“I know geriatrics, because I’ve taken care of a lot of old people.” As a geriatrician, I’ve heard this refrain my whole career from other physicians who are trying to rationalize the care they deliver to older adults. The scope of this refrain is about to expand, and we shouldn’t be surprised to find nursing home administrators opining on clinical care delivery approaches.
What will be the impetus and why is it important? PDPM! PDPM is the acronym for the Patient Driven Payment Model being instituted in October by the Centers for Medicare and Medicaid Services (CMS). The concept is that reimbursement for skilled nursing care, a benefit that all Medicare beneficiaries have paid for over their lives, should be driven by the actual needs of the patients themselves. While this makes sense, we must still be wary of the unintended consequences of this new program.
PDPM may the greatest opportunity the field of geriatrics has ever seen. Being the greatest opportunity, it also has the greatest risk of being hijacked by others who claim to understand our field. The battle for the heart and soul of the field of geriatrics is only beginning, and if we don’t prepare ourselves, the losers will be the older adults whom we have faithfully served since the founding of the American Geriatrics Society in 1942. The greatest underlying threat to our field is actually ageism, which pervades society and the healthcare system.
The term ageism was coined by Dr. Robert Butler in 1969. Six years earlier he first wrote about “the façade of chronological age,” when he predicted that in the future, “more individuals will be seen who are old in years but functionally young.” Today’s social media has viral videos of centenarians running the 100-yard dash, riding exercise bicycles and lifting weights. Yet, when a frail older adult encounters the healthcare continuum, the default reaction is to assume the worst. Hospitalized older adults with classic symptoms of delirium are often misdiagnosed with dementia. Frail older adults with an acute illness are immediately considered for palliative care based on ageist assumptions. The list is endless.
I have seen firsthand situations in the nursing home industry where less value is placed on the lives of older adults who suffer from functional or cognitive impairment. The C-suite talks about “doing the right thing,” but if things don’t work out, the diminished value placed on frail older adults is used as an excuse to rationalize poor outcomes. Antipsychotic medication reduction efforts have been confounded by this type of response from nursing home leadership. It is all too easy to blame behaviors on an underlying dementia, or to minimize the side effects of antipsychotics based on the perceived diminished value of the frail older adult with dementia.
The most common cause of behavioral issues in nursing homes is caregivers lacking adequate training in how to effectively approach residents who are cognitively impaired. Solving this problem requires an investment in education and training. It also requires a proactive approach with the attending physicians, who are typically influenced by staff complaints and concerns. Experienced geriatricians know that the prevalence of antipsychotic use should be less than 5%. National efforts have brought this number down from a starting point of over 20% to around 10-15%. We still have a long way to go, and an important part of the solution involves confronting ageist notions on the part of staff, physicians and nursing home industry leadership. It also necessitates accepting the need to integrate the geriatrics approach to care into nursing homes.
Which brings us back to the opportunity that is PDPM. If we are to provide the most appropriate care to older adults receiving the skilled nursing benefit, we must cast away ageist tendencies and focus on the person. The geriatrics approach to care necessitates a focus on function and quality of life. It requires us to respect the individual’s dignity, autonomy and spiritual needs. It is the embodiment of person-centered care, which requires us to truly know the person. Minutes of therapy was an arbitrary tool used by the government to try to determine appropriate payment. It had no evidence basis. PDPM must be person-centered and evidence-based, which defines the geriatrics approach to care. Geriatricians must take an active role in educating clinicians and non-clinicians alike in determining appropriate care approaches. Nursing home medical directors and attending physicians must demonstrate competencies in geriatrics through the American Board of Post-Acute and Long-Term Care Medicine (ABPLM). PDPM will soon be upon us, and this is the only rational path forward for its effective implementation.
PDF of Weiner's 2019 CALTCM Summit for Excellence Presentation