Quality care, quality life

When Mary Tinetti, MD, received a MacArthur Foundation grant in 2009, she had already put years of hard work into describing the medical significance of falls among older patients. The Gladys Phillips Crofoot Professor of Medicine (Geriatrics) and Public Health, and the section chief of geriatrics, Tinetti has made groundbreaking inquiries that have transformed how people understand injury and illness. Tinetti advances new treatment protocols through her research and advocacy that rely on the best available information about preventing serious fall injuries—which can have catastrophic consequences for the health of older adults. At the same time, she hopes to improve how the medical community and the broader culture in general view older patients, who are often among the most vulnerable in our population. They are our mothers and fathers, our grandparents and great-grandparents, and ultimately all of us if we live long enough.

When did you become interested in the subject of falling, and how health deteriorates after falls? I developed an interest in this subject as a geriatrics fellow under T. Franklin Williams at the University of Rochester and Monroe [Community] Hospital. He’d been taking care of adults for a long time, and had noticed that after older people fell, they were never the same again. It wasn’t something people were looking at then; the phenomenon was seen as an inevitable part of aging and taken for granted. As [I was] a new researcher, Dr. Williams encouraged me to focus on it, understand the problem.

We saw many patients in their homes, as often they couldn’t get to the clinic. I remember one snowy night in Rochester, I visited a woman in her apartment. Her legs had become contracted; after being afraid to get up after a fall, she had decided to live on the floor. After a few visits, she agreed to live at the nursing home I worked at, where the physical therapists loved her. My passion for the field began there, but Williams’ insights helped guide and shape my initial inquiries.

At that fellowship, I learned that while all diseases have physical and psychological consequences, a person’s confidence in their ability to navigate the world was key to their sense of health and autonomy. I also learned that the health system doesn’t always know how to care for older adults with complex health needs. On a broad level, health systems were [not] and are not “age-friendly.”

Can you talk more about this idea of large health systems being age-friendly? What does that mean? At the time I started working on falls in older adults, health systems did not recognize or treat the connection between injuries in older patients and the deterioration that often accompanied those injuries. Breaking your leg or your wrist as an 80-year-old—you underwent surgery or lived in a cast, until the bone was mended. Little attention was given to why the fall occurred; what happens to the person’s function after the fall and injury repair; and what could be done to prevent it from happening again.

Having worked on an issue that had been largely overlooked, we had to start at the beginning. First, we had to identify risk factors; then develop and test effective interventions targeting these risk factors; and then work on implementing these preventive interventions in practice. After 15–20 years, we realized that there were other things that could and should be done differently for the care of older adults.

Clinicians learned to take care of and treat individual diseases or injuries, but they would be in isolation from each other. A specialist would know what to do with heart failure, diabetes, arthritis, or depression. But when you put all that together in one person, treatments would often work in unanticipated ways or not at all, and didn’t give people the outcomes they wanted from their health care. Two-thirds of older patients have at least two diseases, and some have five or more diseases.

Then there was the question of the treatment itself. Some treatments are effective at knocking out a disease, but aren’t “good” or healthy for the patient, so there’s a weighing of harms, burden, and benefits.

I was working along two parallel tracks to try to sort these questions out, trying to identify what interventions provided the best outcomes for persons with multiple chronic conditions, and exploring how best to align health care with the outcomes that each older adult most desired. The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI) were interested in helping figure out how to get health care systems to provide better and more care for older adults without doing harm. I was asked to be a co-leader on a national initiative to help health systems become truly age-friendly.

IHI convened a group of patients, clinicians, and health systems leaders, and met to discuss and consider the core elements that would define age-friendly and that were supported by evidence. We developed a simple framework called the Four M’s: What Matters Most; Mentation; Mobility; and Medications. These were four focus areas where there was strong evidence for improvement so we could reasonably expect to affect them, and which were also priorities for older adults themselves. A health care system that is able to demonstrate that they assess and manage those Four M’s among their older patients can call itself age-friendly.

Terry Fulmer, PhD (President of the John A. Hartford Foundation) established a goal: we’d get 20% of health care systems in the United States to meet this standard of age-friendly. I was skeptical, and said we’d be lucky for a handful of organizations to take on the challenge ... but at last count, 800 health care systems were doing something, were attempting to implement at least a portion of the criteria. That doesn’t mean every adult is getting age-friendly care where ever they go. And in some places that age-friendly care is still superficial, but it is an important start. The biggest part of the challenge is just getting the word out. It can be hard to get above the noise with everything that’s going on right now.

Priorities-driven care is a big part of what you’re focused on today. How did you come up with this concept? After I became interested in the fact that treating multiple conditions in isolation of each other can lead to worse outcomes, I recognized that many disease guidelines are not applicable to older adults with multiple conditions out of alignment. They were constructed from evidence in younger people with fewer diseases and based on assumptions physicians were making about what outcomes patients most wanted. Drawing on work done by Terri Fried, MD, professor of medicine (geriatrics), we were able to figure out that there was a gulf between what patients were willing to sign onto and what doctors were expecting from them. One might assume, for example, that survival was the top priority for patients ... in many cases, it’s not—it’s function. If you put together the facts that a treatment for a particular disease or condition had uncertain benefits, and moreover it was harmful and burdensome, it’s not difficult to understand why some patients were failing to follow protocols.

We began this work with colleagues at Baylor College of Medicine, Aanand Naik, MD, Lilian Dindo, PhD; and at New York University (Caroline Blaum, MD), a team of patient, caregivers, health care leaders and payers, researchers, and clinicians. Over a couple of years we were able to identify a process to help older adults identify their most desired health outcomes and priorities in a way that was realistic and specific enough to inform clinical decision making.

As part of this work, we needed to help clinicians learn how to move from disease-based decisions to decisions that are based on peoples’ priorities. I worked on this with Drs. Naik and Dindo, along with Jen Ouellet, MD, a young clinician-educator in our geriatrics section, and Claire Davenport, MD, assistant professor of medicine (geriatrics) at Mount Sinai to develop strategies for translating older adults’ health priorities into decisions. There were other groups in Houston and at Cornell that looked at other populations. It’s been tested here in Connecticut, and is currently being evaluated by the Cleveland Clinic, the University of North Carolina, and by the VA in Texas. Based on preliminary results, it looks like it does in fact decrease people’s perception of the burden of their medicines and treatments.

Is your group doing any work on COVID-19, or how the virus targets older people? Members of our geriatrics section are working on a few projects that could help understand and care for COVID-19 in older adults. Identifying the common presentation of COVID in older adults is crucial—that presentation is sometimes different from how the infection presents itself in younger patients. A group is also hoping to describe the outcomes of older adults who develop COVID-19.

On a local level, our group is trying to ensure that nursing homes are receiving the PPE and testing capabilities that they need. It’s easy to knock nursing homes as the problem with COVID, but so much of it isn’t the quality of care available at individual nursing homes—it’s the way we’ve designed and built nursing homes and how we pay for the care of this very complex population. So many immunocompromised patients in such a small space, sharing bathrooms, sharing caregivers ... and caregivers often come from high-risk categories themselves, work several jobs, and live with other essential workers—all increasing the risk of spread. Nursing homes couldn’t be designed better to spread infections. The same can be said for prisons. We’ll look back at COVID in nursing homes and prisons as another example of social and economic inequities playing out nationally.

What are you working on now? Our biggest emphasis is spreading the work on patient priorities. We spend a great deal of time and money on health care, and a lot of that money isn’t going toward what people really want. In medicine, we talk a lot about listening to patients. Health systems need to get better at actually doing that.