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July 11, 2023

Terri Fried, MD, section chief

James Lai, MD, clinical chief

With a year’s experience as the Section Chief of Yale Geriatrics, Terri Fried, MD, remains focused on the Institute for Healthcare Improvement’s ‘4Ms’: mentation, mobility, medications, and matters most to promote the mission and values of the section. The section cares for some of the most vulnerable patients — older adults with multiple chronic medical conditions or living with such problems as cognitive impairment or physical disability. For these patients, the use of standard therapies may cause as much harm as good. Focusing clinical, educational, and research in geriatrics around the 4Ms addresses the challenges geriatricians face while weighing different approaches to care in the context of the patient’s current health and goals.

Clinical: Geriatrics Programs and the 4Ms

One of the best ways to assess the 4Ms is right in the patient’s home. Home-based primary care not only decreases the burden of health care for frail and disabled older persons, but also allows the clinician to understand how patients function in their own environments. At the VA, the Home-Based Primary Care service continues under the leadership of Maura Singh, MD. Through the interdisciplinary team at the VA, pharmacists review medications and provide recommendations, and physical therapists assess mobility and provide modifications to the patient’s home. Ann Datunashvili, MD, and James Lai, MD, lead the Yale-based house call program, which is contributing to national quality improvement initiatives for homecare.

The Adler Geriatric Assessment Clinic, under the leadership of Richard Marottoli, MD, provides comprehensive care to persons living with dementia and their loved ones. Using a case management model, the Adler Center provides patients and caregivers with education, anticipatory guidance, symptom management, and connections to community services. The inpatient geriatrics service expanded this year from eight to 22 beds, increasing the opportunity for older persons to be cared for in a unit designed to promote mobility and prevent delirium. At VA Connecticut Healthcare System, the IMPROVE Clinic, directed by Marcia Mecca, MD, addresses polypharmacy and provides education to medical residents about deprescribing.

Education: Interprofessional Educational Activities and the 4Ms

The section continues its educational activities that provide training in the 4Ms to an interdisciplinary group of clinicians at all stages of training. As director of the Interprofessional Longitudinal Clinical Experience, Barry Wu, MD, has incorporated the 4Ms into this course. Chandrika Kumar, MD, brings the 4Ms to one of the master courses, “Across the Lifespan,” as its co-leader. Mecca and Jen Ouellet, MD, lead traditional and primary care resident education didactics. This year’s series focuses on “Matters Most and Medication Management (Deprescribing) and Primary Care for the Older Adult.”

The Connecticut Older Adult Collaboration for Health 4M or “COACH,” under the leadership of Richard Marottoli, MD, MPH, supports the dissemination of educational and clinical activities into the community. With the support of COACH, the IMPROVE clinic has been pilot-tested at the New Haven Primary Care Consortium, involving internal medicine residents, pharmacists, nurses, and COACH 4M faculty. In a second initiative, COACH faculty worked with public health students on a pilot project deploying simple communication technology equipment in long-term care settings to enhance communication among patients, families, and staff.

The section’s newest clinician-educator, Gregory Ouellet, MD, MHS, was accepted into the Department of Internal Medicine’s Advancement of Clinician-Educator Scholarship Faculty Development Program. Ouellet will develop a curriculum focused on training residents in patient-centered decision making for persons with dementia. Alexandra M. Hajduk, PhD, MPH, became deputy director of Scientific Affairs at the Yale School of Medicine’s Office of Student Research.

Research: Aging Research and the 4Ms

Under the direction of Thomas Gill, MD, the Yale Claude D. Pepper Older Americans Independence Center (OAIC), sponsored by the NIH, provides pilot and career development funding to investigators across a range of disciplines whose research is at the intersection of their own specialty and the 4Ms. Notably, Gill was awarded the 2022 Irving Wright Award of Distinction from the American Federation for Aging Research. The OAIC officially launched a new departmental research initiative, focusing on translational geroscience by soliciting letters of intent for its pilot grant program. The new program is designed to facilitate innovative and high-impact translational geroscience research and establish/strengthen cross-disciplinary collaborations.

The section focuses on innovating and testing models to improve treatment decision making for older persons, with a focus on the Matters Most of the 4Ms. Mary Tinetti, MD, continues to disseminate the Patient Priorities Care approach, which addresses the Matters Most ‘M’ of the 4Ms, along with Jennifer Ouellet, MD, and Marcia Mecca, MD, who designed and implemented a national Train-the-Trainer curriculum. Fried published the results of a randomized clinical trial demonstrating the efficacy of the STAMP program on increasing engagement in advance care planning in the Annals of Internal Medicine. Andrew Cohen, MD, authored an editorial on advance care planning for caregivers of persons with dementia in the Journal of the American Geriatrics Society.

Submitted by Julie Parry on July 10, 2023