Current AGS Newsletter

At the University of Utah Hospital in Salt Lake City, Fridays have become a special day for patients in its AGS  CoCare^®: HELP   program. Once a week, a member of the Utah Symphony who volunteers with the evidence-based delirium prevention program plays a cello concert that patients can watch on their iPads. The virtual performances are only one example of the ways in which the Utah program and its counterparts around the country have adapted to the trying circumstances of the COVID-19 pandemic.

The AGS CoCare^®: HELP Program Model

Formerly known as the Hospital Elder Life Program, the AGS CoCare^®: HELP program is a well-studied, effec- tive, and innovative model of hospital care designed by Dr. Sharon Inouye (photo) to prevent both delirium and functional decline. AGS CoCare^®: HELP integrates the principles of geriatrics into standard nursing and medical care on any hospital unit and brings geriatrics expertise to bear on care decisions that impact not only patients enrolled in the program, but those throughout the institution.

The program provides an organized system to manage the markers of and prevent delirium, from maintaining physical and cognitive function to maxi- mizing independence in the transition from hospital to home. This system includes training for interdisciplinary team members to understand the value and practical implementation of daily patient visits, therapeutic activities, early mobilization programs, protocols to optimize sleep, hearing, and vision, and opportunities for smoothing tran- sitions between care settings.

Hospitals across the nation may benefit now more than ever from AGS CoCare^®: HELP, with new cases of delirium manifesting in older COVID-19 patients and social isolation—the consequence of strict visitation policies—exacerbating symptoms in all hospitalized older adults. But it has been no easy feat for institutions currently operating the program to adjust and adapt their procedures in unprecedented ways during the pandemic.

The Resilience of Three AGS CoCare^®: HELP Programs during a Public Health Emergency

AGS News is proud to showcase the incredible adaptations that the California Pacific Medical Center (CPMC), the University of Pittsburgh Medical Center (UPMC), and the University of Utah have made to their programs as they continue providing resources for their patients and detecting new cases of delirium.

Despite new social distancing guidelines and hospital visitation policies, these three centers have continued their programs through a combination of virtual volunteer visits, (by phone and video call), and in some cases, by reassigning staff to assume what were previously volunteer roles.

Two centers are employing technology to keep volunteers engaged and patients connected to their families. At the University of Utah Hospital, volunteers are conducting virtual visits on ten units five days a week via iPads, offering therapeutic activities, orienting communication, relaxation techniques, range of motion exercises, and engaging conversation in order to help prevent delirium. At the California Pacific Medical Center, volunteer training — including instruction in patient interaction with the center’s medical clowns—is now conducted through a day’s worth of video meetings and presentations, and Elder Life Specialists are planning group virtual meetings to share best practices, encourage ongoing volunteerism, and thank volunteers for their work. Staff at both sites have helped patients use iPads to connect with volunteers and their family members. All three centers have developed new resources, including activity packets, to keep patients engaged with protocols that can be carried out independently and cognitively active with games, puzzles, and other brain-stimulating exercises.

What fundamentally unites these geographically remote, unique programs is the creativity, innovation, and commitment to the core HELP principles they have embodied in a time of crisis.

They make HELP founder Dr. Inouye proud: “I have been so impressed with the amazing creativity that HELP sites have demonstrated, as they have responded swiftly and adaptively to the epidemic of delirium we are seeing in older adults during the COVID-19 pandemic,” she told AGS News. “Through our interest groups, online community, various AGS CoCare^®: HELP meetings, and my conversations with sites, I have learned about the tremendous breadth of responses. The bottom line: AGS CoCare^®: HELP is needed more than ever.”

Advice for their AGS CoCare^®: HELP Peers

Each site has words of wisdom to share with other AGS CoCare^®: HELP programs working to keep their operations running smoothly as the country manages the current surge in COVID- 19 cases:

• Elder Life Nurse Specialist Miriam Beattie, DNP, GNP, ANP, and Elder Life Specialist Alijana Kahriman, MS-Geron, at the University of Utah counsel against getting dis- couraged: “Start somewhere and continue to evolve your program to what works for your institution. HELP at the University of Utah is doing what it can to support our most vulnerable population during this pandemic. It is amazing to experience the impact that HELP iPads,” a purchase the program made in April thanks to a generous donation, “have on our hospitalized older adults.”
   
• Olivia Wendy  Zachary,  MD,  medical director of the AGS CoCare^®: HELP program and acute care of the elderly unit at CPMC says you shouldn’t let your hospital forget about the work you do: “Find a presence any way you can, in-person or virtually. Continue to track your data, and, if possible, separate your COVID-era data from your pre- and post-COVID-era data so you can analyze them separately for trends, successes, and opportunities.”
   
• Department of Medicine Chairman Fred Rubin, MD and AGS CoCare^®: HELP Director Phyllis Glass, RN, MSN at the UPMC echo Dr. Inouye in pointing out that the benefits HELP offers are more relevant now than ever: “The COVID-19 syndrome commonly includes delirium in older patients. Those patients can benefit from HELP. Additionally, all patients are feeling isolated now, with reduced opportunities to interact with other patients or visitors. They can also benefit more than ever from HELP.”✦

For more information about AGS CoCare: HELP®, visit us at help.agscocare.org or contact us at cocarehelp@americangeriatrics.org.

In November, the AGS publicly announced its plan for how the organization will begin to address the intersection of structural racism and ageism, after issuing an updated position statement on discrimination this past summer.

“Since we issued that state- ment, AGS leaders have spent the intervening time thinking about what that commitment means for a Society that is focused on address- ing another big “ism”—ageism—in health care. We’ve also been in learning mode, working to under- stand our own implicit bias and gathering ideas for achieving lasting and meaningful change,” said AGS CEO Nancy E. Lundebjerg, MPA.
The AGS has committed to three action  steps  to  address  racism in healthcare, given its impact on older adults, their families, and their communities: (1) affirming the Society’s com- mitment to creating a future  where  health  care  is  free of discrimination and other forms of bias; (2) ensuring its educational programs and products address the diversity of older adults; and (3) setting an aspirational goal of guar- anteeing that all original research published in the Journal of the American Geriatrics Society  (JAGS)  and  presented at the AGS Annual Scientific Meeting will take full account of ethnicity, gender, disability, age, and sexual orientation in design, undertaking, and reporting by 2031.

As a first step, the AGS added the following statement to its vision for the future: “We all are supported by and able to contribute to communities where ageism, ableism, classism, homophobia, racism, sexism, xenophobia, and other forms of bias and discrimination no longer impact healthcare access, quality, and outcomes for older adults and their caregivers.”

“We thought it was important to put our commitment front and center in our statement of who we are,” AGS President Annette Medina-Walpole, MD, AGSF explained. “This commitment has always been a part of who we are  as an organization. Putting it front and center in our future vision reflects our deep commitment  to  achieving  last- ing and meaningful change—which we know will require tremendous energy across the AGS for the foreseeable future —so we’ve also embedded this focus into our strate- gies for achieving our vision.”

To establish a road map for its work going forward, the AGS will be crafting a series of papers that include an issue brief outlining the intersection of structural racism and ageism, and a statement of principles sum- marizing a series of goals for achieving change, as well as recommended tactics and strategies for accomplishing those goals. Parallel to this work, JAGS will be inviting papers that are focused on the state of science when it comes to the diversity of study populations and that will provide a baseline for future efforts in this area.

The AGS will also take immediate action to combat structural racism and ageism in health care by updating its portfolio of products, including the Geriatrics Cultural Navigator app. “The AGS has long been a leader in sup- porting cross-cultural communication in health care, having published the first volume of its Doorway Thoughts series in 2004, and our app is based on that earlier work,” Lundebjerg noted. “We will be creating companion pub- lication tip sheets for each of the 27 different ethnicities and religions covered in the app. As we update our other programs and products, we will also be assessing how best to integrate attention to the intersection of structural racism and ageism in health care into all our work.”

In the coming months, the AGS will be inviting mem- bers to share their thoughts on the new initiative and its implementation through a series of listening sessions and focus groups. “We know that our AGS members care deeply about improving the health, well-being, and quality of life in all older adults’ lives,” Medina-Walpole said. ”We are looking forward to getting their input into how we can accomplish our future vision and embarking on this journey together. We recognize that this is difficult work that will take time and are fully committed to staying the course until we have achieved our vision for a healthcare system that is free of structural racism and ageism.”

To learn more about these initiatives, visit our website. ✦
 

It’s been over a decade since I agreed to serve as co-convener of the Eldercare Workforce Alliance (EWA), where our first priorities were to get the geriatrics health profes- sions re-authorized in the Affordable Care Act and eliminate the compan- ionship exemption that made direct care workers ineligible for overtime pay. Ultimately, through our work with EWA, the AGS was successful on both fronts, with a large part of that suc- cess due to finding common ground with others and working together  to achieve change.

In 2020, I’ve been reminded of what I learned from EWA colleagues during those early days: (1) think stra- tegically; (2) look for common ground and potential allies; (3) speak with one voice; (4) work hard; and (5) play a long game. I think that last point is the most difficult to do in our COVID-19 advo- cacy, given the urgent need to act now. In AGS’ letters to Congress and the Trump administration (12), policy statements (9), and issue briefs (2), our top points were always  focused on those immediate priorities: increas- ing production of personal protective equipment (PPE) and testing supplies; including the direct care workforce in the definition of essential workers and ensuring that all frontline workers had access to paid leave; and investing in our public health workforce.

Sadly, our carefully worded state- ments seemingly fell on deaf ears. Frankly, it felt a bit like we were yodel- ing into the void and the echo we heard was the sound of other voices doing the same. Despite this, we kept at it, recognizing that AGS is an organization that always advocates for policies that will support us all as we age. This is where we come to the long game. Even as we advocated for immediate needs, we also talked about longer-term needs—perhaps most importantly ensuring that there would be geriatrics, long-term care, public health, and palliative care exper- tise involved in planning for future disasters and pandemics.

As I write this column, the media has called the Presidential election for Biden, even as states continue to tally votes and the President’s re-election team files legal challenges. With this context in mind, I want to highlight how our advocacy throughout the pan- demic is reflected in President-Elect Biden’s policy agenda, while noting where that agenda may need some further refinement.

On November 9th, President-Elect Biden announced a COVID-19 Task Force comprised of public health experts and scientists, and the Biden- Harris plan includes invoking the Defense Production Act, which will increase production of PPE and testing supplies. Most importantly, President- Elect Biden and Vice-President Elect Harris are talking now about the steps that all Americans need to take in order to protect ourselves, our neigh- bors, and those who care for us.
Even as I celebrate the adequate supply of PPE for AGS members, test- ing for everyone, and public health messages that are in our collective interest, I know we will need to con- tinue to advocate for programs and policies that are important for us all as we age. You see, the other lesson I’ve learned since the halcyon days of get- ting legislative language into the ACA is that one can never rest on one’s laurels. And with that, I need to put in my own plug for a request that Annie Medina-Walpole makes in her column (page 4), asking each of our members to participate in shaping institutional, local, and state policy by volunteering your expertise. I join Annie in encour- aging you to take a minute to reach out to your governor via the AGS Advocacy Center to let them know of your interest in helping states create and implement policies that support all of us as we age.

I am so very grateful to all our members for your dedication to the older adults that you serve. You’ve risen to the challenges of the COVID- 19 pandemic, and it’s been  inspiring to see your support for each other. Looking ahead to 2021, we hope you will share your thoughts with us when we reach out to you for your input into how we can we can achieve our future vision of a world free of discrimina- tion and bias. As you know from our member alert, our immediate focus will be on addressing the intersection of structural racism and ageism, but our vision is a just healthcare system that is free of discrimination and bias– one that supports us all as we age.
All my best for a peaceful holiday season, and here’s to our continued work together on behalf of older adults. We’ve got this. ✦

Want to learn more? See the following articles from the Journal of the American Geriatrics Society:
•    “Hard Work, Big Changes: American Geriatrics Society Efforts to Improve Payment for Geriatrics Care” (DOI: 10.1111/jgs.15593): 
•    “Putting Complex Older Persons First: How the Centers for Medicare and Medicaid Services 2019 Payment Proposal Fails Older Americans”
(DOI: 10.1111/jgs.15651)

Among whatever else may remain forever imprinted on our minds from the days leading up to and following Nov. 3, 2020, this we should not forget: More votes (more than 156 million) were cast in this year's presidential election than in any other previous U.S. election, and the turnout rate (66.5%) was the highest in over a century.

This notable showing at the polls is a victory for our democracy, which best represents our interests as Americans when we engage in the civic and political life of our communities. Civic engagement, or working to promote the communal quality of life, takes many forms beyond voting: We can join a book club, volunteer at a soup kitchen or coach our child’s tee ball team, volunteer to serve on American Geriatrics Society committees (something I’ve found incredibly rewarding personally and professionally), and advocate on behalf of older adults in our communities.

Healthcare profes- sionals have engaged in political advocacy, or action that supports a political cause, throughout modern history. In 19th century Germany, the father of cellu- lar pathology, physician and politician Rudolf Virchow, championed the refor- mation of sewer and water systems because he knew that improvement in health requires  improvement in socioeconomic conditions; he assigned significant responsibility for social problems to his fellow doctors, whom he called “natural attorneys of the poor.” His British contemporary Florence Nightingale, the mother of modern nursing, focused much of her efforts as a social reformer on the care of the sick in workhouses, as well as the quality of life in their homes and low-income neighborhoods. In her writings, she emphasized the need for special training for public health nurses and the importance of sanitation and disease prevention.

This long tradition of healthcare professional advocacy is alive and well in the modern-day public square, often facilitated by engagement with professional organizations like the AGS. Our Society has advocated effectively for federal programs and policies that improve the health, inde- pendence, and quality of life of older adults because we’ve identified—and invested in—advocacy as one of our core strategic priorities. The not-so- secret key to our strategic success is the willingness of our  members to champion policies that support us all as we age. Whenever we ask, you answer the call—whether that call is doing something as simple as sending a letter to your Congressperson or as involved as serving on an expert panel. You are an army of advocates who live our mission every day through your own commitment to ensuring quality care for older adults.

This year, from the frontlines of the COVID-19 pandemic, we have all wit- nessed the devastating toll this virus has taken on older adults, particularly those frail individuals who live in con- gregate care settings. We were the first to talk about the crisis within the public health crisis—the devastating impact of isolation on older adults as lockdown orders limited visitors and congregate activities, leaving too many alone in their rooms and homes for too long.

We have yet to understand the full impact this public health crisis will take on AGS members, but we do know that you’ve been holding hands, working through your own exhaustion, and supporting each other through the sadness that comes from being the experts in care of older adults.

And  I  believe  that our strength in adversity, our lived experiences, our passion, and our geriatrics expertise have prepared us to envi- sion and call for a new status quo.

In response to the pandemic, the AGS has put forward seven principles that should guide allocation of scarce resources. These principles are rooted in our fundamental belief that healthcare systems must be just, that allocation strategies must be free of bias, and that categorical age exclu- sions are unethical. In this, as in our other COVID-19 advocacy letters and statements, we called on institutions and governments to include public health, geriatrics, long-term care, and palliative care expertise when estab- lishing work groups, task forces, and committees that are focused on pro- tecting the health of the American public. I’m incredibly proud of the way our members have collectively taken to Twitter, served as informal advisors to their state and local governments, and participated in our advocacy cam- paigns as part of our federal advocacy efforts during this time of crisis.

As we enter 2021, I want to encourage each of you to consider vol- unteering to assist your state and local government as they plan ahead for the future. The reality is that there will be much for those of us with geriatrics expertise to do if we are to influence and change scarce resource allocation strategies, ensure a focus on older adults in disaster response planning groups, and help policymakers launch programs and services that support all of as we age.
Our AGS staff has made it easy for us to reach out to our governors, offer our knowledge, and point to important resources that can inform state-level responses to the current public health emergency and future disasters. The results of simply offering your expertise may surprise you! As an example, Patrick Coll, MD,  AGSF, took advantage of a template letter we have posted in our online Health  in Aging Advocacy Center and subsequently received an invitation to join Connecticut’s new Nursing Home & Assisted Living Oversight Working Group. As a fellow AGS Board member, I know what a great addition Patrick is to a planning group like this; his letter reminded Governor Ned Lamont that there are local geriatrics experts he can call on for advice.

In my own home community of Rochester, New York, several geriat- rics health professionals across health systems rose to the challenge and exhibited extraordinary commitment and leadership for our region. They joined a county long-term care COVID- 19 task force to establish a streamlined and supportive community response to the pandemic in the post-acute set- ting. It is examples like these, in each of our communities, that reinforce the invaluable role we can play and the impact we can make with our geriatrics expertise and experience.

On a personal note, my work with the AGS is amongst the most fulfilling of my career, and I remain fully com- mitted to the Society and to all of you as members. “A world where all older adults receive high-quality, person- centered care” is the vision which embodies the American Geriatrics Society. My goal is to inspire each of you to embrace this vision, as I have done, and use it as an inspiration in your daily work as geriatrics health professionals. Please know that you are all my geriatrics superheroes. ✦

In November 2019, the Centers for Medicare and Medicaid (CMS) finalized  extensive  changes  to the office/outpatient evaluation and management (E/M) visits codes set to take effect on January 1, 2021. CMS also proposed a new G-code and some other changes that may be finalized in December.
Over the past two years, the AGS  has worked   as part of a coordinated effort—spearheaded by the American Medical Association (AMA)—to simplify coding and documentation for E/M office visits and reduce administrative burden for clinicians. We are also extremely appreciative of CMS’ ongoing work with the AGS and other key stakeholders to refine and improve payment policy for these services.
Effective January 1, 2021, the following key Current Procedural Terminology (CPT) coding changes will apply to E/M office visits:

• Maintenance of five E/M levels of coding for established patients but reduction in the number of E/M levels to four for new patients; this includes the deletion of CPT code 99201 (Level 1 new patient) and revised CPT code definitions for 99202-99215.
   
• Elimination of history and physical exam from code selection; exam performance will be required only as medically appropriate.
   
• Permission of clinicians to choose the E/M visit level based on either medical decision making (MDM) or total time on the date of the encounter; this change recognizes the work involved in non- face-to-face services, like care management.
  • Extensive changes have been made to the guidelines that define the elements of MDM to focus on tasks that directly affect the management of a patient’s condition.
  • Total time includes non-face-to-face services and clear time ranges for each code.
     
• Addition of a shorter, prolonged service code (99417) that requires at least 15 minutes or more of total time, either with or without direct patient contact on the date of service.
   
• A new Medicare-created G-code for visit complexity (GPC1X) that can be reported with all office/outpatient E/M visit levels (see table for the rates under the proposed rule, which includes the proposed reduction to the conversion factor to maintain budget neutrality). 
   
• Increased payment for most office visits; the AGS played a key role in the American Medical Association RVS Update Committee (RUC) survey of these codes, which made this increase possible. ✦

AGS will be hosting a webinar for members in January to review the final coding changes.

Check your weekly listserv and the member forum for updates on when and how to register.

OFFICE/OUTPATIENT SETTING
2021 Proposed Rates for New and Established Patient Visit

In May 2020, the AGS and the Association of Directors  of Geriatrics Academic Programs’ (ADGAP) Advancing Innovation in Residency Education (AIRE) Proposal to Establish a Medicine-Geriatrics Integrated Residency and Fellowship was approved by the Accreditation Council for Graduate Medical Education (ACGME). This combined Med-Geri pathway, supported by the American  Board of Internal Medicine (ABIM) and the American Board of Family Medicine (ABFM), provides an alternative pathway for training geriatricians by integrating the clinical experi- ences required in a geriatrics fellowship across an internal or family medicine residency. It meets all geriatrics com- petencies in an innovative four-year (48-month) program.

“We’ve been working for a long time on ways to make geriatrics more accessible to trainees, and integrating the fellowship experience into  residency  sets  a  foundation  of geriatrics principles earlier into training,” said Angela Beckert, MD, co-chair of the workgroup that  developed the AIRE proposal and now co-chair of the AIRE leadership team. “Trainees can benefit from this integrated approach because they will have early geriatrics clinical experiences and ongoing mentorship and coaching, and they will receive an individualized learning plan with potential flexibility for enhanced professional development in the fourth year.”

This competency-based combined training model does not shorten the total training time for either residency or fellowship, but rather integrates training to allow for early exposure to geriatrics principles of care and enhanced professional development opportunities during the fellowship year. In this training model, internal medicine (IM) or family medicine (FM) residents will continue to meet all their residency requirements in a three-year period and will continue to sit for their IM or FM board certification examination at the usual time. In addition, geriatrics fellows will continue to meet all their fellowship requirements and have a minimum of 12 months of clinical geriatrics experience.

This ACGME-approved pathway, available for the first time for the residence match in March 2021, will mark its inaugural year at three institutions: the Icahn School of Medicine at Mount Sinai in New York, the Medical College of Wisconsin, and the University of Nebraska.

The program will accept new applications from insti- tutions interested in the Combined Med-Geri Pathway in January 2021. This application cycle is for trainees starting in July 2022.

For more information about the program and to learn about applying, visit our website. ✦
 

Student and resident interest groups in geriatrics are vital to the AGS mission of expanding geriatrics education and experience in training programs. AGS student and resident chapters help foster an early interest in geriatrics and supply connections and resources for trainees to learn about interdisciplin- ary care for older adults.

Despite the unique challenges of the past year, AGS student and resident chapters remained engaged with their communities virtually and kept us #AGSProud of their spirit. We congratulate the following chapters, which applied for AGS support in 2020:

• Baylor College of Medicine
• Dominican University of California
• Geisinger Commonwealth School of Medicine
• University of Connecticut
• University of Nebraska Medical Center
• University of Vermont

I’ve been a member of the American Geriatrics Society since my first year of residency, so it’s been nearly a decade now. I joined as a trainee member because I knew I had an interest in geriatrics and became a full member in 2019—and I’ve enjoyed wonderful career-boosting benefits ever since.
As just one benefit of my AGS mem- bership, I’ve met and worked with a diverse group of geriatrics professionals from many different institutions. When I first got involved, I was responsible for the Residents’ Sessions. Through that experience, I got to know a lot   of trainees who were also interested in geriatrics. During my eight years there, I was able to work and build collaborations with a diverse group of people, and now I’m the Vice-Chair of the Cancer and Aging Special Interest Group. That role allows me to foster collaborations among healthcare pro- fessionals who are interested in cancer and aging.

When asked which came first, my interest in oncology or my interest in geriatrics, I’d have to answer that I’ve been interested in oncology since medical school, when I became involved in cancer research. From there, I developed an interest in the clinical side, and found that seeing patients with cancer really taught me a lot; the advances in research and clini- cal practice makes the specialty really interesting and challenging.

It wasn’t until my residency that I became aware of geriatrics—I hadn’t realized that geriatric oncology existed. The field was new, and had only really begun in the early-to-mid 2000s. My residency program at that point was at Baystate Medical Center where I got to work with Dr. Maura Brennan. She’s very active in AGS, and she really nur- tures residents’ interest in geriatrics. Truth be told, when I did a geriatrics rotation during my intern year, I wasn’t sure that it was for me at first, because of the challenges that older patients and their often complex medical prob- lems can present.

But by  the  end  of  that  rotation, I found that I’d learned a lot of medi- cine—and the experience taught me  a great deal in terms of approaching patients with complex medical prob- lems. I came to see that working with older patients was both challenging and rewarding, but I had a hard time figur- ing out how to combine geriatrics and oncology. And then I learned about the existence of geriatric oncology as a field and that training in both was possible, which was perfect for me. I ended up applying for and completing both fel- lowships at the University of Rochester Medical Center, and now I specialize in taking care of older adults with cancer, specifically those with blood cancer.

Recently, I was delighted to receive the Arti Hurria Award for Emerging Investigations in Internal Medicine Focused on the Care of Older Adults, awarded by AGS and the AGS Health in Aging Foundation.

I was especially honored to receive this award, because Dr. Hurria was a close friend of my mentor, the geriat- ric oncologist Dr. Supriya Mohile. I got to interact with Dr. Hurria quite a bit since meeting her in my third year of residency. I think of her as having been a kind and a fierce advocate for older adults—she had an amazing ability to unite people around her vision. She was a devoted mentor with a passion for raising up the next generation of geriatric oncologists. This has affected me deeply, and I strive to continue her work and live up to the example she set. So, getting this award really means a lot to me, and I hope I can help others realize that taking care of older adults with cancer is important and rewarding work. ✦

Print and share this tip sheet from HealthinAging.org with patients and caregivers!

Avoiding COVID-19 Scams