January 17, 2020

Your Geriatric Patients and Vertebral Compression Fractures

backladyBy Mark W. McFarland, DO and Raj N. Sureja, MD

Vertebral compression fractures are observed in any age demographic due to trauma from a fall or a car accident; however, they are most prevalent in the geriatric population. Significant loss of bone may occur due to pathology (cancer, osteomyelitis); chemotherapy or radiation therapy used to treat cancer; age-related conditions (hyperthyroidism, menopause, osteoporosis) or can be caused by an overuse of steroids.  When enough bone loss occurs, and a vertebra becomes unstable, spinal fracture or collapse is likely to occur.  These vertebral fractures can be extremely debilitating for the seniors who suffer them, causing pain, uncomfortable neurologic symptoms, disability and urinary or fecal incontinence/retention.

Until recently, these individuals would have been sent to the hospital for treatment with Vertebroplasty or Kyphoplasty procedures.  Both procedures provide a method for stabilizing the vertebral fracture, using a bone cement to restore height and strength to the collapsed or fractured bone.  Kyphoplasty differs from a Vertebroplasty, mainly because a balloon is inserted into the fractured vertebra, inflated to restore the height and then cement injected into the space, which hardens to provide stability. In an outpatient setting at a hospital or ASC, the patient would be usually subjected to general anesthesia and a stay which typically would take four to six hours.   The hospital cost for the procedure is substantial, resulting in a greater out-of-pocket expenditure for the patient.

In 2012, Medicare approved in-office Kyphoplasty for reimbursement, due to significant improvements and miniaturization of the required instrumentation, such as smaller needles and special blocks for anesthetizing the operative site. After this approval, many Orthopaedic Spine physicians and Radiological Interventionists began performing this procedure in their clinical office procedure suites.  The patient is awake during the procedure, which takes about 30 minutes, and is ready to go home in approximately 90 minutes.  Another improvement occurred in 2014, with the development of a small trochanter which provided a less-invasive way for the surgeon to enter the body near the fractured vertebrae, causing less trauma for the patient.

Although a few earlier studies brought the efficacy of Kyphoplasty into question, more recent clinical research has found that Kyphoplasty is preferable over Vertebroplasty and non-surgical management for vertebral compression fractures.  Kyphoplasty provides distinct benefits when measured against in pain reduction, disability management and quality of life indicators.  Anecdotally, we observe these patients in our office on a regular basis.  They frequently arrive in a wheelchair, unable to walk and in a great deal of pain.  After their in-office balloon Kyphoplasty, patients can walk, their disability gone. The pain relief they experience is immediate, and their gratitude is one the best rewards for any physician performing the procedure.

We perform several Kyphoplasties a week in our office at OSC.  Our patients tolerate the procedure very well and experience immediate relief from their symptoms.  If your geriatric patients experience vertebral compression fractures, consider the benefits of in-office Kyphoplasty.

MacfarlandSurejaMark W. McFarland, DO (Orthopaedic Spine), and Raj N. Sureja, MD (Interventional Pain Management) practice at Orthopaedic & Spine Center in Newport News, VA.  For more information on Kyphoplasty, please contact them at 757-596-1900 or visit osc-ortho.com.

Physical Therapists as Physician Extenders

PTBy Wayne MacMasters, PT, MSPT

One of the most important cost saving concepts in medicine today is the use of the physician extender.  When I started practice in 1985, there was no such term; but look up ‘physician extender’ in the dictionary today, and you’ll find:  “a health care provider who is not a physician but who performs medical activities typically performed by a physician.”

Physician extenders can provide care at a lower cost to patients and their insurance companies.  They are competent in treating many health care issues, and have the knowledge, training and experience to determine when a physician consult is appropriate.  Usually, we think of Physicians Assistants or Certified Family Nurse Practitioners.

But there are other health care providers who are primary care providers for patients with musculoskeletal problems: Certified Athletic Trainers and Licensed Physical Therapists.

Athletic Trainers (ATC) certified by the National Athletic Trainers Association typically work in institutional settings.  They are usually the first responders at an injury scene.  They triage the injured athlete and decide if a physician consult is appropriate.  For minor problems, the patient is managed without physician involvement.

Most Physical Therapists (DPT) are doctorate degreed professionals licensed through their respective state Boards. Their practice requirements are similar to Physician Assistants.  In a recent study of family practice and orthopaedic physicians, published in The Journal of Orthopaedic Sports Physical Therapy, physical therapists were found to be second only to orthopaedic surgeons in performing competent musculoskeletal exams.

Physical therapists have been physician extenders throughout the world for a long time, but only in the past 15 years has the American medical community endorsed the model.  Recent research demonstrates it is safe and effective, and 49 states (including Virginia) are considered Direct Access states; that is, referral by a physician is not necessary in order for care to be provided by a licensed physical therapist.

For my Direct Access Licensure, I obtained further education for differential diagnoses and additional course work.  Since 2011, I have been practicing Direct Access Physical Therapy.

I must admit I was hesitant to endorse my profession as physician extenders.  I was trained thirty years ago under a traditional model and continue to have great respect for our physician community and the medical profession.  But times change, our education has progressed to doctoral level training, the research is clear and we all have to control medical costs.

So who should see a physical therapist directly?  Any patient with significant trauma or a severe injury should go to the ER or a doctor, but an adult with mild to moderate muscle aches and pains, a runner with over-use injuries, or a welder with persistent muscle or joint issues can see a physical therapist to help determine the cause.  If physical therapy is indicated, tissue tightness, muscle weakness or alignment disorders can be treated with modalities, exercise and manual mobilization of joints or soft tissues can be treated by law for up to 14 business days without a prescription from a physician.  The treating physical therapist sends a report to the patient’s doctor, and if progress is not made, a physician consult is requested.

Working together – physicians and all physician extenders – we can serve our communities and our patients, offering the best care in the most cost effective manner possible.

WayneWayne A. MacMasters, PT, MSPT, is the president and founder of Tidewater Physical Therapy, Inc. Mr. MacMasters, a practicing physical therapist, received his undergraduate degree from the College of William & Mary and his Masters degree in Physical Therapy from Duke University.

Year-end Tax Planning for Your Practice

TaxplanningThere’s never a bad time to review your current tax situation. But year-end can be an especially good time to plan and implement tax-saving strategies.

Time Year-end Payments
If your practice uses the cash method of accounting, it may be a good idea to review the timing of year-end payments so that you can more effectively coordinate their tax impact. For example, you can increase your 2014 deductions by paying certain expenses in December instead of January.

Expenses paid by credit card in 2014 are deductible in 2014 even if you don’t pay the bill until 2015. The same holds true for an expense paid by check in 2014, since the amount is generally deductible in 2014 even if the check does not clear the bank until 2015.

Buy Medical Equipment
If you have thought about buying new medical or office equipment for your practice, now may be a good time to take the plunge. The Section 179 expensing election allows you to take an immediate deduction for the cost of most kinds of depreciable assets in the year they are acquired and placed in service (within tax law limits) instead of claiming depreciation deductions over a multiyear period. The dollar limit on asset purchases eligible for Section 179 expensing is $25,000 for the 2014 tax year. The $25,000 deduction maximum is reduced dollar for dollar to the extent that the cost of qualifying property placed in service during the taxable year is greater than $200,000.

Identify Credit-eligible Expenses
As opposed to a tax deduction, which lowers taxable income, a tax credit directly offsets tax liability. Two credits that may be of interest:

A disabled access credit for expenses paid or incurred to modify or acquire equipment or devices for disabled individuals, or to improve an older building to make it accessible to the disabled

An energy credit for the installation of solar or certain other energy-efficient property in your medical office building.

Various limitations and requirements apply.

Copyright 2014 by DST. All rights reserved. The general information in this publication is not intended to be nor should it be treated as tax, legal, or accounting advice. Additional issues could exist that would affect the tax treatment of a specific transaction and, therefore, taxpayers should seek advice from an independent tax advisor based on their particular circumstances before acting on any information presented. This information is not intended to be nor can it be used by any taxpayer for the purpose of avoiding tax penalties.

McPhillips, Roberts and Deans, PLC  Trusted business advisors for over 40  years providing accounting, tax and consulting services.  http://www.mrdcpa.com/Industries/Healthcare

“Patient” Conversations

By Kathryn Freeman-Jones and Diane L. Dull

DNRIn today’s health care environment, patients are confronted by an ever-expanding myriad of technologies and treatments, leading to an increasing reliance on the clinical experience, advice and guidance of their physicians when making difficult medical decisions. Navigating the waters of health care decisions with patients can be challenging, especially in the midst of increasing patient loads, decreased and restrictive reimbursements, and the implementation of electronic health records, all of which impact health care providers’ available “face time” with patients.  However, failing to engage patients in conversations about their priorities and treatment preferences and encouraging them to complete an advance directive and to appoint a designated decision-maker to act in the event of future incapacity comes at great cost.  The absence of thoughtful planning can impose significant burdens on patients, their families, treating health care providers, and the sustainability of an already over-extended system of health care in the United States.

A recent study1 of capable adults who are not currently confronting end-of-life care issues confirmed their thinking about end-of-life care preferences and priorities, but a majority had not completed an advance directive to communicate and make those preferences legally enforceable.  More than 60 percent of individuals aged 18 years and older wanted their end-of-life wishes to be respected, but only 33 percent had completed an advance directive. The reasons stated included 25 percent who did not know about advance directives. Others felt they were too young or too healthy to complete them or expressed concern about the cost, complexity, or time required to do so. Cultural differences including family-centered decision-making, distrust of the health care system, and poor communication between health care professionals and patients were also contributing factors.

Not surprisingly, participants confirmed a preference to obtain advance directive information from their doctors or other health care providers, rather than from attorneys, clergy, or online sources, creating a unique opportunity for primary care physicians to play an invaluable and critical role in engaging patients, young and old, in conversations about their priorities and treatment preferences in various health care scenarios and at the end of life. Despite time limitations, as physician and author Atul Gawande, MD observes, these conversations with patients need not be lengthy to be successful:

“[T]he best way to learn those priorities is to ask about them… [using] just a few important questions: (1) What is their understanding of their health or condition? (2) What are their goals if their health worsens? (3) What are their fears? (4) What are the trade-offs they are willing to make and not willing to make?  These discussions must be repeated over time, because people’s answers change…”2

Many advance directive templates can seem legalistic, lengthy and confusing. This should not inhibit physician efforts to discuss these important questions. Patient- and provider-friendly directives are readily available from a variety of resources. We encourage you to take time to engage your patients in these critically important conversations.

References
Morhaim, D. and Pollack, K. Am J Public Health. 2013;103(6):e8-e10.

Gawande, A. “Being Mortal: Medicine and What Matters in the End,” Metropolitan Books, 2014.

Aging with Dignity – Five Wishes @ http://www.fivewishes.org/; Virginia Hospital and Healthcare Association –Healthcare Decision-Making (Forms in English and Spanish) @ http://www.vhha.com/healthcaredecisionmaking.html; American Bar Association Commission on Law and Aging – Myths and Facts About Health Care Advance Directives @ http://www.americanbar.org/content/dam/aba/migrated/Commissions/myths_fact_hc_ad.authcheckdam.pdf; American Bar Association – My Health Care Wishes App @ http://www.americanbar.org/groups/law_aging/MyHealthCareWishesApp.html

1Morhaim, D. and Pollack, K. Am J Public Health. 2013;103(6):e8-e10.

2Gawande, A. “Being Mortal: Medicine and What Matters in the End,” Metropolitan Books, 2014.

Kathryn Freeman-Jones is an attorney and Diane L. Dull is a health care paralegal with the law firm of Goodman, Allen & Filetti.  Freeman-Jones focuses her practice primarily in providing legal services to health care providers in the areas of hospital liability, patient competency issues, guardianship matters, and ethics.  Dull works as an initial point of contact and resource for health care clients in the areas of hospital risk and liability, quality and safety, patient competency, court-ordered treatment, guardianships/conservatorships, and clinical and organizational ethics.  804-346-0600 or visit: www.goodmanallen.com.

Blindness: Preventable and Reversible

By Alan L. Wagner, MD, FACS

EyesDuring the past seven years, there have been miraculous improvements in the tools available to prevent and reverse blindness.

Before these improvements, I hated explaining to patients that we are going to help them live with vision loss. Now, that is no longer necessary.

The leading cause of blindness in the industrialized world is diabetes.  Until recently, we treated blood vessels in the eye damaged by the disease with lasers.  If necessary, we would operate inside the eye, to salvage sight.  Today, we have a wide spectrum of minimally invasive tools to treat the disease during varying levels of progression. The earlier we catch the disease, the greater the success.

Wagner Macula & Retina Center, in collaboration with Eastern Virginia Medical School and corporate partners, is engaged in research that is preventing blindness.  In most cases we can restore some, if not all, the vision that has been lost.   Most importantly, the effects of these treatments are durable: when the treatment plan is started and continued, more than 80 percent of the patients will see a lasting positive effect.  Patients will be independent—they may even be able to return to driving. The successful treatment of eye disease allows the patients to live independently, go to work, grocery shop and cook. Above all, being able to see the faces of loved ones once again is priceless!

All of our research and treatment of patients is very important.   However, getting the word out about prevention and early detection is crucial.

We tell our patients how important it is to “feed the eyes normal blood at a normal pressure.” Obviously, that’s not as easy as it sounds, but it really is that important.

Fortunately, or unfortunately, vision loss from diabetes is painless.  The same is true for another eye disease – macular degeneration.

Regular monitoring is critical.  It should be done both by an eye professional and by patients at home.  For patients at high risk of developing macular degeneration, there is a new FDA-approved device, Foresee, which detects the earliest changes that will cause blindness from macular degeneration.  The compact Foresee device communicates directly to our office, allowing us to quickly detect problems and start treatment right away.  Prior to this new technology, just looking at a piece of graph paper was the best resource available.

If patients take responsibility for protecting their eyesight, we can preserve, and even restore, their sight.   It is essential that patients see an eye professional regularly so that we can help keep their vision intact.  With the ability to see, patients can continue to have full and prosperous lives!

wagnerAlan L. Wagner, MD, FACS, founded the Wagner Macula & Retina Center in 1987. A Board certified ophthalmologist specializing in vitreoretinal surgery, Dr. Wagner received his medical degree from Vanderbilt University School of Medicine. He completed his residency in Ophthalmology at EVMS, and furthered his training as the Dyson Fellow in vitreoretinal disease and surgery at Weill Cornell University Medical Center.  757.481.4400 or  www.wagnerretina.com.

Riverside Fall 2014

RiversideLOgo

 

 

 

Riverside Lifelong Health:
Empowering Aging Patients to Control Their Destinies

“As I age, I will control my destiny in a place of my choosing.”
— Riverside Lifelong Health vision statement

Every day since January 1, 2011, 10,000 Americans have turned 65, a trend that’s expected to continue – every day – until the year 2030.  Ask any one of these individuals what they want most as they age, and the answer invariably comes back, “good health, and the ability to maintain my independence.”  Dig a little deeper, and a more thoughtful response often follows: “I don’t want to be a burden.  I want to stay in my home for as long as I can.”  In other words, “I want to control my own destiny.”

Dr. Allen, Medical Director for Geriatric Medicine and Lifelong Health; Vice President of Clinical Integration for Riverside Health System

Dr. Allen, Medical Director for Geriatric Medicine and Lifelong Health; Vice President of Clinical Integration for Riverside Health System

The job of providing medical care for these aging Americans falls to a healthcare system that is already overburdened, as the cost of providing care continues to rise.   And while Americans may be living longer, they’re not necessarily living healthier.  According to the latest data from the federal Centers for Disease Control and Prevention, at least 70 percent of American adults are overweight and even obese, while 26 percent have diabetes and 31 percent have hypertension – all of which points to an even greater financial strain on the system.  In fact, the Centers for Medicare and Medicaid Services report that 15 percent of the nursing home population in America is under 65 years of age, having acquired geriatric conditions years before reaching that milestone.

To Riverside Health System, it makes more sense to invest in keeping people healthy all throughout their lives through coordinated, integrated care.  And as they age, Riverside’s innovative Lifelong Health Division empowers patients to live the way they want to live, by creating an atmosphere in which they can grow older gracefully and independently.

 At Riverside, age really isn’t ‘Just a Number’
In 1935, the Committee on Economic Security proposed 65 as the retirement age under Social Security, and that number has become a milestone for crossing from middle to old age.  When Riverside looks at age, however, it uses a more expansive definition, dividing patients into three distinct categories, explains Dr. Kyle Allen, Vice President of Clinical Integration and Medical Director for Geriatric Medicine and Lifelong Health:

• Active – healthy, living independently, playing tennis, etc.;

• Chronic – dealing with three or more chronic illnesses like hypertension or diabetes;

• At risk – the frailest patient, in need of intensive nursing home care.

“We want to empower those we serve, regardless of age, disability or situation,” Dr. Allen emphasizes, “recognizing that each experience is different, depending on the patient’s individual medical and personal needs.”
Over the last thirty years, Riverside has developed an unrivalled network of services providing focused care and expert capability to its aging community.
“We’ve had extraordinary leadership under visionaries like former CEO Richard J. Pearce and former Senior Vice President Michael Martin, a gerontology trained administrator who led our aging related services for more than 27 years,” says Robert Bryant, Senior Vice President of Riverside Lifelong Health and Aging Related Services Division.  “And that well-founded tradition is continuing under the leadership of Bill Downey, the current CEO of Riverside Health System, as well as Dr. Allen, who we were fortunate enough to recruit from Ohio.  Dr. Allen is Board certified in geriatrics and family medicine, and is nationally recognized as a thought leader in the field of caring for older adults.  Bringing him to Riverside reflects our commitment to expanding our services to meet the needs of our growing community.  Dr. Allen is a strong believer in person centered care, innovation and working collaboratively to coordinate care – which are the very foundations of Riverside Lifelong Health.”

Dr. O.T. Adcock, lead physician for Riverside’s Patient-Centered Medical Home model, doing an annual wellness exam for one of his primary care patients.

Dr. O.T. Adcock, lead physician for Riverside’s Patient-Centered Medical Home model, doing an annual wellness exam for one of his primary care patients.

Continuing the legacy of dedication and commitment.
“Based on our experience, the expertise of our professionals and the dedication of our team, we have developed a series of thoughtful commitments to patients, their families and caregivers,” Bryant emphasizes. “And we’ve turned those commitments into practices and protocols in accordance with Riverside’s Care Difference Philosophy: ‘putting patients (their families and caregivers) at the heart of all we do to ensure the highest safety and quality, treating every patient with kindness and respect, reflecting a fundamental belief that healthcare is a lifelong relationship that spans the continuum of need.’”

Riverside is committed to clinical models of care that treat the whole patient.
It begins with Riverside’s innovative Patient Centered Medical Home model of organizing primary care.
The Patient Centered Medical Home is an approach that emphasizes interdisciplinary care, coordination and communication among all medical providers, at every step of the patient’s healthcare experience.  “The care is comprehensive,” says Dr. O. T. Adcock, Service Line Chief for Primary Care and a family medicine physician with Riverside Medical Group.  “We provide daily care to children and adults of all ages, but our biggest focus is working with our geriatric population.”

For Riverside, working with the geriatric population means taking care of 7,000 older adults each day, who require varying levels of care and different services.  The Patient Centered Medical Home is the coordination and communications arm that ensures each provider knows what the other providers are doing, and that patients and their caregivers know as well.  “We schedule appointments, tests and lab studies,” Dr. Adcock says, “and ensure follow-up and referral as appropriate, whether to our ACE unit, one of our rehabilitation facilities, a skilled nursing home, an assisted living facility, physicians house calls practice, skilled home health care, or hospice.  The Patient Centered Medical Home provides access to the full complement of medical care.”

Bob Bryant, Senior Vice President of Lifelong Health

Bob Bryant, Senior Vice President of Lifelong Health

The Individual Plan of Care.
When aging patients require more than in-office medical care, Riverside’s Care Navigators work with them and with their caregivers to determine exactly what’s needed, and help align those needs with the expanded services Riverside offers. As with all aspects of care at Riverside Lifelong Health, it starts with talking to the patient, family and other caregivers, and asking some fundamental questions: “What do you want?  What matters most to you?  What are your goals?  What do you want to accomplish?  Where do you want to be?”

Once the answer is known, explains Patricia Russo, Vice President of Care Management, “We develop an Individual Plan of Care, a specific care plan tailored to each patient’s situation, looking at the patient’s function, cognition, ability to pay for medications, access to nutrition and fresh air, interests, in addition to clinical presentation.”

Riverside’s Continuing Care Retirement Communities – a Lifestyle Choice 
For individuals who seek the ease and sociability of retirement home living, there are many choices today. One of the most innovative and popular options is the “continuing care retirement community,” or CCRC. CCRCs are specifically designed to meet the lifestyle and health needs of older adults throughout their retirement years. Each of Riverside’s three CCRCs offers independent living apartments and homes, as well as assisted living, skilled nursing, memory care, and rehabilitation on one campus. Because the full continuum of care needs is anticipated and delivered in one location, residents living at each of these communities can avoid having to move if their needs—or the needs of their spouse—should change.

Heron Cove at Sanders is changing the culture of nursing care, as well as the physical environment.

Heron Cove at Sanders is changing the culture of nursing care, as well as the physical environment.

Riverside currently operates three Continuing Care Retirement Communities across the region: Warwick Forest, Patriots Colony, and Sanders (home of Heron Cove), each with its own unique identity and brand of care.  Each offers independent living apartments and homes, as well as assisted living, skilled nursing, memory care, and rehabilitation on one campus. Because the full continuum of care needs is anticipated and delivered in one location, residents living at each of these communities need not move if their needs should change.

Walking through the open kitchen inside Heron Cove at Sanders, Virginia’s first deinstitutionalized nursing facility

Walking through the open kitchen inside Heron Cove at Sanders, Virginia’s first deinstitutionalized nursing facility

Sanders Retirement Village has been caring for residents on the Middle Peninsula for more than 50 years.  Patients who need the structure of more extensive, long-term care often reject the idea of residential care because they fear losing many of the things they value, including a sense of control over their lives and their environment.  Riverside Health System is changing the way care is delivered in these settings, reflecting a new culture that is all about patient choice.  Within Sanders is the innovative community known as Heron Cove, which features the framework known as the Household Model.  Heron Cove sheds the institutionalized regimentation, the top-down management emphasis on efficiency first that is the stereotypical image of the traditional “nursing home,” focusing instead on relationships and choice. Residents make decisions about how their household will function and about how they will manage their own personal lives.  Heron Cove’s approach recognizes and fosters dignity, respect, love, and privacy – values every individual needs.

Lt. Governor Bill Bolling visits Heron Cove at Sanders to learn about this new model of care.

Lt. Governor Bill Bolling visits Heron Cove at Sanders to learn about this new model of care.

In 1988, recognizing the growing needs of the Peninsula’s aging population, Riverside opened its first retirement facility, Warwick Forest.  Today Warwick Forest offers the entire continuum of care: Independent Living, Assisted Living, Nursing and Memory Care, as well as Rehabilitation.

Patriots Colony was founded by a group of retired military officers who saw the need for a community dedicated to those who shared the common bond of service to country.  They approached Riverside Health System with their plan, and in 1996, Patriots Colony opened in 1996.  Today, Patriots Colony is a Continuing Care Retirement Community offering all levels of care on one expansive campus.

Patriots Colony’s health care services, including The Berkeley Assisted Living, Springhouse Memory Support and The Convalescent/Rehabilitation Center, are open to the public.  Reflecting its origins, Patriots Colony’s Independent Living section is restricted to retired and former (honorably discharged) officers of the seven uniformed services, retired and former civilian employees of the federal government (grade GS-7 & above), and their spouses or widow(er)s.

Riverside is committed to serving patients who wish to stay in their own homes.
ChooseHome: retirement community care – available in the home.
The Commonwealth of Virginia recently passed legislation allowing for the development, licensing and regulation of “community-based continuing care” programs, also known as “life care at home” or “continuing care at home” programs.  Riverside’s ChooseHome option offers patients 60 and older a comprehensive and cost-effective option to long-term care insurance, bringing the individualized resources patients need to continue living safely and comfortably in their home.  These resources include wellness and home safety assessments and individualized plans, in-home technologies, medication dispensing units, adult day services, home health aide, homemaker assistance and personal care, among others as needed.

Recognizing that as patients’ conditions change, so do their needs, ChooseHome provides members with a Personal Services Coordinator  (or navigator), who functions as an advocate and guide, helping patients and their families determine their goals and which programs best meet immediate and future needs at every step of their care.

The ACE (Acute Care for Elders) model of care.
Dr. Allen was one of the investigators who helped study how to improve hospital care for older adults and participated in the clinical trials of the Acute Care for Elders Model of Care.  He has helped implement the ACE model of care at Riverside, which combines principles of geriatric assessment and quality improvement.  The ACE model is designed to foster independent functioning of older patients during their hospitalization, to reduce hospital- associated conditions, e.g. confusion, and to prepare them to function at home as well.  The ACE program at Riverside provides patients and caregivers with tools and support to encourage them to more actively participate in the transition from hospital to home, and once home, to master effective self-management skills.  Riverside has also partnered with the Eastern Virginia Care Transitions Partnership, which uses the Coleman Care Transitions model, a model that assigns a coach to patients and their caregivers to help them better understand their medication schedule, to know what to be alert for with their medical condition, to know about appropriate follow-up care and maintaining a personal health record.   This coaching model is activating patients and caregivers to become more confident in their self-care of their health. In addition, because RHS knows how important care transitions are, the ACE unit is innovatively creating a simulation of what being at home will be like, with nursing and therapy staff providing education and skills before discharge, to help patients and caregivers prepare adequately.

“These transition times can be particularly challenging and stressful on patients,” Russo says.  “It’s well understood that any time a patient moves from one care setting to another – whether from inpatient to skilled nursing facility or from inpatient to home, even from primary care to a specialist – there is the opportunity for miscommunication, so part of our focus is always to insure a smooth transition from one provider to the next.  We make sure the patient and the family understand the transition plan, so that when they move from one venue to another, they’re a part of the process, as well as the care team.”

“We believe in activating the patients in self-care, self-management as much as possible,” Dr. Allen adds.  “A large part of that is teaching them how to be a partner.”

Critical to the success of ACE – and all of Riverside Health System – is the initiative known as NICHE – Nurses Improving Care for Health System Elders.
NICHE is the leading nurse-driven program designed to improve the care of older adults across the health system.  It provides nurses with education and best practice models for responding to the unique needs of older adults.

“We opened our ACE unit in October 2013,” says Kathleen R. Fletcher, a Doctor of Nursing Practice who serves as Director of the Geriatric Nurse Clinical Practice Program at Riverside, and was instrumental in establishing NICHE at Riverside.  “The unit consists of 24 private rooms dedicated to those patients who are over the age of 55, typically living at home, who benefit from our team approach to rehabilitation.  There are daily rounds on the ACE unit based on the interdisciplinary plan of care for each patient,” Dr. Fletcher explains.  “The team includes a physician, a social worker, nurses, physical therapists, all working with patients who may be struggling with different aspects of day-to-day activities.  We work aggressively with them, providing services as needed to transition them back to home.”  NICHE relies on evidence-based protocols that allow for intervention by nurses, which may well preclude escalated conditions that might result in an ER visit, or even hospitalization.

There are no hard and fast rules for what constitutes qualification for ACE care at Riverside, Dr. Kennedy notes, because “people age and develop chronic conditions differently at different paces.  That’s one of the reasons why this utilization of a model for care that enhances the skills and knowledge sets and capabilities of people taking care of older adults enhances our ability to prevent complications and hospital readmissions.”

In addition, notes Dr. Terris Kennedy, Riverside’s Chief Nursing Officer, “NICHE provides us with a geriatric nursing research curriculum, as well as a patient care curriculum, to enhance and heighten Certified Nursing Assistance observation skills and geriatric nurses’ ability to intervene, based on what they observe in real time.  It provides us a laboratory in terms of how we’re caring for older adults with chronic co-morbidities, which we can then translate and take from the ACE unit to our smaller community hospitals.”  Riverside is also using the NICHE program through all its acute care and post-acute facilities.  The National NICHE office is interested in this work and has been working closely with Dr Fletcher to understand better how NICHE can be used system wide to improve care of older adults.

CEALH – helping patients control their destinies by ensuring that both they and their families fully understand their situation and the options available to them.   

Dr. Christine Jensen, Coordinator of the Virginia Caring for You Program meets with Former First Lady Rosalynn Carter in Georgia to discuss the program’s impact in Virginia, October 2012.

Dr. Christine Jensen, Coordinator of the Virginia Caring for You Program meets with Former First Lady Rosalynn Carter in Georgia to discuss the program’s impact in Virginia, October 2012.

The Riverside Center for Excellence in Aging and Lifelong Health (CEALH) provides services ranging from geriatric assessments to teaching individuals with chronic conditions how to manage their symptoms, to providing resources and education for caregivers.

An example is CEALH’s Geriatric Assessment Clinic – one of only six in Virginia – which provides a comprehensive look at each patient, and includes a comprehensive evaluation conducted by a team that includes a geriatrician, a nurse, counselor and physical therapist focusing on memory loss, incontinence, fall risk, depression and medication issues.  Referrals are made as appropriate, with follow-up and recommendations for families and caregivers individualized to the findings of the assessment.

Either you are a caregiver, you rely on a caregiver, or you will become a caregiver.
“We recognize that caring for the aging patient also means caring for the patient’s caregivers,” says G. Richard Jackson, CEALH Executive Director.  “We train family members as well as professionals to understand the person they’re caring for and the diseases that patient has.”

Since the “Caring for You, Caring for Me” training, a program of the Rosalynn Carter Institute on Caregiving, was introduced at Riverside, more than 250 family and professional caregivers have enrolled in the five-week program at CEALH, which brings caregivers together in a relaxed setting to discuss common issues, share ideas and learn about available resources.  “This program has received Best Practices Awards from both the Southern Gerontologic Society and the Commonwealth Council on Aging,” says gerontologist Christine Jensen, PhD, Director of Health Services Research.  “The cost of the entire course is $35, which includes educational resources.”

It also includes a caution: caregivers frequently neglect their own health in the stress of taking care of older patients, Dr. Jensen notes.  “Their own immune systems can become compromised, so we tell them to be sure their own physicians know they’re caring for an older patient.  And we share Mrs. Carter’s entire quote with them: ‘There are only four kinds of people in the world: those who have been caregivers, those who are currently caregivers, those who will be caregivers, and those who will need caregivers.’”

Much like the “Caring for You, Caring for Me” program, CEALH also trains leaders to go out into the community to hold group sessions for individuals suffering from chronic diseases, to help them understand how to make decisions that will positively affect their health.  “We talk about diet, exercise, stress reduction, spirituality – anything and everything that would help them manage their disease,” Jackson explains.

CEALH also serves as the Research and Discovery arm of Riverside Lifelong Health.
“In fact, we’re a hybrid of an interdisciplinary aging research agency and a provider of special services for older adults,” Dr. Jensen explains, “which allows us to conduct clinical trials designed to explore and evaluate new treatments and medications, as well as clinical and academic research that can be directly applied to the older population.  Whenever we’re involved in one of those programs, we’re also studying and documenting it for future use.”

Both Jackson and Dr. Jensen emphasize that while the specialized services CEALH provides are available on a sliding pay scale, “Nobody who knocks on our door is denied service because of the inability to pay.  Every grant we write contains a request for scholarship funds for marginalized patients.”

A Riverside PACE nursing assistant listens to the heartbeat of a PACE participant at the Center in Hampton

A Riverside PACE nursing assistant listens to the heartbeat of a PACE participant at the Center in Hampton

PACE – A Program of All-Inclusive Care for the Elderly.  
The PACE model is centered on the belief that it’s better for the well-being of older patients with more chronic care needs and their families to be served in the community whenever possible. Riverside PACE serves individuals who are age 55 or older, who are certified by the Commonwealth to need nursing home care, who are able to live safely in the community at the time of enrollment, and who live in a PACE service area.  There are six PACE centers within the Riverside Lifelong Health system, overseen by Medical Director Dr. Paul Evans, a Board-certified geriatric and family medicine physician.

“One of the most positive aspects of PACE is the acknowledgement that taking care of older patients isn’t just about medicine, it’s not only providing medical care,” Dr. Evans says.  “It includes all the other parts of someone’s life – their finances, their ability to get to social events, the ability to get adequate food and housing, appropriate resources. It recognizes the importance of things like clean air, clear water, housing free of insects and lead paint, all other social determinants of care and health.  PACE acknowledges what doctors have always known,” Dr. Evans says, “that there’s so much that goes into poor health, poor outcomes, that’s out of the control of medicine.”

The benefits of participating in the PACE program are multifaceted, and include extensive outpatient services, home healthcare services, inpatient hospital care and nursing facility care.

“Even when there’s not much we can do for these patients medically, the things we can do for them through PACE can help them achieve better health, and be more functioning,” Dr. Evans says.  “We work closely with the families of our patients, providing aides during the day or at bedtime when required.  We modify the home if necessary, as the patient’s needs dictate: we provide aides in the home, or at bedtime, we install ramps and even provide bus transport services.  The focus is on what can keep patients at home, what will maintain their highest level of function, what will bring them the most joy, and what will support their families.”

Riverside’s sixth PACE Center, Blue Ridge PACE, opened in early 2014

Riverside’s sixth PACE Center, Blue Ridge PACE, opened in early 2014

Invaluable and Innovative Tools for In-home Patients and Caregivers
“Technology has allowed us to provide products and services for our patients that keep them safer, and enable them to go home from a hospital or nursing home earlier than they would if they didn’t have access to such products,” says Daniel Ballin, a physical therapist and Administrator of Riverside’s Wellness and Outpatient Services.  He’s particularly excited about Riverside Alert, a personal emergency response system (PERS) that features immediate 24/7 access to Ask Riverside with just the touch of a button.  “This can be a great comfort to patients who have questions or concerns,” he says, “as they can get answers virtually instantaneously.  It’s an equal comfort to family members who aren’t local, knowing their loved one has ready access to help.”

chairA medication dispensing service is also available.  It organizes complex drug regimes, and provides both audio and visual reminders to the patient, including a missed dose alert.  Emails are provided to caregivers, who can also monitor patient compliance online.  “This is a vital service, because one of the primary reasons older patients are admitted to the hospital is medication mismanagement.

Technology has also enabled remote vital sign management.  “Our nurses will visit patients at home and leave a blood pressure monitor,” Ballin says.  “We can even track blood sugar, glucose and weight five days a week.  We can recognize early warning signs, and immediately send nurses out to check on patients when needed.”

House Calls: a new spin on an old medical tradition.  
Under the direction of Dr. Teresa McConaughy, a Board-certified family medicine physician, Riverside’s House Calls Practice provides primary healthcare services to home-limited adults unable to access regular medical care.  “It was on Dr. Allen’s wish list when he came to Riverside,” Dr. McConaughy says.  “He created a business plan and model to make it work, and I was immediately interested.  I had a large geriatric practice, but I wanted to do geriatrics in a different way, and this presented that opportunity.”

With House Calls, Dr. McConaughy and Dr. Travers Edwards function as their patients’ PCP.  “Some of them have family doctors, but they’re too sick or too weak to visit them, so we take on their care,” Dr. McConaughy says.  “We also get referrals from home health agencies who ask us to step in on behalf of their patients.  We coordinate all medical care, including specialty services, whatever they need that we can treat in the home.”

House Calls physicians are able to spend more time with patients, and develop warm and ongoing relationships with these patients, and putting a human face and touch on the technologies available to them through Riverside’s Lifelong Health division.  They find that they’re able to have much more meaningful conversations with patients about their care – and about their lives – when they’re comfortable in their own homes.

Dr. Cunnington works with a family at Riverside Regional Medical Center to develop an Advance Care Plan

Dr. Cunnington works with a family at Riverside Regional Medical Center to develop an Advance Care Plan

Compassionate care when it’s most needed.
For patients with advanced illness, the concern turns to one of the most sensitive decisions in a family’s life: what to do as the end of life approaches.  Words like ‘palliative care’ and ‘hospice’ can seem foreign and frightening to patients at a time when they feel most vulnerable and their family members feel helpless.

It doesn’t have to be that way, says Dr. Laura Cunnington, Riverside’s Medical Director of Palliative Care and Hospice Services.  “We know these are very difficult times for everyone involved.  It’s hard to contemplate death, especially your own, and it can be even harder to talk about it with people you love, especially if that death seems imminent.”

The hope is that physicians will talk to their patients about what they want as they age, Dr. Cunnington notes, “but these conversations can be difficult for doctors as well.  They have special relationships with their patients, and it can be hard for them to accept the fact that a patient might be dying.  I do a lot of education, one-on-one with doctors, in didactic type settings, to give them better skills as well.”

Advance Care Planning Facilitators assist patients and families.
To assist patients and their families (and when appropriate, care providers), Riverside offers the services of trained Advance Care Planning Facilitators, who are certified by Respecting Choices®, an internationally recognized advanced care planning program.  “These facilitators talk with patients and their families about quality of life issues,” says Carol Wilson, Director of Palliative Care and Advance Care Planning.  “They ask the same fundamental questions: ‘What are your goals?  What do you want to accomplish?  Where do you want to be?’”  There’s no medical jargon in these conversations, Wilson notes.  It’s just about finding out what the patients want.

With this information in hand, an Advance Care Plan can be created and documented and made a part of the patient’s medical record.  Patients are satisfied that their dearest and most personal wishes will be honored when they can no longer speak for themselves, and both families and healthcare providers are relieved of the burden of having to make decisions that might be in opposition to those wishes.

Riverside care providers can then proceed to honor those wishes in all aspects of the patient’s care, whether on palliative care or in hospice, delivering and coordinating the highest quality and most appropriate care.

“That’s what Compassionate Care is really about,” Dr. Cunnington says: delivering team-based care at the end of life, focused on the patient, in relief of suffering, and provided in the setting the patient wishes.

It’s also about educating the community about the resources Riverside offers to patients and families, particularly with regard to Advance Care Planning.  Riverside Lifelong Health is part of the Advance Care Planning Coalition of Eastern Virginia, which also includes Sentara, Bon Secours Hampton Roads and Chesapeake Regional Medical Center.  Branded “As You Wish,” the Coalition works to increase public awareness of Advance Care Planning among all adults over the age of 18, and those filing Advance Care Planning documents.

Riverside Lifelong Health – making Virginia a great place to grow older.
If Riverside Lifelong Health seems like an overwhelming labyrinth of products, services and initiatives, it’s just as much a roadmap for patients, families, caregivers and healthcare providers to maintaining health and vitality – and to enjoying the wisdom and ease that come with age.  And to knowing that the fondest and most deeply held personal wishes will be honored.

With a commitment to caring for older patients that spans more than three decades, earning a statewide and national reputation for excellence, Riverside Lifelong Health is acknowledged as the expert on caring for some of Virginia’s greatest assets – her elder citizens.

For more information visit our website www.riversideonline.com/lifelonghealth. Or call (757) 856-7030

Marissa Galicia-Castillo, MD

MarrisaLrgSection Head of Palliative Medicine at the Glennan Center
Medical Director of Palliative Medicine at Sentara Norfolk General Hospital
Medical Director of Harbor’s Edge
Sue Faulkner Scribner Professor of Geriatrics, EVMS

Dr. Marissa Galicia-Castillo is an anomaly:  born in Hampton Roads, she attended college and medical school in Hampton Roads, completed her residency and internship in Hampton Roads, and did her fellowship in Hampton Roads.  An early interest in science and medicine drew her to the Magnet School for Health Professionals, a collaboration formed in 1986 to initiate early preparation for high school students for careers in the health professions through innovative biomedical curriculum and mentoring.  She attended Old Dominion University for three years, completing her fourth and final year at EVMS, graduating in 1994 with a degree in Biochemistry and Biology.

She received her MD degree from EVMS in 1997, completing her internship and residency in Internal Medicine, followed by a fellowship in geriatrics in 2002.  Dr. Castillo is Board certified in Internal Medicine, Geriatrics and Hospice and Palliative Care.

Her specific interest in geriatrics grew out of two events:  as a teenager, she saw her grandmother grow suddenly ill and deteriorate, very soon dying of kidney failure.  “She was only in her 60s,” Dr. Castillo recalls, “and she seemed so healthy.  The next thing I knew, she was in ICU and then she died.  It never made sense to me.”

Then during the year of her internship, she met two geriatricians – Dr. Stefan Gravenstein and Dr. Janet McElhaney – and working with their patients ignited her interest even further.  “Not only were their cases more complicated and interesting from a medical perspective, I also found that for the most part, the patients were so appreciative, even of the tiniest gesture,” Dr. Castillo remembers.  “We’d do something so small, so simple, and it made a huge difference to them.”  Even getting them out of bed made a difference, she discovered.  “You still see it today with geriatric patients,” she notes.  “When they won’t (or can’t) get out of bed, they can decondition so quickly.  It has a tremendous impact on them.”

Caring for geriatric patients is about more than practicing internal medicine.  It’s also about talking to patients about what they want, and learning what their goals are.   “The biggest difference is that their care is a team event,” Dr. Castillo notes.  “And not just doctors.  We need to also work with nurses, dieticians, physical therapists, occupational therapists, social workers so we address all areas to really take care of these patients.”

When Dr. Castillo isn’t serving as a Palliative Medicine physician in the hospital, she tends to patients at Harbor’s Edge, a Continuing Care Retirement Community in Norfolk that features independent apartments, assisted living, skilled nursing, and long-term care.  She focuses her practice in those who live in the Health Care side of Harbor’s Edge.

Dr. Castillo has found that more and more, patients coming to skilled nursing facilities are much more ill than they used to be even five years ago.  “Sometimes, they’re so debilitated, they’re at the point where rehabilitative care isn’t needed or wanted,” she says.  “We see patients who have congestive heart failure and renal failure, maybe emphysema, and maybe cancer as well.  Their prognosis is very limited.  These are the patients who need palliative care and sometimes hospice.”

Much of her care depends on understanding what these patients want, and tailoring their treatment accordingly.  She describes a typical situation:  “A patient has a deadly combination, congestive heart failure and kidney failure.  If I treat his heart failure by getting rid of the fluid, his kidney failure worsens; it’s a vicious cycle.  So I ask him what his goals are, and he says he just wants to be comfortable.

“That’s what’s so interesting about geriatrics and palliative care: it’s all about function, and what’s important to the patient.  In that patient’s case, knowing that he won’t suffer because of his kidney situation, and understanding what he wants, I pursue comfort measures for him.  I give him medication to reduce his shortness of breath.”

It always depends, Dr. Castillo says, on what the patient wants.  “Often they’ll say ‘please don’t send me back to the hospital, no poking or prodding, just make me comfortable.’  Others might say they want some measures taken, like some labs and maybe a ventilator, if there’s a chance they can come back.  And others may want a full-court press: everything that’s medically appropriate.  That’s why talking – and listening – to patients is so important.

“Geriatrics is much like palliative medicine, in the sense that we try to improve quality of life and function for these patients, to the best degree possible.  These two concepts go hand-in-hand, and they are enormously satisfying.”  At EVMS, Dr. Castillo teaches primary palliative medicine to medical students, residents and Fellows, which includes teaching them to talk to patients and their families about the entire spectrum of caring for geriatric patients.  She laments the shortage of both geriatricians and palliative care physicians, and hopes that training the next generation of physicians in both Geriatrics and Palliative Medicine concepts can help address the growing need.

Teresa L. McConaughy, MD and Paul E. Evans, III, MD

coupleLrgTeresa L. McConaughy, MD
Medical Director, Riverside House Calls

Paul E. Evans, III, MD
Medical Director, Riverside Program of All-Inclusive Care for the Elderly

Dr. Teresa McConaughy and Dr. Paul Evans have a lot in common.  They’re both Board certified in Family Medicine; they’re both Assistant Clinical Professors of Family Practice at Virginia Commonwealth University.  They’ve both dedicated their careers to caring for the at-risk older population.

They also happen to be husband and wife – and while they both did their residencies at Riverside Regional Medical Center, they’re quick to note that Dr. McConaughy went to medical school in the South (Medical University of South Carolina College of Medicine) while Dr. Evans earned his MD in the North (at the University of Connecticut School of Medicine).

The two physicians met while they were both on the faculty of Riverside Family Practice, in the residency program.  “At that time, geriatrics wasn’t really a fully established specialty,” Dr. Evans says.  “There were people doing geriatrics for many years, but there wasn’t formal special training.”  When the fellowship in geriatrics was introduced, Dr. Evans became its first director.

Dr. Evans and Dr. McConaughy both enjoyed the residency program and genuinely liked teaching, but ultimately decided to leave the faculty and go into practice.  They joined the Commonwealth Family Practice in Newport News, where they treated men, women and children.  “There were a lot of geriatric patients,” Dr. Evans says, “and eventually, Riverside asked us to start a new practice in Grafton, Patriot Primary Care, in 2006. We stayed there until 2013.”

He also began doing geriatric consultative work at the Center for Excellence in Aging in Williamsburg (now the Center for Excellence in Aging and Lifelong Health, or CEALH), working with patients with early geriatric syndromes.  Through the Center’s research arm, Dr. Evans and his colleagues were working with new medicine and other innovative treatments for Alzheimer’s disease.  He serves as principal investigator for clinical studies at CEALH.

“And then, PACE had just opened in Hampton,” Dr. Evans continues.  “Dr. Petitjean, who had served on the residency faculty with us, was the primary physician at the program, which had quickly grown to 70 or 80 participants.  Dr. Petitjean was still doing some teaching at the residency program, so they asked if I would be willing to help out.  I began splitting my time between Patriot Primary Care and PACE.  That transitioned to full time at PACE, which in turn transitioned to my being named Medical Director at PACE.”

When Dr. Evans left Patriot Primary Care, Dr. McConaughy says he bequeathed her many of his patients, adding to her already large practice.  “I had been thinking about leaving the office practice, and looking for ways to do geriatrics differently,” she remembers.  “I love family practice; I was enjoying taking care of babies and adolescents and all other ages that came along with family practice, but I was evolving as a physician.

“With older patients,” she says, “I loved listening to them, I liked hearing their life stories, and getting to know them and their families.  And I wanted to be able to provide care that would better help them transition to wherever they were going.”

When Dr. Kyle Allen came to Riverside in 2011, he brought a number of innovative ideas with him, one of which was establishing a house calls practice.  “It wasn’t a novel idea,” Dr. McConaughy says, “as they’re in existence all across the country, mostly in the midwest.  But it was definitely a novel idea for Riverside.”   It was an idea that touched her personally, as she had seen her own mother’s health decline in the final years of her life, and understood immediately how a program of regular home visits could benefit such patients.

Today, as Medical Director of Riverside House Calls, Dr. McConaughy cares for more than 130 patients, seeing each one about once every four weeks.  “In a busy practice, I might have 15 minutes with a patient in an exam room,” she explains.  “Now I can manage my time to accommodate a half hour to 45 minutes in their home, whatever time it takes. And I can spend the time I need to spend to do a better job taking care of these incredibly amazing people.”

Part of taking care of these patients can involve conversations about sensitive topics like advanced care planning and end-of-life decision making.  “Both Paul and I look at it as part of our responsibility to initiate the conversation and help people articulate their wishes,” Dr. McConaughy says.  “It’s one of those things that too often gets shoved under the rug, and unless we bring it up, patients won’t bring it up.  So we have to do it in a way that expresses our commitment to respect their wishes and needs, so that they know we’re guiding their care based on what they want.”

The physicians’ paths don’t often cross these days, they say, although they sometimes have the opportunity to send each other patients.  “Typically, I might wave to her on I-64 if I see her car going by,” Dr. Evans says, “and she’ll wave if she sees mine.”

They acknowledge some of the same stresses inherent in caring for older, frail patients with complex medical conditions.  “We share stories of our patients,” Dr. Evans says.  “We ask what the other would do in a particular situation.  We share the joys and some of the hardships – and we always learn from each other.”

Robert M. Palmer, MD, MPH

PalmerUse

John Franklin Chair of Geriatrics, EVMS Director, Glennan Center for Geriatrics and Gerontology

Dr. Robert Palmer took a somewhat circuitous route to the directorship of the Glennan Center for Geriatrics and Gerontology.  He says he was born to be a doctor, but didn’t realize until he was in medical school that he was destined to become an internist – and it wasn’t until 10 years after his residency that he went into geriatric medicine.  The two compelling passions that have inspired him throughout a nationally distinguished career have been internal medicine – “It offers the combination of taking care of patients and focusing on the mechanisms and treatment of disease,” he says – and working to improve the way healthcare is delivered, on both a small and grand scale.

He received his medical degree from the University of Michigan at Ann Arbor, and as his interest in public health continued to grow, he earned a master of public health at the University of California at Los Angeles.  He calls those years transformative.  He worked for the LA County Department of  Health Services in Pico Rivera, a primarily Mexican-American community, where with funding from the National Heart, Lung and Blood Institute, he was principal investigator and director of a program to create hypertension screening, detection and treatment in the community.   That program, he says, has been the template for everything he’s done throughout his career.

From LA, he took a position at Oregon Health Sciences University Medical School in Portland, ultimately being appointed director of the internal medicine residency program.

At that time, geriatrics was a new specialty, not yet a certified fellowship program.  “There was such a lack of understanding about how to take care of older people,” he says.  “Our knowledge of aging was almost non-existent.”  In geriatrics, he saw opportunities both as an educator and a community advocate to enter a field that clearly needed champions.

After pursuing a fellowship in geriatric medicine at UCLA, he moved to Cleveland and joined the faculty at Case Western Reserve University Medical School.  With his colleagues at Case, he created a comprehensive geriatrics program focusing on hospital, long-term and outpatient care.

He became research partners with Dr. Seth Landefeld, a general internist and kindred spirit. “We wanted to figure out a cost effective way to take better care of hospitalized patients, in a continuous quality improvement process,” Dr. Palmer says. Their work became known as Acute Care for Elders – or ACE – a nationally recognized model that offers enhanced care for older adults in specially designed hospital units, delivered by an interdisciplinary team of medical professionals, including geriatricians, advanced practice nurses, social workers, pharmacists and physical and occupational therapists.  The care in an ACE unit is compassionate and patient-centered, with a demonstrated measurable reduction in the length of hospital stays for these patients.  In addition, the costs are less on an ACE unit than on typical care units. Despite this, Dr. Palmer says, “We’re still struggling to get this model of care to become standard practice.”  The National Institutes of Health agrees: in a recent abstract, NIH researchers wrote, “Low presence of ACE units warrants further research as to reasons more hospitals have not included them, given the available evidence for clinical, functional, and economic benefits.”

Dr. Palmer assumed the directorship of the Glennan Center for Geriatrics and Gerontology in 2011, and he has attacked that position with the same zeal and innovation that marked his other endeavors.  Since his arrival, the Glennan Center has collaborated widely with other departments at EVMS in a variety of research and educational endeavors, and continues to strengthen its ties to organizations within the community.

The faculty of the Glennan Center enjoy clinical practice in outpatient, nursing facility, and palliative care settings. The Memory Consultation Clinic performs detailed evaluation of patients with cognitive decline through a comprehensive team approach to both the medical and psychosocial needs of the patient and caregivers.  Dr. Palmer and his colleagues are expanding the practice and the research program, adding a Geriatrics Consult clinic to provide a comprehensive geriatric assessment for frail seniors, with recommendations given to the patient, family and referring physician.

He is working with Dr. Marissa Galicia-Castillo to expand clinical programs in hospital and long-term care-based palliative medicine:  “We’re now providing inpatient palliative care consults in two Sentara hospitals and a Sentara skilled nursing facility.  We’re also directing a palliative care and hospice program in collaboration with our partners at Beth Sholom Village and Jewish Family Services.”   He’s also a consultant at one of the Sentara hospitals that feature an ACE Unit, and direct Geriatric Medical Services at Sentara Norfolk General Hospital.

His commitment to improving the quality of resident education in geriatrics is evident.  “We’re heavily engaged in teaching of all learners at EVMS,” he says, “medical and physician assistant students, residents in internal medicine and family medicine, and fellows training in geriatrics. This past year we launched a grant to train Chief Residents of nine different departments in the principles of geriatric practice, patient safety and quality improvement.”

Future plans for the Glennan Center include creating innovative, sustainable clinical programs to benefit the seniors in the community, and to expand research in geriatric safety, palliative care and dementia.  With its community-based health care partners, the Glennan Center is ready to implement the “Triple Aim”-to improve the patient experience in all sites of care; to improve the health of the elderly population of Hampton Roads; and to reduce the costs of health care.

“The challenge for us now,” he says, “is to more deeply engage the community in advocating for even better care for our seniors.”