CENTER FOR THE AGING

Director: John H. Wasson, M.D. The Center for the Aging (CFA) at Dartmouth Medical School, housed in the Department of Community and Family Medicine, was established in 1992 with the receipt of the Herman O. West Endowment and the allocation of Program Development Funds (PDF) from the Office of the Dean. The CFA represents, in part, a successful "spin off" of the Dartmouth COOP Network's research and demonstration projects. It aims to improve the quality of life for northern New England's more than 350,000 elderly, by fostering research, education and interdisciplinary collaboration. GOALS: The Center serves as a catalyst for the continuing improvement of the care of the elderly. The goals of the Center for the Aging are to: improve care delivery to the elderly and contribute to the body of research on the care of the elderly develop collaborations and partnerships to share information expand educational opportunities to the Dartmouth community and beyond By design, the Center devotes a significant portion of its resources to institutions and persons customarily considered outside the domain of a medical center. The Center's primary focus is to build networks and collaborate on projects that improve geriatric care. The Center's success depends on close collaboration with northern New England's universities and state agencies, as well as with home health agencies, hospitals, nursing homes, policy makers and community based organizations. Care Delivery: Perhaps the most significant and representative research project to improve the care of the elderly has been demonstrated with "Community Centers of Excellence for the Aging. " (CCEA) Since 1993, the John A. Hartford Foundation has supported this project and its successors to create better partnerships between patients and their doctors by enhancing better communication, educating patients about their health, increasing physician awareness about health needs of their patients and responding to unmet needs... ultimately improving the quality of life for the elderly. Using the Dartmouth COOP Clinical Improvement SystemÅ as well as the "Improve Your Medical Care" questionnaire the intervention has yielded positive results. Eighty percent of patients believe that the quality improvement approach has improved their health, and that their clinicians have become more aware of important and otherwise unmet patient needs. More patients are aware of preventive measures, such as flu shots, and many patients now have advance care plans. There is improved knowledge about home health hazards and about the importance of keeping track of medication. Patients who have begun to exercise say that they feel much better. The project is now in its second phase, and versions have been designed specifically for Spanish speaking and disadvantaged elderly patients. These models are currently being disseminated in federally funded Community Health Centers in Maryland, Pennsylvania, Texas, Iowa, and California. This effort has been sponsored by the John Hartford Foundation of New York City. Hitchcock 80+ Project: In the fall of 1996, the Hitchcock Clinic and the CFA agreed to work together over the next years to improve the care of persons 80 years of age or older. Although these persons constitute only 22% of the Medicare population, they account for 35% of its costs. The cost of care of this age group shows three times as much variation as that provided to younger Medicare beneficiaries. Many of these persons express a preference for care and comfort if they become seriously ill, whereas current Medicare payment patterns encourage the provision of acute care services. More than the 1,000 physicians who provide care in the Lahey-Hitchcock Clinic health care system (LHC) are increasingly under pressure to improve the value of care they provide to the elderly. Because of the associated risks, costs and variation of their medical care, 80+ patients are sentinel for elder care quality within LHC. The entire Journal of Ambulatory Care Management, scheduled for the Summer of 1988, will be devoted to this topic. In addition, the Institute for Healthcare Improvement (IHI) will use the CFA's 80+ project as a program for national dissemination in the Spring of 1998. Other clinical improvement projects include: Flu Shot and Elderly Assessment Program - to heighten physician awareness of patient needs and improve patient awareness of health issues and common problems of the elderly In collaboration with the COOP, the CFA is developing and evaluating systems for enhancing the physician-patient and physician-nurse communication to improve elderly patient care and satisfaction. These can be used in any of the six model clinics (Paul Model Clinics). Collaboration: The Center has formed solid relationships with health care providers and organizations in Maine, New Hampshire and Vermont. Its efforts to improve care of the elderly have strengthened communication among the leaders of aging programs at the Universities of Vermont, Southern Maine, and New Hampshire and representatives of the 3-state governments. Ongoing collaboration has lead to the development of the Northern New England Partnership in Aging. As a result, the academic collaborators work jointly as a component of the Harvard Upper New England Geriatric Education Center (HUNEGEC). Related projects include: Development of innovative approaches to improve information quality and utility about long-term care, through the development of a uniform dataset across NH, VT and ME. The Commonwealth Fund and New Hampshire's Health Care Transition Fund have supported this project to develop and test a brief, standard data system for monitoring the health of the States' aged populations in Maine, New Hampshire, Vermont and Virginia. Creation of newsletters and symposia on Aging activities both at Dartmouth and in the community Development of a speakers bureau comprised of health care professionals who speak to community organizations on aging issues and geriatrics Education: More than one thousand physicians, nurse practitioners and registered nurses have participated in community-based geriatric educational programs in the three states. Educational topics included the care of persons who have less than one-year of life expectancy, the management of geriatric emergencies, and the assessment of cognitive problems. Effective January 1, 1997, retired New Hampshire physicians are able to offer pro bono consultation and education to the elderly. With increasing focus on efficiency of the health care system, busy clinicians find it difficult to spend extra time on patient education. The goal of this project is to develop and implement a program through which retired physicians are trained to provide focused health education and non-therapeutic consultative services "pro bono" to elderly residents in New Hampshire and Vermont, in particular the underinsured and impoverished. The national American Association of Retired Persons (AARP) worked with Dartmouth's Rockefeller Center and the CFA to present policy questions in an informative and useful audiovisual format -- the "Intergenerational Video." The AARP was also instrumental in securing the passage of the "Pro Bono" legislation described above. The Department of Veterans Affairs and the non-Veteran population now have available a videotape on Advance Care Planning and Living Wills developed with the assistance of the Center for the Aging. The Center for the Aging and the Center for Improving the Care of the Dying at George Washington University have completed a national survey of the very old and an analysis of national data to address this question: Is there enough overuse of hospitals that reallocation within Medicare could provide sufficient funds to enhance home care and community services? The answer is yes. This policy research was supported by the Robert Wood Johnson Foundation. The Emily Davie and Joseph S. Kornfeld Foundation, the National Cancer Institute and the New Hampshire Health Care Transition Fund have generously supported work to improve the care of the dying. Elective Course - "The Dollars and Sense of Aging." This 8 hour course will distill Center for Aging clinical improvement expertise, its experience in providing education to large numbers of busy clinicians and lessons learned from an enduring and highly successful seminar series between College undergraduates and residents of a nearby retirement community. The aging elective will be coordinated with the 80+ project to enhance housestaff understanding of geriatric needs and methods to improve care. EVALUATION: Because of the research focus of the CFA, evaluation is built into most projects. Publications resulting from its work currently include: Wasson JH, Stukel TA, Weiss JE, Hays RD, Jette AM, Nelson EC. A Randomized Trial of Streamlined Geriatric Care for Physicians' Offices ; submitted: JAMA, submitted. Wasson JH and Jette AM. A project designed to illustrate how understanding the "patient world" can improve geriatric care in physicians' busy practice settings. In: Netting FE and Williams FG, editors. Enhancing Primary Care of the Elderly. Garland Publishing, Inc., New York. In press. Wasson JH, Jette AJ, Johnson DJ, Mohr JJ, Nelson EC. A Replicable and Customizable Approach To Improve Ambulatory Care and Research. J Ambulatory Medicine 1997;20(1):17-27. Fortinsky RH, Wasson JH. How Do Physicians Diagnose Dementia? Evidence from Clinical Vignette. Amer J Alzheimer's Disease 1997; (12(2): 51-61. Welch GH, Albertsen PC, Nease RF, Bubolz TA, Wasson JH. Estimating treatment benefits for the elderly: the effect of competing risks. Annals of Internal Medicine 1996;124(6); 577-584. Nelson EC, Wasson JH, Johnson DJ, Hays RD. Dartmouth COOP Functional Health Assessment Charts: Brief Measures for Clinical Practice. In: Spilker B, ed. Quality of Life and Pharmacoeconomics in Clinical Trials. Philadelphia: Lippincott-Raven, 1996:161-168. Fortinsky RH, Leighton A, Wasson JH. Primary Care Physicians' Diagnostic, Management, and Referral Practices for older persons and families affected by dementia. Research on Aging 1995;17(2):124-147.