All Hands on Deck: Training A Geriatric Workforce

All hands on deck.

That’s how four state universities won federal grants to help train a woefully unprepared California geriatric workforce — especially in underserved communities.

The grants mark an important shift in the way older adults will be treated in the future. Instead of a single physician, teams of health professionals will offer wraparound care spanning physical and behavioral health as well as social services and referrals to community groups.

In some cases, “physician extenders” like nurses will be specially trained in geriatrics and injected into health systems facing a shortage of geriatric expertise.

While mainstream medicine typically dislikes the phrase, this represents an important step towards “holistic healthcare” for aging adults.

With 20 percent of Californians projected to be over 65 by 2030 — more than 8 million seniors — the demand for physicians and health workers who understand the unique needs of ailing older adults will soon overwhelm a system sorely lacking geriatric expertise. In the decade before 2013, only 3% of graduates from residency programs in internal medicine or family medicine pursued geriatric medicine fellowships.

This summer, the federal Health Resources and Services Administration handed out $35.7 million in national grants as part of its Geriatrics Workforce Enhancement Program. The four California recipients of the three-year, $2.5 million grants are UCLA, USC, UC Irvine and UC San Diego.

“These are very ambitious grants,” says Lisa Gibbs, who leads the UC Irvine effort as head of its division of geriatric medicine and gerontology.

Besides primary care physicians, these health teams often include social workers, psychologists, pharmacists, physical therapists and “physician extenders” like nurses, physicians assistants and nurse practitioners.

The goal: make the lone physician caring for an ailing senior a thing of the past.

Although each school targets a different population, they share a team approach and other common threads: partnering with local community groups and targeting underserved communities — including Latino, Vietnamese, Korean, veterans, homeless and LGBT seniors.

USC, for example, is serving aging Latinos in Los Angeles County, which is nearly half Latino. UC San Diego focuses on homeless veterans. And in Orange County, UC Irvine works with the largest concentration of Vietnamese residents outside Vietnam.

Gibbs says Orange County’s vast disparities in care indicate problems throughout ethnic populations statewide.

“There are not enough services for them, or enough professionals in the community who understand them,” says Gibbs.

There are today only a handful of progressive, team-based systems for older adults in California, including Berkeley’s Over 60 Health Clinic and San Mateo’s Ron Robinson Senior Health Care Center.

With its short appointments, today’s health system is often unable to treat the complex needs of older adults. Chronic diseases like diabetes, hypertension, heart disease, obesity, arthritis — or behavioral health issues like depression — can’t be handled effectively in a time frame shorter than it takes to watch an American sitcom.

“It’s not the way medicine will be practiced in the future,” says Dr. Zaldy Tan, medical director for UCLA’s Alzheimer’s and Dementia Care Program.

UCLA is launching PICATE (the Program for Improving Care of Aging adults through Training and Education), which will infuse new geriatric care into three teaching clinics through UC Riverside’s School of Medicine at its primary teaching site — Riverside County Regional Medical Center.

Currently, the medical center has only one geriatrician.

Central to this effort, says Tan, UCLA will “hire, train and embed a nurse who will be the catalyst to transform care for older adults” in each of the three county clinics. Besides seeing patients onsite, this nurse will also make home visits, train primary care physicians in geriatric issues, and work with the county’s Department of Public Services to host monthly interprofessional aging seminars.

UCLA is also developing educational programs for caregivers, families and patients, with a special emphasis on dementia.

Neighboring USC emphasizes the intersection of dementia and chronic disease in underserved populations with TWIG — Training a Workforce in Interprofessional Geriatrics. It targets underserved and uninsured non-English speakers at Latino-heavy Los Angeles County Hospital.

USC’s Bonnie Olsen says the effects of chronic disease in older adults are especially vexing.

“When those co-occur with dementia, managing those patients becomes very complex,” says Olsen, vice chair of academic affairs for the USC’s department of family medicine. “These are the folks that are hard to keep well after discharge.”

A team of faculty members from USC’s Keck and Los Angeles County hospitals — physicians, dentists, psychologists, occupational therapists, physical therapists, pharmacists, social workers, and physicians assistants — will meet to discuss these difficult patients, thereby helping overwhelmed primary care physicians.

“Often physicians are happy to refer them,” says Olsen.

Nationally, half of all geriatric training fellowships go unfilled, says Dr. Diane Chau of UC San Diego. The reason is simple: busy physicians lose time, money and patients when putting their practice on hold for a year.

To address the problem, UCSD has customized a one-year training course for nine working professionals: three each from its pool of student health professionals, local community practitioners, and neighboring health providers who actively care for geriatric patients. Each will spend 120 hours training in geriatrics, earning a stipend to offset lost productivity from existing practices.

The fellowships target both Latino and homeless geriatrics.

At UC Irvine, two programs are collaborating to improve the health of minority populations in Orange County. The university’s Division of Geriatric Medicine and its Program in Nursing Science will develop a new geriatric medicine curriculum for family medicine residents taught by an inter professional faculty.

The school is also launching geriatric care clinics into two federally-qualified health centers (FQHC’s) operated by UC Irvine Medical Center. Meanwhile, the school is collaborating with AltaMed, the nation’s largest operator of FQHCs – and a health center for Vietnamese Americans – to train clinicians and staff in geriatric care.

Each California university shares similar goals: to work in the surrounding community to disseminate knowledge about the aging process to improve care, reduce chronic disease, limit falls, support caregivers, and lessen the challenges of dementia.

Team treatment. Wraparound care. Community involvement.

It’s not here yet, but the future of aging care has begun.

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