As Helen Fernandez, MD, MPH, cleverly noted with a grin during our conversation, “Ageism is a bias of your future self, because there are only two choices.” In this edition of Macy Notes, we recognize and celebrate Older Americans Month by speaking with Dr. Fernandez, a highly respected and accomplished geriatrician and educator at the Icahn School of Medicine at Mount Sinai. Dr. Fernandez shares what led her to the field of geriatrics—a career she clearly loves—as well as exemplar programs and initiatives that benefit older patients and those who care for them, such as her Macy-supported LEAP into Leadership Training Program to prepare geriatrics and palliative care fellows for healthcare leadership roles. The following represents an excerpt of our conversation.
Holly J. Humphrey (HJH): Dr.
Fernandez, it is an honor to have the chance to speak with you today. Your
tireless and nationally recognized work related to educating the next
generation of geriatric health care providers is inspiring and deeply needed
given the growing number of older Americans. Can you begin by talking about
what led or motivated you to pursue a career in geriatrics and, more
specifically, to educating those in the health professions about geriatric and
palliative care?
Helen Fernandez (HF): Thank you for this opportunity to share a little bit about my journey. I am trained in internal medicine and pediatrics, and it was through that experience in pediatrics where I began to see family-centered care, which I loved. In geriatrics, I appreciate the holistic approach to care, its interdisciplinary nature, and that patients and their families and their caregivers are at the forefront of care.
I am a Colombian American, fluent in Spanish, who grew up in New York. As a medical student and resident, I was drawn to care for patients who lived in the inner city where there were a lot of health disparities. Within this population, older adults had particular needs in terms of utilizing care, medical interpretation, issues around health literacy, and issues about being seen. I believed this was an area where I could make a difference and improve care.
Many of us have our grandparents or an older adult in our lives who influences our choices. My grandmother was an amazing woman who raised five children and had a major business because her husband, unfortunately, had a tragic accident in his fifties. As she grew older and had several strokes, my grandmother demonstrated to me how important it was that she maintain her independence, that her quality of life was measured by that independence, and that remaining within the home was important. I saw my family struggle in terms of acting on her wishes, coordinating in-home care, and adjusting the environment to adapt for her needs. Through her example—by leading a tremendous, fulfilling life despite having devastating strokes, as well as her perseverance, growth, and perspective on what is important for an older adult—my grandmother’s experience drew me to the field of geriatrics.
HJH: What are some of the greatest challenges facing those in the health professions who provide care to patients who are older? In your view, what opportunities do these challenges offer?
HF: I think one of the biggest challenges is ageism. Ageism is a bias of your future self, because there are only two choices. We don’t really have a choice of living young forever, and yet there is an “us versus them” mentality. COVID exploded the realities of ageism in terms of exposing neglect in care. Nursing home care did not get the attention it needed prior to COVID. The other issues are related to having age-friendly systems—health systems that value older adults, that have priorities that are important to older adults and help them live their highest quality of life, and that include and invest in programs that are going to help them achieve that high quality of life.
A hospital is not the answer to all of it, although it is part of the solution; but you need alternatives in order to provide that type of age-friendly care. Healthcare providers in the field of geriatrics need to be the voice that helps form the policy and inform and drive the change that is needed to adapt more age-friendly systems.
HJH: One of the things you did not mention is the payment schedule and funding mechanisms. How big of a challenge is that? As someone who is not a geriatrician, but whose heart is with the geriatricians and always has been, I see two data points on a not infrequent basis: One is the very poor reimbursement structures for providing multidisciplinary integrated geriatric care, and the other is job satisfaction among geriatricians often being highest among all physicians.
HF: I think the reason we stay happy is because we have that mission of the patient and the family at the center of our work. Many of those who become geriatricians came to the field of medicine because of the patients and their families.
I think the payment structures are not to be ignored. Here at Mount Sinai, we try to embed those models of care within the budget of the health system; we cannot rely solely on funding outside of that health system. Our approach is to look at how many other things we are preventing—bad outcomes in the hospital, unnecessary hospitalizations—and to decrease utilization appropriately. It doesn’t mean less care. It means appropriate care that the patient wants, that’s directed to what the patient’s preferences are, and also what we think is clinically relevant. We have been able to show where that value is; I think that’s the important piece and will help pay for interdisciplinary models. Interdisciplinary care that utilizes social workers, nurses, and nurse practitioners as part of that model is the only way—it’s not all driven by the physician. It is a shared collaborative team approach to provide this high-quality care.
Training others in primary geriatrics, whether it be the surgeons or another type of provider, is also important. By providing non-geriatricians with skills and tools so that they can do some of this work and also collaborate with them with very complex cases, we can move in a positive direction. Not everybody is going to become a geriatrician and that is not the whole solution, because no matter what, we’ll never meet that need. But embedding the principles within the priorities of the health system and the community gets us closer to meeting that need.
HJH: The theme of this year’s Older Americans Month is Age My Way, meant to provide the opportunity to “explore the many ways older adults can remain in and be involved with their communities.” As one whose professional career has been invested in geriatric and palliative care medicine as well as building the geriatrics health workforce, can you share some examples of programs or initiatives that you believe to be exemplary in their ability to allow older Americans to stay in their homes and communities as they age?
HF: One model can be found in visiting doctors programs, or house call programs, for home-bound older adults where students of all disciplines see care being delivered within the home. There are several such programs throughout the country, but we need to expand those programs to make them more longitudinal. Most house call programs happen in the third year of medical school or at the end of any kind of discipline training, and they should be incorporated earlier in the span of education. We should even aim to establish longitudinal, clinical experiences for learners where they see the longitudinal aspect of somebody aging within a home. Even one visit can be enlightening as students realize, “Wow, that’s how many medications they have? That’s what they have in their refrigerator and I’m giving them a diet that doesn’t fit within what’s actually in their fridge?” It is eye-opening.
The expansion of telehealth also offers to the opportunity provide care in the home. Telehealth has to be done carefully, because you want to make sure that it is accessible to everybody and that patients have the resources and the support to be able to do it. The Home Based Primary Care program for veterans is a great example; for decades, the VA has been using technology as a way, especially in rural areas, to do sub-specialist consultations over video. I do boot camp training throughout the country in Indian Health Services and for VA Primary Care. Another example is the Program for All Inclusive Care for the Elderly, or PACE, which started in San Francisco and has now spread throughout the country. These are more than just aid programs; they are all-inclusive. PACE serves patients who would otherwise be in a nursing home setting, with chronic illness and high need for clinical care. PACE brings them into a day program and provides everything—the physician, the nurses, the home attendant service—in a group setting. The care team goes home, and they come back the next day. PACE is a neat model because it decreases hospitalizations and increases socialization as well. Cost also decreases because you are providing care in a group setting.
The other innovations at home have been hospital-at-home for patients who are not necessarily home bound but may have low acuity medical diagnoses. Instead of admitting them to the hospital, the patient is “admitted” to their home. We have this type of hospital-at-home program here at Mount Sinai. For something like cellulitis or an uncomplicated pneumonia where a patient just needs a course of antibiotics, the patient stays within their home, eats their own food, and is cared for by their own family; we do nursing and doctor visits every day. We also have a palliative care program at home for those who may not be hospice eligible.
HJH: The Macy Foundation recently awarded you a President’s Grant for your project titled “Learn, Educate, Advocate, and Promote (LEAP) into Leadership: A New, Innovative Fellowship Prepares Geriatrics and Palliative Medicine Physicians for Healthcare Leadership Roles.” What was the impetus for this project and what do you hope to achieve?
HF: Within our fellowship program in geriatrics, we found 60% of our graduates from the last 15 years went into leadership roles right at graduation, and within three years, 100% went into leadership roles. One of my former fellows, Dr. Ayla Pelleg, one of my colleagues, Dr. Elizabeth Lindenberger, and I conducted focus groups and interviewed graduates of our geriatrics fellowship program from the last 15 years. During these semi-structured interviews we asked, “What would you have wanted in your fellowship to help you position yourself in these new leadership roles?” The leaders in geriatrics felt that there was an opportunity to start thinking about training fellows in areas such as emotional intelligence, interpersonal communication beyond the patient and their caregivers, financing budgets, and business models—topics that are not typically part of medical school curricula or residency training. These study results led us to think about and revamp our fellowship program and recruit fellows who would spend two years with us learning not only about core geriatrics but also learning leadership skills by taking on a capstone project within the health system, working with administrators to see the project to fruition, and do a needs assessment—layering the leadership training necessary for them to be successful in their next steps.
With LEAP into Leadership, our mission is to be a site that will disseminate this leadership training, not only within Mount Sinai and in New York, but on a national platform as well. We want to create something that others can use and modify within their home institutions. With this grant, we have the opportunity to think about instructional design, dissemination, and evaluation, because we need to share these resources. There is a huge need and thirst for it.