on credentialing
• New partnerships with schools of public health.

Such challenges, along with others addressed elsewhere in this report, suggest the timeliness of creating a national center, as proposed by Dr. Christine Cassel, dedicated to enriching academic geriatrics management and leadership skills.

Strategies

Capitalize on the quality care movement. Dr. Cassel, who is executive director of the American Board of Internal Medicine (ABIM), suggested a focus on quality issues in geriatrics. “Any way in which geriatricians are seen as vital resources for hospital problems and challenges will help the field. This may mean that academic geriatrics programs will have to develop skills they don’t have, recruit those in quality improvement science and measurement, and develop a more sophisticated understanding of Medicare and other payers in their area.”

Engage in the public policy arena. Demonstrate excellence in key policy issues, raise the visibility of geriatrics in those areas, and enhance relationships with legislators. For example:

• Develop expertise in policy issues. “The collective body [of academic geriatrics] needs to have more impact,” Dr. Cassel said. “But as we look at these struggling academic centers, I suggest that each program has a couple of people working on policy.” She notes the advantage to geriatrics of having faculty who can help the dean figure out how to utilize new opportunities. For example, although Dr. Cassel does not see academic leaders paying attention now, “as soon as there is money on the table, they will say, ‘Why can’t we be a medical home?’ Geriatrics programs need someone inside who goes to policy meetings to learn about the issues, and who can be valuable on their own campus.”
• Increase the visibility of geriatrics in the policy arena. “The policy arena is very hot right now,” Dr. Cassel said. “We really need new blood, as well as sustained senior leadership in this area.” She strongly supported efforts to enhance the role of board-certified geriatricians in forthcoming Medicare demonstration programs, so that the primary care field does not dominate initiatives directed at frail older adults. “We [at the ABIM] are studying the primary care shortage with policymakers. Everyone has focused on the decline in primary care. What is happening in geriatrics is part of the same phenomenon, but more so.”
• Focus on tying reimbursement to credentials. Jack Rowe, MD, professor at the Mailman School of Public Health at Columbia University (and retired Chairman and CEO of Aetna, Inc.), argued that the only way for the academic geriatrics model to become self-sustaining is to improve reimbursement. Referencing the April 2008 Institute of Medicine report, Retooling for an Aging America: Building the Healthcare Workforce—for which he served as chair—he emphasized that an “increase in payments is not only essential but also realistic. Senators are usually ‘allergic’ to increased payments, but substantial increased payment for those who are qualified is not really going to cost anything because of the small number of board-certified geriatricians.”
• Don’t neglect modification in compensation schedules. Dr. Rowe’s interest in geriatrics “led me to get Aetna more involved in the Medicare program. I hired a geriatrician to be the head of Aetna’s Medicare and disease-management programs. Some of these programs focused on frail older adults are very promising. Coming out of Aetna, I saw the incredible power of modification in compensation schedules. Physician behavior is incredibly influenced by even small changes in compensation levels, and those in academic geriatrics have not focused on that.” (For further information on geriatrician compensation see Resources below.)
• Bring legislators to the academy. Dr. Judy Salerno, who became executive director of the Institute of Medicine in 2008, noted: “When Congressional representatives are in their Washington offices, you might get in the door if you are from their districts. But you can have an even greater impact if you interact with them when they are in their district offices, where they can see the connections between academic geriatrics programs and community services. Invite them into academic settings to give a talk or have a tour.” (See Resources below.)
• Create teaching moments. Dr. Salerno, whose background includes leadership of a multi-city program linking medical students and active older adults, Vital Visionaries, suggests seeking “ways to spotlight what you are doing through community-based programs. Those are teaching moments for the geriatrics community to educate members of Congress.” She also suggests a “National Take Your Senator to Home Care Day” to show them how “fundamentally important to quality of life and aging the geriatrics care team can be.”

Expand partnerships with schools of public health. Several CoEs utilize their schools of public health for research training for fellows. Some geriatrics faculty have MPH degrees and/or conduct collaborative research with public health colleagues. Two deans envision further connections. Linda Fried, MD, MPH, who left the geriatrics division at Johns Hopkins School of Medicine in 2008 to become dean of the Mailman School of Public Health at Columbia University, emphasized, “There needs to be intentional investment. I took the job at Columbia because I felt that in parallel with clinical geriatrics, we had to have public health embracing geriatrics, which is not done currently.” Dr. Robert Golden, dean of the School of Medicine and Public Health at the University of Wisconsin-Madison, reported that his school is going through a unique transformation: “It is the first in the country with a combined School of Public Health and Medicine that melds together the full continuum of basic science and clinical care. We have a geriatrics center and cancer center, and want to link community-based screening programs with molecular biology programs.” Crediting his predecessor, he reported, “This whole vision was crafted even before the National Institutes of Health Clinical and Translational Science Awards (CTSAs).” (For more on the CTSAs, see Chapter 2.)

Create a National Center for Academic Geriatrics. Dr. Cassel suggested creating a national center specifically focused on management issues necessary to develop and expand academic geriatrics programs. Geriatricians not only “need a broad spectrum of medical knowledge, but are also asked to be good systems managers, manage teams, and deal with managed care,” she explained. “These are all skills that require a lot of training, which most physicians don’t receive.” As a model she suggested the Center to Advance Palliative Care, which combines training, consultation, networking, and other resources.

Resources

For the Institute of Medicine’s 2008 report, Retooling for an Aging America: Building the Healthcare Workforce, and related PowerPoint and other materials, see the IoM web site:
http://www.iom.edu/?ID=53452

For information on geriatrician compensation and other geriatrics workforce issues, see the Association of Directors of Geriatric Academic Programs (ADGAP) Status of Geriatrics Workforce Study web site: http://www.adgapstudy.uc.edu/Home.cfm

See also the Health and Human Services Bureau of Health Professions National Center for Health Workforce Analysis web site at: http://bhpr.hrsa.gov/healthworkforce/

For information about Medicare’s Pay-for-Performance (P4P) programs, see the American Geriatrics Society web site: http://www.americangeriatrics.org/policy/2006p4p_indext.shtml

For information about geriatrics and health policy and advocacy, see the American Geriatrics Society web site: http://www.americangeriatrics.org/policy/

For information about a geriatrics and healthcare quality scholars program, see: the Special Fellowship Program in Advanced Geriatrics of the Center for Primary Care and Outcomes Research of the Stanford School of Medicine and the Center for Health Policy of the Greeman Spogli Institute for International Studies web site: http://healthpolicy.stanford.edu/fellowships/special_fellowship_program_...

For information about geriatrics quality assessment, see The RAND Assessing Care of Vulnerable Elders (ACOVE) project: http://www.rand.org/health/projects/acove/

Continue to Chapter Two, Managing Training and Research Activities ⇒