The Elderderm: Episode 6, Combatting Barriers to Care For Elder Patients

Collaboration and consideration are key to a successful medical intervention. This is even more true for the aging patient population. To get the goods on combatting barriers to care for the elderly, hosts Dr Adam Friedman and Jaya Manjunath, MSIV of GW SMHS welcome their first guest, who also happened to be the first speaker at the inaugural Elderderm conference, Dr Christina Prather, Associate Professor and the Director of Geriatrics and Palliative Medicine at GW SHMS. Make sure to tune in TODAY to take home tools to improve adherence to dermatologic therapy regimens...as we ain't getting any younger! 

Transcript:

Dr Friedman: Welcome back to the Elder Derm Podcast. I am your co-host, Dr Adam Friedman from the George Washington School of Medicine Health Sciences, and I'm joined by my partner in crime, Jaya, who is a fourth-year medical student also here at GW, applying for dermatology. So keep your eyes out for her. Very lofty and heavy application coming to an Aris website near you. We are so unbelievably fortunate to have with us Dr Christina Prather, who's an associate professor and the director of geriatrics and palliative care, also here at GW. Her talk barriers to care considerations and tools to improve adherence to therapy led off our inaugural Elder Derm conference. And so it's no surprise she's our first guest on the Derm Conference. Dr Prather, thank you so much for being here with us.

Dr Prather: Thanks for having me. This is exciting.

Dr Friedman: So first and foremost, I love that word that you used exciting because I think that your lead off talk really set the tone for our conference. I think it was only 20 minutes, it should have probably been 20 hours given the extraordinary amount of pearls and also opportunities you presented for dermatologists to engage their elder patients. Maybe to start, could you maybe talk a little bit about what are some of the key care seeking barriers facing the geriatric patient population, especially from your perspective and maybe putting that into the mindset of the dermatologist because that one day with us, I am sure you got a real sense of what we're all about.

Dr Prather: Yeah, I think it's really important that we're having this conversation because you're right, this is my bread and butter. This is what I do every day. And the conference really highlighted the opportunity for us to have more synergy and learn from each other. And so the two things that I would highlight to the dermatologists listening today are that first one of the biggest barriers have is getting the care they need when they need it. And we know it can be more difficult for older adults to access healthcare. And often there's a timeliness component that our health system struggles to meet when patients need care quickly or even at a time when someone bringing a patient to an appointment can actually be available. And then the second thing I would say is that clinicians need extra time when taking care of older adults, and that's not always something built into our health systems. And then you need to have the knowledge and training to know how to better assess for their needs and to address that efficiently within all the confines of your practice.

Jaya Manjunath: Dr Prather, honestly, your talk at the elder room conference was one of my favorite talks period. And I definitely agree that we should definitely have more time and I really, really enjoy hearing all you had to say. And I've also been seeing in clinical practice, it does oftentimes take older adults a long time to get to the dermatology visit. I actually remember during my researcher, I saw this patient and we had to bring her back for a biopsy later on and she said, well, I need two to three weeks advanced notice because I need to schedule this visit. And then even the day of, I have to be ready four hours before the visit to actually get the transportation to bring me to the clinic and then also according drop offs. So oftentimes it can be really challenging. So thank you for highlighting that. A one aspect of your talk that I really liked a lot was when you talked about the five M framework, and I think that's really applicable to dermatology care. So I would love for you to kind of chat more about that. What is it and how can we apply that to dermatology?

Dr Prather: Yeah, so when we think about the five M’s, they are a mobility medications, what matters and multi complexity. And this framework is really a nationwide initiative that's driven by the Institute for Healthcare Improvement and the Reynolds Foundation to encourage healthcare providers and health systems to think about how they can provide more age-friendly care in a forward thinking capacity. So in geriatrics, we've always taught something called the comprehensive geriatrics assessment, and honestly, it's time consuming. It's unwieldy, it's not generalizable, and I get an hour with my patient and that is this luxury that I know doesn't exist in a lot of other places in the health system. And so the idea is how do we take what we do and make it bite-size that anyone in any specialty can do it. And so the FIMS is really meant to empower anyone to take an age-friendly approach when they're with older adults in their practice. You don't have to be a geriatrician.

Dr Friedman: Yeah, I think you hit on such an important point about the time historically needed to address all these. You could spend probably 45 minutes just doing medication reconciliation in some of these patients. And there is a disconnect between, especially in dermatology where I think a little fortunate for us being academics, we can stretch out the visits a little bit more, 15, 20 minutes. But in private practice, there's a lot of pressure to be seeing patients every 10 minutes or at least being booked every 10 minutes, which really means you are consistently behind, you're behind before you walked in the door, let alone later in the morning. And so I think to your point, having a condensed way to think about what are the key things that could interfere with good patient care in this patient population is so important. And I love alliteration, so having five M’s is definitely very on brand for me. But I wanted to maybe start with the last one because it seems obvious, but maybe it's not, which is multi, what does that mean?

Dr Prather: Multi complexity basically means it's all in your lane. Anything that can impact a patient's ability to participate in their care or ability to have a less good health outcome, it can be anything from considering the impact of arthritis and whether someone can open up the top on a cream you prescribe to how frequently you dose a topical ointment for a patient that can't reach the center of their back and they have to have someone come in and do that for them to recognizing that if you write a script for someone that needs a compounding pharmacy, can they actually go find a compounding pharmacy? Can they get on the internet, find one, get there, drop off the script and go back and get it? It is pausing when someone doesn't have a wound healing the way you think it should be healing and having the ability to pause and be curious and say, I wonder if nutrition's playing a role. Hey, what did you have for breakfast? What did you have last night? Do you have food security? And so any of these things fall in multi complexity. And this is also where I put belief systems. So anything that someone believes we have to join in their belief system and make it part of our treatment plan if it has the potential to enhance the health outcome or serve as a barrier to the desired health outcome.

Dr Friedman: It's funny, when you talk about these things, they seem so obvious, but I don't think there is enough emphasis of this in residency training in med school. Jay, there's a little bit of a delta between our ages in terms of when I trained and you're wrapping up your training, I'd just be curious to hear from you, is there an emphasis, it may not be called the five M’s or multi complexity, but do you feel that there is a growing trend in medical stool to focus on these obvious and not so obvious things that can really play a big role in adherence and continuity of care?

Jaya Manjunath: Yes, I definitely think there is a growing trend towards shared decision-making. And of course in the past I feel like traditionally if a physician had a treatment plan in mind, that's what goes, but that I feel like in medical school, we're really trained to approach medical care holistically and consider things like access to care, cognitive status, mobility, many of the things that Dr Prather was already talking to us when treating the whole patient. And I will say just to Dr Prather's point, I did a rotation for primary care and I got to spend time in the geriatrics department. And I loved getting that one hour to talk with the patients. I preceptor just said, Hey, go talk with them, come back in an hour or two whenever. And that was great to really get to know about all these barriers. But I will say it's really challenging with the 15 to 20 minute dermatology visit to really understand a patient at all these levels. And I think that's really the focus of our conversation today. And Dr Prather, I know you were mentioning medication access and to that point, polypharmacy is very common in the older adult population. Do you have any ideas or suggestions for what we can do to efficiently handle polypharmacy in the clinic?

Dr Prather: So, I love the brown bag biopsy now. It really kind of comes in as a right aid white plastic bag or a CVS white plastic bag. But we have to ask our patients to bring in what they're actually to. What do you have? What are you using it for? How do you use it? That in itself is a little bit of a mentation screen. If they can't tell you that's a red flag. If what you've been prescribing doesn't seem to be having the outcome you think it should be having, if they're not telling you that they're using it as you've previously instructed, that tells you that the treatment plan might not be manageable for them. If you've prescribed something and it's not there, why, what was the lived cost of that medication? It might've not seemed like a high number, but it might've been a high number to them. And then another piece of this is, is potentially something that can be done by other members of the clinical team. Is it something that an MA can do in partnership with you with training or potentially a pharmacy technician, a student that wants some clinical hours? So is there an opportunity to extend the visit so that 10 minutes when Dr. Friedman comes in, you've already spent or someone else has already spent 10 minutes doing this piece of the work?

Dr Friedman: Yeah, something you said that just triggered hopefully something that could maybe make things a little easier, which is working into the kind of pre-visit workflow where offices could ask patients to bring all their meds in with them. And I love the nomenclature of the brown bag biopsy. I find it's often more one gallon Ziploc, and for us it's usually crumpled up tubes of probably triamcinolone is my guess what everyone loves to give out. But I think that that could really make a difference, right? If by the time they're in the office and even your staff are asking what medications you're on, well it's the one in the blue bottle, it's the white has a five or maybe a nine on it, that's not going to, and that gives you a lot of sense of maybe mentation and memory. But I think working that in and considering that when your call center, when your scheduler is making that appointment, say please bring in all your medications with you, especially if someone's above a certain age can really get around that.

So, I think that would be good for everyone, but especially in dermatology, because I think aside from documentation and just knowing the patients are on, this could be very dangerous medication interactions, especially when you think about CYP P inhibition given the number of different medications someone this age range could be on that could be life-threatening, especially when you think about a CYP P inhibitor. And there are definitely medications that we use that go through similar systems or can inhibit and lead to significant consequences. A great example, beta blockers and terbinafine, this patient population high risk for oncomycosis, terbinafine can interfere with metabolism of a beta blocker and before you know it, that patient's more bradycardic than a lump of log. So definitely a very important thing. Why I think that's a really important consideration in terms of workflows to make sure exactly what your patients are on and to that effect with this being a good litmus test fermentation, how do you address a patient who can get by? I mean there's obviously the patient who is a and O times zero, but I think the more dangerous patient is the one who can slide by under the radar, can answer questions just enough that you think they are present, that they have a good understanding and wherewithal to self-care, but they actually can't. What suggestions you have in terms of kind of, I don't want to say rooting out, but really identifying those patients so you can get them the proper care and also the appropriate mechanisms to ensure that they're well taken care of.

Dr Prather: That's a good question. So I think if you start with that brown bag biopsy and you ask people what are you using, how are you using it? And what's your understanding of whether or not what it's supposed to accomplish, how is it supposed to help? And we can take the time to really be curious and listen, one thoughtfully asked question can tell you more than a couple yes no questions that don't require an open-ended answer. We all learned in medical school that the answers in the history, and one of the problems with people experiencing memory loss is they can't always provide a reliable history. And they might come to you not remembering their skin health history or what treatments they've had, what's worked, what hasn't. If they've even had skin cancer, they might have a care partner who's coming in and doesn't know any of that either.

And so, I think having your Sherlock sense up of when things just don't fit is a good red flag to say, hold on a second. I want to make sure I ask some more open-ended questions. I want to listen for reasoning. The number of times I see a patient and can honestly diagnose them with moderate stage dementia when they've been regularly seeing specialists in primary care in our health system is a little scary because people come in, they say, how are you doing? Are you taking your medications? How's your wife? You're enjoying retirement? And they say, yeah, okay, refill this script so I'll see you in six months. And we didn't actually give the patient time to talk or respond to an open-ended question. So that's one thing we can definitely do. And then the other thing around mentation as well is we need to be able to communicate better.

If I know I'm sending a patient for a dermatologic evaluation and I have concerns about their cognition, it's sometimes very hard to convey that I can write that in the chart that they need someone else to support capacity for decision making or that I'm worried about something in particular they don't remember to tell you, but you have to have access to my notes, you have to have time to read it. Or if I'm really worried about someone, I have to be able to communicate with that to you in a way that's not in the chart. And so we do have an opportunity there for improved collaboration as well.

Dr Friedman: Yeah, a follow-up question to that, let's say you do identify that, and I just think everyone listening is now going to utilize more open-ended questions. Not saying, are you using the meds, but rather I love the how are you using them because that next order really requires the patient to demonstrate verbally an understanding of what the medicine's for and how they're supposed to use it based on the recommendations. But let's say you do identify a passerby, what should be done here? I mean, you mentioned one thing in terms of that making sure that this individual is accompanied by someone who can help and can really orchestrate care and orchestrate visits, but what type of resources are available or what should we be doing when we do identify these patients?

Dr Prather: I think as far as when you develop a care plan, as clear as you can make that, I mean it comes down to labeling, labeling topicals in the most clear how often for what purpose in layman's terms, but having that reported in your medical records in a way that primary care physicians can really partner with you to follow up. And regardless of memory or not, people have questions and they see their primary care the most often. And that's one thing. Number two is encouraging them. Take the time to even write and wrap up, bring a family member with you next time, have your call center, get into the practice of four older adults saying, Hey, we really encourage everyone to bring an advocate to a doctor's appointment with them. I go with my husband to his doctor's appointments because he needs me to, he needs his doctor wife to go and advocate for him. And so we can just normalize that in our health system too, that health is not a solitary thing. And so we start to build in supports around people with memory loss.

Jaya Manjunath: That's a really important point, and I think you really touched on an important area where dermatologists and geriatricians can really collaborate moving forward. One sort of thing I've noticed is in patients with cognitive impairment, it tends to be the support system, the caregiver, the spouse that starts speaking for their wishes, what they may want. And sometimes that of comes back to the idea of shared decision making. And if a patient is causing gleam impaired, how do we still make sure that we understand what matters most to 'em? Do you think you can maybe touch on the importance of shared decision making and understanding that in these patients?

Dr Prather: I think we can take that even bigger and talk about it independent of cognitive concerns and just how do we align with older adults in having treatment plans and shared decision making. And I'll share when my grandfather was in his mid to late nineties on anticoagulation and underwent a procedure for growth on his forehead. Looking back, it would have been very nice to potentially have a conversation about what were the risks and benefits of removing that as we dealt with a lot of bleeding and a poorly healing wound and was it really necessary? And so I think as we're working with older adults, something to think about is what is really the goal and what is the total cost of that? And so as we're having a conversation with someone around, we could do A or B or C actually depending on what your desired outcome is, and to that patient that needs an appointment scheduled three weeks in advance with metro access and someone to bring them, and it's a four hour affair that might really help guide you into selecting a treatment recommendation that's more feasible and aligns with their outcome. It's really goal-directed when we can take the time to say, what are you really trying to achieve?

Dr Friedman: Yeah, I love that example you brought up. I think that was very much in line with the panel discussion you had with our director of Cutaneous Oncology, Dr Vishall Patel, which by the way ended up on the front cover of Dermatology News. Awesome photo of you too that you guys have not seen it. Make sure to check it out. But I think that is one of the great examples of thinking beyond the rigid borders of what you were taught or what's in the textbook. And I am always reminded when this subject comes up of my wife's 95-year-old grandfather who had a squamous cell on his scalp and they wanted to do MO surgery. And I'm like, why would you put this guy through this? Does it really make sense to do a surgery on an area that does not heal? Well, this is not going to kill him.

And I think that may be more of extreme version, but to your point, not treating the condition, not treating the tumor, but treating the person and taking the whole into account when you make that decision making, it's certainly well beyond the management of cutaneous malignancies. But even when you think about chronic cutaneous conditions, whether it be inflammatory, aplitic diseases, really making it make sense for them, and I love that you brought the concept A, what matters most and of course what matters most to the patient and certainly what matters most to us as the physician may not necessarily be in parallel what matters most to the patient. So I think getting congruence on that is really important. Another thing I find is that very often when we talk about these lofty concepts of like, this is what should be happening, this is what we need to in order to really address the needs of these patients, often these kind of discussions are missing the actual resources, the tools from maybe outside the house of dermatology that may make that transition, may make that translation more realistic. So with that in mind, Dr. Prather, are there tools from the geriatrics world, from your arena that can be employed by dermatologists or even are there ways to learn more about this? I think we had the good fortune, and I say, I mean it was 100% Jay and I just came along for the ride, published a study that education on this area for residents is absolutely lacking, which is why we have Elder Derm conference. But from your perspective, what is out there that we could utilize right now?

Dr Prather: So, I know the American Geriatric Society is always looking for partnerships with other subspecialties. And so we've done that with cardiology and with orthopedics and with others to build curricula that are specialty specific and help enhance knowledge and awareness because it's really about taking our mindset about how we approach older adults and finding a way to blend that with your expertise. I don't have your expertise. I can just teach you an approach. And so there's an opportunity for synergy there. And one thing that is core to the geriatric approach is a team-based model for care and really looking at other professionals in the health system. And so two takeaways I would give people are, one, occupational therapists are your best friends. Occupational therapists are the people who developed those great OXO items that we've all used with our kids to help them learn how to hold onto things when their hand grip doesn't quite work.

Occupational therapists’ role is to help people function in their day-to-day lives. And so they can help a patient of yours potentially with organizing their medications or understanding how to better apply something with a mobility limitation and they can see patients in their homes or in clinic. The second service that's worth noting our home health. And so home health is a referable service paid for under Medicare and most commercial payers where nurses and therapists can go out to the home. And a nurse in home health has saved my butt on wound care, many a time for a home bound individual or a person with limited mobility where I need to see that wound. And it's hard to see it on telehealth, and it's really hard for that individual to come in and so a home health referral can have a nurse going out and actually really supporting you with wound care between your clinic visits.

Dr Friedman: Great advice.

Jaya Manjunath: Yeah, no, that is really great. I mean, I feel like I've sometimes seen in clinic visits residents and physicians sort of offer ideas like the back applicator, but then that's kind of sometimes assuming that they can actually reach all the way behind their back to use. So those are definitely good ideas and things that I will definitely be sharing with patients in the future. So, Dr Prather, thank you again so much for being on our podcast today. Do you have maybe a couple of key takeaways or conclusions that you want our listeners to remember from our conversations today?

Dr Prather: So, I think if you try to ask yourself to take every five M’s and every visit in your 10-minute visit, it feels overwhelming and there's no way to do this, right? And so I invite you to just take one action item out of today's talk, pick one patient every day and ask one M related question. So if you have one patient and you might ask them, was it difficult for you to get to today's visit, would it be helpful to think about a televisit follow-up for another patient? You might ask something like, Hey, how are you doing with your medications? And are the costs of these okay causing any trouble for you? Is that something we need to think about? I noticed you had a whole lot of medicines in your round bag when you brought it in. How are you managing all that?

Do you have questions? If you have a wound that's not really healing the way you think it should be, you might say, I'd like to ask you about urine nutrition. It's really closely tied to wound healing. Can you tell me what you had for breakfast this morning and dinner last night? Now we're opening a big opportunity for what do we do with that information, but we're closing out our podcast, so we'll have to come back for round two. But if you start just changing your practice, one question, one patient at a time, you'll slowly move mountains. We all have to start somewhere.

Dr Friedman: I love the kind of what about Bob-esque approach, the baby steps of integrating the five M’s, which in my mind, I'm going to remember them by the five M’s for managing that it doesn't have to be all at once, that we can ease them in. And I think that's a reasonable approach pick. I think a lot of, especially in dermatology, a lot of what we do is integrating new things, but especially off label things or things that are outside of the typical straight and error wheel. So I think this is very much within our framework to integrate new approaches. But it could be slow, it could be one. And then as we get more comfortable, certainly expanding them and we will certainly be doing that here in both our resident faculty practice. So, I will echo is thanks. Thank you so much Dr Prather, for your insight energy, your time. And I know a guy we could probably get you back on if we make some magic happen behind the scenes. So thank you for being here with us.

Dr Prather: Thank you for having me. This was great. I appreciate you guys doing this.