Geriatrics fellowship during COVID-19: expanding impact, using innovation and maintaining balance.

The COVID-19 pandemic provided an opportunity for geriatricians, especially geriatrics fellows, to demonstrate leadership in a crisis that has significantly affected the 65 and older demographic. Given their expertise in care delivery to complex, multimorbid patients, as well as their ability to navigate different healthcare settings, geriatrics fellows became a valuable resource during the pandemic, particularly at one large, urban academic health system. Their training in patient-centered, value-based care helped determine the best course of action for patients not only in the hospital, but also in the community. Utilizing innovative strategies such as a newly developed Palliative Care Hotline (PATCH-24 line), telehealth, and community paramedicine, fellows delivered services to complex patients in community settings. In addition to providing direct patient care, geriatrics fellows also taught their skills to frontline physicians of other specialties. Strong support from the fellowship program's leadership, as well as an ongoing focus on clinician wellbeing and resilience, have been central factors in the success of geriatrics fellows during the COVID-19 crisis.

Navigating the Cancer Screening Decision for Patients with Dementia.

PURPOSE OF REVIEW: The risks of developing cancer and dementia both increase with age, giving rise to the complex question of whether continued cancer screening for older dementia patients is appropriate. This paper offers a practice-based clinical approach to determine an answer to this challenging question. RECENT FINDINGS: There is no consensus on the prevalence of cancer and dementia as co-diagnoses. Persons with dementia are screened less often compared to those without dementia. There is significant literature focusing on screening in the geriatric population, but there is little evidence to support decision-making for screening for older patients with dementia. Given this lack of evidence, individualized decisions should be made in collaboration with patients and family caregivers. Four considerations to help guide this process include prognosis, behavioral constraints, cognitive capacity, and goals for care. Future research will be challenging due to variability of factors that inform screening decisions and the vulnerable nature of this patient population.

Geriatrics and palliative medicine leadership is needed now more than ever: What are the training gaps?

BACKGROUND: Geriatrics and palliative medicine specialists are uniquely trained to provide expert coordinated care for older adults and seriously ill and complex patients. Health system leadership geared towards this patient population is critically important as society ages. Currently, there is no standardized approach to teaching core leadership skills. To assess the leadership training needs of geriatrics and palliative medicine fellowship graduates, we conducted a needs assessment to identify (1) early career leadership trajectories and challenges and (2) knowledge and skills deemed essential for effective leadership. METHODS: Individuals identified as leaders in geriatrics and/or palliative medicine completed an electronic survey and a semi-structured qualitative interview. These leaders were divided into two categories: Icahn School of Medicine at Mount Sinai (ISMMS) trained leaders or non-ISMMS trained leaders. The semi-structured interviews were recorded, transcribed, and reviewed using thematic analysis. RESULTS: Within 1 year of fellowship graduation, 50% of ISMMS trained leaders had leadership positions; within 6 years, 100% had a leadership role. Based on qualitative interviews, both ISMMS trained leaders and non-ISMMS trained leaders perceived leadership training gaps in two domains: (1) knowledge and (2) skills. Knowledge and skill gap themes included communication and management, mentorship and negotiation, program development, knowledge, and apprenticeship. CONCLUSION: Geriatrics and palliative medicine physicians obtained leadership roles quickly after fellowship. Both ISMMS trained leaders and non-ISMMS trained leaders often felt unprepared, learned "on the job," and sought out additional leadership training. Early leadership training is needed to prepare fellowship graduates for the pressing demands of accelerated leadership.

Creating a Colocation Unit for End-of-Life Care during a Pandemic.

Background: Palliative care seeks to support the physical, psycho-social and spiritual needs of patients and families who are facing life threatening diseases. Advantages of establishing a palliative care unit, or alternatively co-locating patients, include promoting optimal physical and psychological symptom management; increased family satisfaction; and facilitating resource allocation. Objective: To design a stand-alone hospital unit to provide end of life care during a pandemic. Setting: Mount Sinai Hospital (MSH), a 1,144 bed tertiary- and quaternary-care teaching facility and Brookdale Department of Geriatrics and Palliative Medicine of the Icahn School of Medicine at Mt Sinai. Method: Tracking key indicators signaling the need for conversion to a COVID-19 unit, and identifying factors to facilitate a successful conversion. Result/Implementation: Using previously identified key focused action categories as framework, we describe our successful palliative care unit (PCU) conversion into a COVID-19 care unit. Conclusion: We believe that these operational insights gained from transforming our unit during COVID-19 will be helpful to other programs and institutions during a pandemic, or public health emergencies.

Integrating case management and palliative care.

Most seriously ill Americans live at home under the care of their primary physician and with the support of family caregivers. To reduce costs while simultaneously improving the quality of patient care, insurers have increasingly turned to the concept of case management. While case management is targeted to individuals with life-threatening illnesses, palliative care assessment and interventions are typically not included in the management protocols. An academic/care management/health plan partnership between Mount Sinai School of Medicine, Franklin Health, a care management organization, and South Carolina Blue Cross Blue Shield, was formed in 1998 to test the utility of integration of case management with formal palliative care assessment, feedback and recommendations to treating physicians, and ongoing support for implementation of a palliative care plan. The goal of the project was to ensure identification and optimal care of seriously ill patients' complex needs, while facilitating doctor-patient continuity, improving patient/family/physician communication, providing assistance with decision-making, ensuring quality care at home, and promoting efficient use of health care resources. Care management nurses were randomly assigned to a control (usual care) group or to the intervention (palliative care) group. Intervention nurses were trained in formal palliative care assessment and interventions, supported by treatment protocols and communication strategies with treating physicians. Measurements included symptom burden, prescribing practices, advance care planning status, satisfaction, and health care utilization. These results are pending completion of study run-out and analysis. Preliminary programmatic results indicate that combining palliative care with the case management approach is a logical, feasible, and effective strategy to improve the care of seriously ill patients living in the community. Franklin Health has offered the program to their entire client base because they feel that the integration of palliative care into their case management program improved the standard of patient care. Blue Cross Blue Shield of South Carolina has also chosen to sustain this enhanced model of care management for seriously ill patients.

Geriatric hospital medicine.

Over the last decade, there have been dramatic developments in hospital geriatric care. These improved practices have been supported by the development of quality indicators, which allow physicians and other health care professionals to monitor and measure targeted processes and outcomes of care. This new understanding of the clinical complexity and heterogeneity of the hospitalized elderly population should not be perceived as solely the purview of geriatricians. All physicians involved in the hospital care of elderly patients should strive to attain the knowledge and skills described in this article. As the Baby Boom generation approaches 65 years, physicians and those involved in their training must anticipate and prepare for the reality that many of their patients will be elderly. Special expertise will be needed to provide the highest level of hospital care for this population, especially considering the potential negative effects of hospitalization on older adults.