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“The secret sauce of the Transitions, Referral and Coordination (TRAC) team was including a  lawyer.”  This is brilliant and will ring true to those of us who care for complex older adults who end up in the hospital for long, long, long admissions.

On today’s podcast we talk with Kenny Lam, Jessica Eng, Sarah Hooper, and Anne Fabiny about their successful interdisciplinary intervention to reduce prolonged admissions, published in NEJM Catalyst.  Many of the problems that older adults face are not medical.  How to find housing.  How to stay in their homes.  How to get a paid caregiver to help them stay at home.  How to get someone to pay bills.  How to assign a surrogate health care decision maker.  The legal obstacles to accomplishing these tasks for complex older adults, particularly those who may have marginal decision making capacity, can seem insurmountable.  Having a lawyer on the team is brilliant – in much the same way that having a handyperson on the team for project CAPABLE to keep people at home was brilliant.  For more, listen also to our prior podcast with Sarah Hooper on medical-legal partnerships.

Eric: Welcome to the GeriPal Podcast! This is Eric Widera.

Alex: This is Alex Smith.

Eric: Alex, we have a bigger than full house today. I see a lot of people up on screen.Who do we have in our house today?

Alex: We have a wonderful lineup today. We’d like to welcome back to the podcast Kenny Lam, who’s assistant professor at UCSF in the Division of Geriatrics and a geriatrician. Welcome back, Kenny.

Kenny: Thank you, Alex.

Alex: And we have Sarah Hooper, who is a lawyer and faculty member at UC Hastings School of Law, and she directs the Health and Law Center there. Welcome to the GeriPal Podcast, Sarah.

Sarah: Hi, guys.

Alex: Eric, is Sarah the first lawyer we’ve had on the podcast?

Eric: No. Sarah’s saying no.

Sarah: I was on the podcast before.

Alex: Oh! [laughter]

Alex: Eric, have you been on the podcast before with me? Oh, boy. Okay, insert foot in mouth. Welcome back to the GeriPal Podcast, Sarah.

Sarah: Nice to see you again.

Alex: And we have Jessica Eng, who’s associate professor at UCSF, and director of the Geriatrics Clinic at the San Francisco VA. Welcome to GeriPal Podcast.

Jessica: Glad to be here, especially since my office is next to where you guys usually record the podcast, so I’ve heard the songs through the wall for many years. So I decided to be here.

Alex: And last but not least, we have Anne Fabiny, who’s professor of medicine and associate chief of staff for the Geriatrics Group at the San Francisco VA. Anne, I don’t know if she remembers this, but when I was a resident at the Brigham and Women’s Hospital back in Boston some … gosh, almost 12 years ago?

Anne: A long time ago.

Aex: A long time ago, 15 to 20 years ago. Anne actually taught our geriatrics small group session for the primary care residents. So-

Anne: I do remember that, Alex. You and I have known each other for a long time.

Alex: Long time. Yeah. I’ve been learning from Anne for a long time, and we’re delighted to welcome you to the GeriPal Podcast, Anne.

Anne: Thank you. And I want to say the first memory I have of you guys doing this work is you with Ken Covinsky and the liquid thickening agents and the taste test.

Eric: We’ve had a lot of great experiences, and I just want to acknowledge: We did have Sarah Hooper on for a medical-legal practice clinic for seniors; that was back in 2017. We’ll have a link to that in our Show Notes.

Eric: But that’s not really exactly what we’re going to be talking about today. We’re going to be talking about a New England Journal Catalyst paper on the interdisciplinary care team that reduces prolonged admissions amongst older patients with complex needs in the hospital. We’re going to be talking about that study.

Eric: But before we do, does somebody have a song request for Alex?

Anne: I do. My longtime favorite song, John Prine’s Angel from Montgomery. Alex, take it away.

Alex: Love this one. Thank you, Anne.

Anne: Mm-hmm (affirmative).

Alex: (singing)

Eric: That’s a beautiful song, Anne.

Anne: Thank you, Alex.

Eric: Why is that your favorite song?

Anne: Oh, it’s full of longing and regret and somebody reflecting on his life. And it’s always really meant a lot to me. Yeah. Just that sense of longing and regret.

Eric: Thanks for recommending that. I’m going to listen to that afterwards, too.

Eric: But let’s jump into the topic at hand. We’re going to be talking about this New England Journal of Medicine Catalyst paper that you were all part of with others, including Erika Price, Megha Garg, Nate Baskin, Megan Dunchak. I’m going to probably turn to you, Anne, first. You were in this project since inception. Is that right?

Anne: That is right. I arrived at the San Francisco VA in 2015, which is really when this first started.

Eric: What motivated you to be part of this, and to help start this project? What were you trying to address here?

Anne: When I got here, my observation was that there were so many smart, committed, compassionate clinicians caring for a really complicated population of patients. And everyone was siloed. There was so little collaboration across disciplines, across programs. And there was just an enormous amount of frustration that I heard from people as I got to know people and understood how the system worked.

Anne: I discovered that all these committed, compassionate, smart people didn’t really know each other. And had not had the opportunity to collaborate together, to take care of this population of patients. That was it.

Anne: People were acting like they were the only ones caring for complicated patients, but you’d turn to the next person and hear the story of, oh, they were taking care of really complicated patients too.

Anne: Everyone was frustrated, feeling like patients fell through the cracks. Patients got lost. Too many ED visits, long hospital stays; I have a very clear memory of the first day. The 30 people, some of whom had been working at the VA for decades, had never met each other. It was the first time they’d met each other to talk about how can we do a better job of caring for these complicated patients?

Eric: Yeah. And Kenny, when I read this paper, it seems to be focused on people who’ve been in the hospital for a while. People who people anticipate may be difficult to discharge, or there’s a lot going on. Hospitalization, let’s say, for heart failure. People come in for heart failure, you give them Lasix, then you discharge them. Why do we need a whole ‘nother structure for these people?

Kenny: Good question. I mean, there is obviously a lot going on, and if it was just the heart failure, then yeah, I mean, I think we have a pill for that.

Kenny: But I guess as a fellow coming in, and as someone who trained in a different system, I was really trying to figure out how was I recognizing the same people that I saw where I trained in Toronto? Like these older people where it wasn’t just the heart failure that needed to be dealt with. But all these other … really what I summarize as disabilities, physical problems, cognitive problems, and complex social dynamics.

Kenny: How was this in fact very similar, and how could I apply some of the principles that I learned in managing for these people, to this new setting? And it’s really when all of these things come together that you end up with this beef that’s just not just the sum of its parts.

Eric: Yeah, so it’s not just oral diuretics and send them home. For some … I see Jess laughing in the background. Jess, what are you thinking?

Jessica: I was just thinking about Anne and Kenny said, is that not only were there people not talking to each other, I want to say that people were talking crap behind each others’ backs. Outpatient would be like, “There’s someone who’s really unsafe at home, and send them to inpatient. And they just sent them back out again. Don’t they know what we’re trying to deal with, and what we’re trying to protect the patient from?”

Jessica: And similarly, if you talk to someone inpatient, they’re like, “Can you believe the outpatient team, that they sent them in, and think that we’re going to fix all the problems that they couldn’t do, like when they’re in the patient’s home?”

Jessica: I think a lot of our first meetings was really being like, “Hey, we’re all good people. We’re all really trying hard to do what’s right for the person.” It’s really uncomfortable when you’re not sure if someone is optimally living how you would choose to live, around safety or taking all their meds or all these things.

Jessica: And trying to get deeper into what people were … I don’t know, afraid of, in terms of keeping people in the hospital and being afraid to discharge them out. Or what people were upset about when people left the hospital, and didn’t think that they should have left the hospital.

Jessica: I think those are some really hard conversations than just being like, “Oh, why can’t we just send this one to a nursing home to live for the rest of their life? That would be the best thing for them.” And there’s a lot of conversations about who are we to decide what’s best for the patient? Or how much input should we have from the patient about how they want to live their life? And how much do we, the system, want to override that? I mean, what are the guiding principles around that?

Jessica: And I really appreciated, when Kenny joined us fairly early on when we were doing the team, is that he started thinking about how do we think about these patients that we feel a lot of people are frustrated and stuck on?

Eric: Yeah. It seems like the social determinants of health, which we have multiple podcasts on, it’s not just the medical problems; although medical complexity and co-morbidities play a role. Like dementia or people with heart failure, how does bladder incontinence play a role?

Eric: But also, all of these other social determinants including housing and money they have. Is that how we were thinking about including a legal perspective, too? I’m going to turn to Sarah. What are your thoughts?

Sarah: Yeah, we have had a medical partnership for seniors focusing on older adults for many years at the VA. We had become interested in this problem of complex patients from both a theoretical standpoint and a practical “This is so preventable” standpoint in our communities.

Sarah: You see someone who’s been in the hospital for three months because they can’t be discharged for social reasons. They didn’t have access to planning, to choose caregivers. Their caregivers are highly strained and don’t have access to resources. There’s barriers to long-term care access in settings that people want and need.

Sarah: These are all preventable, some of them, if we think upstream. And all of them are preventable if we think upstream far enough. Right? If you think about why is it that 5% of healthcare spenders in the U.S. account of 50% of costs, it’s because we are paying for social choices in the medical system.

Sarah: 40 years of increasing healthcare fragmentation put the burden on patients and caregivers with disabilities and low income to navigate those resources. And on providers, too, right? There’s a lot of moral distress.

Sarah: There’s 50 years of putting more pressure on individual consumers to save for their own retirement, and rely on the stock market to do that. That’s a lot of financial decision making we’re asking people to do, at a time that they’re least able to do that. And their family members are not prepared.

Sarah: Then you think about persistent social inequality and structural racism; that a veteran in one neighborhood may have his whole life have had access to fewer resources and more stress that is now culminating in issues that we’re seeing at the bedside.

Sarah: So when I say they’re preventable, they don’t always feel preventable from the viewpoint of TRAC Team. But they are, if you think upstream far enough. Those are the reasons that I am interested in this, and our team at the law school is interested in this.

Eric: So Anne – you created something called a TRAC Team. What was the goal of this intervention? What were you trying to do?

Anne: Well, the goal was to bring content experts to the table together. We started this before the pandemic, so at one time we were actually at a table together, to do really complex, high-level consultation and problem solving so that we could provide a plan of action to the primary team who’s caring for the veteran.

Anne: Most often, or initially, our consumers or our constituency was the inpatient teams. We’ve expanded our reach, and now our home base primary care program is also one of our customers, as is the Outpatient Clinic and the Emergency Room. And so- [crosstalk 00:14:38]

Eric: And who’s on this team?

Anne: Inpatient social work, outpatient social work, inpatient geriatrics, outpatient geriatrics, home-based primary care. Our lawyer colleague, who’s one of Sarah’s colleagues, Sarah Huffman. We have outpatient nursing-

Jessica: We have a representative from inpatient mental health.

Anne: Right. Right. And I would say that Sarah Huffman, the lawyer who’s with us, is the secret sauce. One thing that I’ve really learned is that because doctors are the only professionals to whom an older adult can visit, or come to with problems, and not have a bill to pay, is a doctor.

Anne: Patients who have low legal literacy, just like most doctors have low legal literacy; patients bring all their problems to the doctor’s office or to the emergency room or to the inpatient service. And healthcare professionals, we’re trying to solve legal problems, to try to turn a legal problem into a medical problem so that we felt we could solve it.

Anne: But it turns out that actually, there are legal problems independent of medical problems, although they’re very often linked. And when there’s a lawyer present to articulate the legal problem, with the expertise to solve the problem, it just really facilitates the problem solving in ways that I had not been able to contemplate until Sarah was working with us to do this.

Anne: And I’d be eager to hear from Kenny and Jessica, who’ve been doing this as long as I have, how they think Sarah Huffman’s role has transformed the way we as clinicians think about the problems that our patients bring us.

Jessica: In my mind, TRAC is bringing what we do in Geriatrics and into professional team meetings to a larger venue. I think that we in Geriatrics, we’re caring for these patients. And I think we handle the expertise and we’re talking to them. But what TRAC does is it opens it up to not just the 400 patients who are cared for in Geriatrics Clinic, which we did have access to the medical-legal partnership for seniors before TRAC was involved.

Jessica: But really, opening it up to other people for this interprofessional team discussion about really challenging cases. I spent a lot of time talking to primary care providers about patients, and telling them that what is the thing that’s going to have the biggest impact on your patients’ health? It is not their adherence to their blood pressure meds. It is, no, having access to a caregiver. Making sure they still have housing.

Jessica: And if you, as a primary care provider say, “My prescription for you is to please fill out the MediCal application. That will have the biggest impact on your life. Not the medication I can prescribe, not another medical professional trainee to refer you to, but MediCal application.

Jessica: “So you can get a caregiver. So you can stay in your home. Having a rep payee so that you have someone to pay your bills, so you can still stay in your home. Or you’ll be able to maintain some independence at home, live there longer. Fill out an advance directive so that we understand what it is that you want, and that we know who to call if something happens.”

Jessica: These are the things that sometimes people need to hear from their doctors, and that’s why I think we have the doctors. It’d be like, “I know that you’re all focused on their medication adherence, but if they lose their housing, that’s going to have a much bigger impact than them not taking their Lasix.”

Anne: And also a financial decision maker.

Sarah: Moving back to something that Anne said earlier about the importance of everyone working in silos, legal intervention is also not as helpful if it’s not integrated. One of the things that we heard when we first started working as part of this team were very different stories of what was happening with the same patient.

Sarah: And a person’s behavioral needs and cognitive status, and what is happening with that person, informs what their legal options are. And it wasn’t until I think we all worked on a tool, the TRAC form, for compiling information about the patient. I think the piece that we added was, what are the legally relevant social conditions, including what’s their decision making status? Who are the people in their life that could be decision makers? It wasn’t until we could knock that out and really provide clarity that the legal option became more apparent.

Sarah: That was really clear, because if initially, we would hear a case, and I would say, “Oh, okay, this is a long-term care access issue.” And then it was like, “Oh, this is a conservatorship issue.” “Well, no, actually, it’s not a conservatorship issue. It’s a access to in-home support services issue. And by the way, we think they have enough capacity to still appoint someone, and we can avoid the need for conservatorship.”

Sarah: So that point of getting everyone on the same page about the basic facts of any particular case is really critical. And it’s very helpful to the legal team as well.

Jessica: I think one of the things, for instance, one of the basic facts is the people who refer to us, it’s like, where ideally do you think this person should live? What’s the right level of care? And we end up arguing what a residential care facility or assisted living facility, why they think that that is the right place for someone. Because people have certain assumptions about why, or- [crosstalk 00:21:01]

Eric: And most doctors probably haven’t been into an assisted living facility before…

Anne: Right. Right.

Jessica: Most of the time I’m just like, “Well, that would be really nice, but there’s no way they can afford that. So that option’s off the table.” I don’t know how many times I’ve talked to PPP where they’re just like, “Oh, I tell them they need to move to an assisted living facility.” I’m like, “Well, that is an incredibly unhelpful piece of information for that patient, because they can’t afford it.”

Alex: Before we move on can I put just put a pin in some … well, I just want to talk briefly about … Kenny, you were on the podcast with Sarah Szanton.

Kenny: Yes.

Alex: And on that podcast, we talk about our capable intervention, which was a multi-component intervention to help older adults remain in their homes. And she’s capable as lauded, appropriately, because it has this secret sauce ingredient of a handyperson who can go in and help install grab bars, shower chairs, things like that. Make environmental modifications. And Sarah, of course, said, “That’s only piece. There are all these other pieces.” That’s true, but it’s kind of the secret sauce.

Alex: I liked what Anne just said, that the secret sauce to your intervention is the lawyer.

Sarah: The lawyer.

Alex: Kenny, I’m wondering from your perspective, your thoughts about that in reflecting on what distinguishes this from other interventions.

Kenny: Yeah, well, I think maybe what I should lay out as a little bit of how I conceptually think through how medical issues interface with legal issues. Because in my head, I think it’s really funny, right?

Kenny: From a medical standpoint, we’ll talk about diseases like Alzheimer’s disease, I don’t know. Some plaque is eroding someone’s brain, and it’s chewing away at it.

Kenny: And the reality is that once it gets to a certain point, that makes living very difficult. And all the aspects of living have to sit in legal structures defining what are the things that constitute living. I feel like law creates boundaries in how we live. It creates these fences. And if we don’t really know where those fences exist in the rest of society, then we can’t really figure out how this disease, this plaque, then plays out to cause all these effects that might be quite detrimental to someone’s health.

Kenny: I obviously wrote that paper also on equipment needs. And the way I’ve always thought about it is, echoing what Jess said: that from a medical standpoint, we focus so much on pills and procedures to treat specific diseases. And yet at some point, for an aging or aged population, I don’t think it’s the pills and procedures anymore. It’s the services and equipment that we provide for them. But those services and equipment sit in legal structures. Right?

Kenny: To get service, you have to meet certain eligibility requirements, depending on where you sit. And that requires all sorts of expertise to understand as well. I just think it’s funny that we can predict that people will decline in certain ways because of any number of diseases. And we’ve seen that with our older population.

Kenny: And yet, once that interfaces, we don’t have legal structures. We don’t have system structures, we don’t have legal structures that are really designed well for the inevitable problems that arise.

Kenny: And I think the TRAC Team was a really good way for me to begin learning, and continue to learn, and I think even for the VA system to learn. What happens? What are the problems, and what are the problems that repeat themselves in a lot of quite often, more often than we expect?

Kenny: The paper is structured around discharge planning, which is like a hook, because that’s what costs things. But I think you’ve heard already from everyone at this table: we are actually very motivated about what are the problems that people are facing? And what are the avenues that we can actually start sifting out what the real problems are, rather than getting really focused in our specific training?

Eric: And you had a specific framework, right? That you used for the TRAC framework.

Kenny: Yeah, the TRAC framework.

Eric: Tell me about that.

Kenny: I think I tried to build it so I was writing mostly to a medical audience, so I start with this idea; it’s an oversimplification. We know it, but let’s say that we’re a particularly junior physician. We’re thinking about things just … discharge. All that matters is that they’re medically stable. Are they on the right meds? Are their vitals stable? Well, then get them out of there.

Kenny: I was trying to figure out how would I teach someone to start thinking about other categories that could potentially be problematic with discharge? Using particularly complex cases, to inform what that framework would look like.

Kenny: I just sat down, moved the pieces around, and I felt like it boiled down to these other factors that get highlighted on the right side of the framework. Namely that even if someone is medically stable, you have a hard time discharging them because you can’t identify a safe and appropriate discharge destination.

Kenny: If you can’t identify who is an appropriate decision maker who is capable, has the patient’s interests in mind, and is legally allowed to make that decision. Then also, who’s paying for this destination that we’ve identified?

Kenny: I think just starting there; there’s probably another thing that will come into TRAC framework 2.0. In other words, for discharge, how do you actually physically get the person from the hospital to another setting? Which actually has all sorts of its own complications.

Kenny: But these end up being the sticking points. Because once you get those, I don’t really know what gets in the way of discharge, if you can figure those things out.

Eric: It’s almost like the people who are the TRAC members, it’s almost like doing a little mini-fellowship, where you’re building institutional knowledge and community-based knowledge about how to care for complex older adults that you don’t get as much experience if you’re just doing a lot of different discharges. Is that right?

Jessica: We started out as interested people and we became the subject matter experts, because we come together every week to talk about these difficult patients. And then we’re like, “Hey, do you guys remember that case last year, where someone we discharged and somehow we flew them down to … what kind of plane was that?” I mean, we’d just talk about because we dealt with all sorts of different situations.

Jessica: I want to go back one thing about medical-legal being the secret sauce, because not only is it the secret sauce that there is someone, a lawyer, who meets with us every week to talk about the legal issues; but then we’re like, “Hey, is this an appropriate referral for you?” And she’s like, “Yeah, if the patient agrees, I’ll see them on Friday.” If they have the capacity, I will help them set up their DPO for finances.

Eric: Wow.

Jessica: That is to really move things along. I mean, being able to distill the legal issues, but also be able then see the patient and take care of them, is a big part, I think, of the secret sauce.

Eric: Yeah.

Sarah: Yes. And that’s the difference between the medical-legal partnership model and referrals in the community. I’m seeing a lot of population health efforts that are attempting to figure out screening and referral protocols. And I think those work for a lot of patients, especially ambulatory care patients. But they don’t work for this population. Right?

Sarah: This is a population where you need to go to them, and they’re having integrated advocacy on site; at the hospital, outpatient clinics, long-term care facilities, is really critical to reducing the barriers to access, to legal care.

Sarah: Because what’s extraordinary is that there is legal service available for older adults in the community. And for very high-need older adults, it’s funded through the Older Americans Act, and it’s available in every community. But is very disconnected, often from other social service providers, and in particular, from the healthcare system.

Sarah: Even self-diagnosing is an issue, as legal or having solutions, is something that people really struggle to do.

Eric: So this all sounds amazing and nice. But did it work? Does it do anything?

Anne: Take it away, Kenny.

Kenny: Yeah, good question. Good question. We also did not know whether or not we were doing anything. Because you can imagine what every single week, you just discuss very difficult cases. You sit there and you’re like, “Wow, we are not making any progress at all.”

Kenny: That’s when I just ran the data where we said, “Well, we know that our focus isn’t just discharge alone. But that’s where we started, so let’s examine and see what the trend was.” So we used a run chart; this is like a quality improvement method. But the idea is you’re just trying to find out what is your baseline, and you’re using statistical principles to figure out have you deviated significantly from baseline?

Kenny: And the answer was that at least around the time that TRAC started, we did see a reduction in the number of really long-stay patients. Then the question becomes, in any quality improvement method, you can’t figure out whether or not that change was because of what you did. All you have is that time-based trend. That’s where I followed up with just a study to find out, “Well, it’s nice and all.” But as a researcher, as a geriatrician too, I think I just remain skeptical about everything.

Kenny: That’s why we did follow-up surveys from participants, just to find whether or not people felt like it was working. And what were concrete stories of where they felt like it had actually made a difference. I think it’s really pairing those two things together that’s helped the paper come out, and help us understand what it is that we’re doing.

Kenny: We highlighted that people felt like they were not just learning in TRAC, but they were learning how to care for their patients, as you had mentioned, through this forum. Also, people were talking quite concretely about a couple of things that were smoother processes that grew out of TRAC.

Kenny: One of the things that comes up, at least I think the reason why I set up the framework the way that I did, was that sometimes we got really focused on one aspect of discharge. Like, is this the right place for this person? You talk to OT and you talk to PT and they’re doing all these assessments and you’re trying to figure that out.

Kenny: And no one has started the financial piece. Or no one has really assessed the path for me to even know, do we have someone to sign off on this decision? Can they sign off on this decision? And the whole point about that whole framework is that you can actually run these processes in parallel.

Kenny: Sometimes in TRAC, that’s one of our recommendations. Where we say, “We can tell you how this is going to go after you’ve figured a couple of more things out. Do it all at the same time, because we can’t really predict what will happen.”

Kenny: So that’s just one of the ways that I think we’ve actually reduced these really long stays: that we just start the process earlier.

Eric: Well, let me ask you another question: This does not sound like a low-cost intervention. When you think about the amount of time and expertise; you got lawyers, multiple physicians, you got tons of other team members, it sounds like, part of this group. And it’s great that they’re developing experience and it sounds like there’s a decrease in stay.

Eric: Bottom line, for the C-suite, does it actually reduce overall costs? Do you have any idea on that?

Anne: The short answer is we think so. I say that based not on the work that we’ve just published in the Catalyst, but some work that Sarah Hooper, Sarah Huffman and I did a couple of years ago, looking to us when Sarah Huffman, our lawyer colleague, was doing consults for veterans in our Community Living Center, our nursing home.

Anne: We did a calculation to show that Sarah’s consultation with six veterans in the CLC and the hospital, over the course of one year, saved the hospital $800,000. Or saved the medical center $800,000. So six consultations, one free lawyer, $800,000 in savings.

Anne: Cost savings is always a little bit of hand-waving. It’s hard to stand on solid ground with that. But it was enough at the time that our CEO said, “Let’s hire a lawyer. Let’s pay her to do this full time here at the VA.” It turns out at the time, that wasn’t possible for a VA to hire a lawyer to represent veterans.

Eric: Oh.

Anne: So we had to table that, but there’s currently legislation … it’s part of one of President Biden’s packages to give the VA permission, or the ability, to hire lawyers to represent veterans.

Anne: So we’re hopeful that that will pass.

Jessica: I want to point out that there are probably like 10 people that show up to TRAC every week. And none of us get specific time out of our schedule to do that. I mean, we think what we’re doing is effective, and I learn a lot. We all volunteered to do it from the beginning. And then one wonders whether they should be paying us more to do it.

Jessica: But I think we enjoy going because it’s a way for us to solve the problems that we see in our day. As a director of Geriatrics Clinic and geriatrics consultation, it sounds like, “Yeah, discharge that patient, have them come see my clinic. I’ll follow up with them around capacity.” The more business I say, I’m able to justify more positions for geriatricians, because this is what’s needed in our system.

Jessica: I feel like I have a finger on the pulse of what our system needs to address these patients, in inpatient and outpatient. So I feel like it does dovetail with the rest of my job, and I feel like that’s probably why everybody else shows up, too. Because it feels like we are actually solving some problems, and helping figure out how we can move forward to do more of it.

Eric: You think it would work outside of the VA? VA integrated healthcare system? There’s incentives to reduce length of stay in a hospital, but also manage people with an outpatient. Would it work elsewhere?

Jessica: Absolutely. I absolutely think it does.

Anne: Yeah.

Jessica: All right Kenny, go ahead and say something else.

Kenny: Oh, as I said…

Eric: Not in Canada, Kenny. In the U.S.

Kenny: I’m always a skeptic; it’s the part of me that actually, having trained in Canada, I don’t know how it works in private centers. I mean, I hear anecdotally that they start charging patients, and then that moves them to a nursing home.

Kenny: But I also know that there is an insidious pathway from hospital to short-term nursing home stay to long-term nursing home stay in the U.S. as well. I don’t have as much vantage point on that. But if any listeners want to fund a randomized trial, look at cost, I’d be more than happy to run it, or work on that.

Kenny: But as Anne said, all cost literature is a bit of hand-waving, and it doesn’t take too long to realize leaving people in hospital, or even in a nursing home, when that might not actually be necessary, is a very expensive way to do it. A hospital day is $4,000 a day, when you look at the VA data. And a nursing home, they cost $56,000 a year to put someone or to leave someone in a nursing home.

Kenny: And so you really ask the question, as Sarah Szanten asks this question too: Do you really need to go somewhere else for this? Or could you make some adaptations to the home, or bring someone in for a shorter period of time? This is obviously a huge area for our field; we’re constantly trying to demonstrate our value, I think, as geriatricians.

Kenny: But I mean, what is evidence that moves money around, depends on who you talk to, really.

Jessica: Yeah, the big thing for this is I think that TRAC has become a venue for different people in our system to discuss cases that are incredibly distressing, and leading to burnout.

Jessica: And to be able to talk to a team and say, “Hey,” we tell them, “you guys are doing everything that you can. And I know that you’re thinking maybe about sending this person to the hospital or you’re thinking about time to conservatorship. But I’m not sure; the conservatorship is not going to give that person any more money. It sounds like you’re really trying hard to listen to the patient’s values, that they want to stay in their home.”

Jessica: But it’s distressing to watch someone continue to live in [inaudible 00:38:42]. Maybe one thing you could do is ask permission if they would be willing for us to contact their family members for that to be their emergency contact if something … or try to identify a small step.

Jessica: We now take more cases for outpatients, as we’ve reduced the number of long-stay patients and inpatients. To be able to do that, I think that is huge for healthcare systems, especially during this pandemic, of offering to teams a way to talk about the more complex patients and identifying next steps for …

Jessica: Because I think there are a lot of people who are thinking about these patients at night. Wondering if tomorrow is going to be the day that they get the call that someone isn’t doing well, and wondering whether or not they could have done something to prevent something bad from happening to someone who was high risk.

Jessica: I think that is a huge value, both for inpatient and outpatient teams, to have that, as we’ve been talking a lot about burnout in the healthcare system.

Anne: I think geriatricians are very good at tolerating uncertainty. And we discovered that our colleagues across the healthcare system are not. I honestly think that one of the things that we have taught our colleagues is how to tolerate uncertainty and ambiguity, and come to understand that you can’t control everything. And that patients’ autonomy is important. That it’s not easy, it doesn’t always feel good as a clinician to send somebody off to an uncertain future.

Anne: But when you can share that uncertainty, and share the distress, it makes it possible for people to say, “Okay, I endorse that plan. Let’s try it.” It’s been a huge learning experience for all of us.

Eric: Yeah. Kenny, my last question. An institution wants to do this. Where do they start?

Kenny: Start by meeting. We spent a lot of time trying to figure out what was the minimum product. And it’s the meeting. I mean, there are a lot of ways we could have thought about it differently. Is it a process? Right, but meet, and try and find a local legal group to help with it.

Eric: Sarah, how do you do that?

Sarah: Contact your local area Agency on Aging, or your local law school. And in the same way that it’s important to have different disciplines represented, it’s also important to know what kind of lawyer you’re looking for. Your hospital risk manager ain’t it, right? They’re a representative of the hospital; they’re trained in a very different way.

Sarah: They’re not substantively in the areas that people need help with, which is Medicaid, long-term care advocacy, capacity. Those are elder and disability law, and poverty law competencies; your hospital counsel doesn’t have those. You need to find someone in the community who is patient facing and there for the patient, not there for the hospital.

Anne: I would also add too that we welcome observers to our weekly TRAC Team. We have had many observers. I think it’s the best way to see what we do.

Anne: The other thing I would also add is that it took us months to acquire the discipline to use the hour effectively and efficiently. I would say that I was really, pardon the expression, a hard-ass in keeping people on track and bringing us all the discipline that we needed to really be effective during that meeting.

Anne: So as Kenny said, it takes a lot of practice. It took us months to figure out how to do this.

Eric: Well, speaking of making sure we stay efficient and on time, I want to thank all of you joining us for this excellent podcast. We’ll have a link to the New England Journal of Medicine Catalyst paper. Amazing job, amazing program.

Jessica: I want to give a shoutout to the VA Quality Scholars Fellowship, during which Kenny did this work. And if you’re interested in that, you should definitely contact us too, because it’s a great way to do quality improvement and research.

Eric: Great! That’s at multiple VAs, too. Right? Right?

Jessica: Yes, it is. 11 across the nation, I think?

Eric: Alex, you want to sing us a little bit more of … What was the song’s name again?

Alex: An Angel from Montgomery.

Eric: Angel from Montgomery.

Eric: By John Prine. I saw Bonnie Raitt and John Prine play it in concert. It’s such a great version.

Eric: Yeah.

Anne: Yeah. My favorite.

Eric: Love it.

Eric: (singing)

Eric: Thank you all for joining us for this podcast. Thank you Archstone Foundation for your continued support. And to all of our listeners, thank you for supporting the GeriPal Podcast. Bye, everybody.

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