Dr. David Shaw, director of medical education at Scripps Mercy, says studies have shown that seniors have the most difficulty with medications. (photo/alanandeckerphoto.com)

It’s old news to UCSD’s John Daly that San Diego’s population of seniors 65 and older is growing fast. Between now and 2030, that group will grow by 56 percent, compared with 23 percent for the entire county population. In 25 years, 20 percent of San Diegans will be seniors, up from today’s 11 percent.

As head of UCSD’s geriatric medicine fellowship program, Daly is working hard to meet the needs of this increasingly active, healthy and service-demanding group. The aging of San Diego, and America, is a big deal.

“There has never been a time in history where we have seen such a large portion of the population reach the full life expectancy,” says Daly. “The most rapidly growing segment of the population is that segment over age 85.”

At Scripps Health, specialized programs aim to manage health care and assist seniors and their family caretakers. For three years, Scripps Mercy Hospital has offered its Palliative Care Program, a multidisciplinary approach that focuses on relieving suffering and improving the quality of life for patients with serious, life-limiting and terminal illnesses. It is the first hospital in San Diego to launch such a comprehensive program and is doing so in collaboration with San Diego Hospice. “About 40 percent of patients we provide consultation for are older than 65,” says Dr. Renee Smilde, the program’s medical director. “Palliative care is basically extending the principles of hospice care into the population that is not ready for hospice.” Hospice care is for a six-month or less terminal diagnosis. Palliative care can go on for much longer.

“About 50 percent of what we do is pain management,” Smilde says. “In the elderly, you have to be very careful in using medications as they are often already on a number of medications for other conditions.” The pain can be related to anything: cancer, surgery, a fall or chronic disease. The program’s goals include identification and treatment of physical symptoms as well as psychosocial and emotional suffering; improvement of communication between health care disciplines and patients and their families; and assurance the care provided meets needs and goals of the patient.

Physicians may request formal palliative care consultation from the palliative care team at any time. Close coordination with case management, social work, behavioral health, physical and occupational therapy and spiritual care are established to provide the care on all in-patient units. These services are limited to in-hospital care. As they are discharged, patients are given referrals to home care services, which Scripps offers, or retirement home living providers.

Keeping Track Of Drugs

In response to the difficulty and dangers in tracking prescription drugs being taken (especially by seniors) Scripps Mercy, funded in part by The California Endowment and the VHA Foundation, began a medication reconciliation program. “This (creates) a clear set of instructions for patients on what medications they are supposed to take, at a level they can understand and in their own language,” says Dr. David Shaw, director of medical education at Scripps. It is not only for seniors, but studies show this group has the most difficulty with medications. “They tend to have more and they tend to have a harder time getting their minds around what they are supposed to be doing,” Shaw says.

While in the hospital, patients’ medications are monitored and controlled by medical staff. However, once the patient returns home, it is difficult to assess if medication instructions are being followed. The first step is to sit down with the patients and make a list of medications. Often, Shaw says it’s important to find out if the meds are being taken as instructed. “Very often seniors, for economic reasons, will hoard medications. They take half a dose or take them every other day in order to reduce their costs. Obviously that can have an effect on therapy. Very often they are not on the dose you think they are on.”

The complete and correct list is then given to the pharmacy technician, a new position created through grant funding. The technician will input the patient’s correct medication list into a computer program for the physician who will use it to make adjustments.

A new and accurate list with instructions is printed and reviewed with the patient. Once in the system it will be simple to upgrade, and a written list encourages the patient to track changes they make. A similar process was tested and demonstrated to improve compliance with discharge medication from 50 percent to 90 percent, and that hospital readmission due to medication noncompliance was reduced from 12 percent to zero percent.

“We are trying to create a process that is easy to do, that doesn’t require a lot of extra time, that can be incorporated into a normal, daily work flow, and that will result in improved compliance with the medications,” Shaw says. The next step is spreading the practice throughout Scripps Mercy, the entire Scripps system and then nationwide. “We hope to infect others with the enthusiasm of our idea,” says Shaw.

Taking Hospital Care Home

Cleo Ariosta is community resource specialist at Palomar Pomerado Hospital, which provides a home health care program.

In addition to its comprehensive senior services program, North County’s Palomar Pomerado Hospital extends medical care and support into the community through its Home Health program. The service provides three divisions of specialized in-home care: Medicare, supportive and private. “Each patient is different,” says Cleo Ariosta, PPH community resource specialist. “It depends on what their needs are.”

Ariosta meets with patients to create a personalized care plan. “It’s a guideline so that when an employee goes into the home they can look at it and see what their duties are,” she says.

Services are provided from four hours to 24 hours a day. Some people may use the program for a few weeks, others may require long-term care. There is no limit to the length of care; Ariosta has clients that have received services for eight years.

Medicare visits require a physician order and the patient be homebound. Visits are done by licensed nurses, physical therapists and speech therapists.

Supportive services include everything from personal care, companionship, medication reminder and transportation to “companion homemakers,” who provide someone to care for the house and run errands.

Private home care provides licensed vocational nurses to care for homebound patients who may require more specialized care, injections, may have a feeding tube or be on a ventilator.

Part of the program includes a sitter service in the hospital or providing someone to sleep over at the home. It provides sitters in situations where family caretakers may need a break or are unavailable and don’t want the patient to be alone.

Private care has operated for 16 years. PPH home health services are paid by insurance or privately. It allows a patient to remain in his home in lieu of moving to a retirement or care home. “We are the only hospital in the area that does this,” Ariosta says.

Considering Aging Needs

Among the most popular services at Kaiser Permanente is the recommended annual health appraisal to anyone older than 65. “We give all our members over 65 a 45-minute appointment — rather than the standard 30 minutes — to meet their additional needs,” says Donna Lupicanni, department administrator of Preventive Medicine and Health Appraisal Clinics. “We do all the recommended screenings and soon will be offering a dexa scan on site to both males and females, in line with the new Medicare guidelines.” Dexa scan is a bone density test to identify osteoporosis in its earliest stages. “Often, husbands and wives come together and make it their annual ‘health day out.’”

A poll conducted by Kaiser revealed seniors like appointments outside of peak commuter hours. Now clinic scheduling accommodates this need.

Recognizing that an increasing number of seniors are becoming computer literate, Kaiser created a Continuing Care Services page online to provide detailed information and services. The site describes what the department does, tells how to access services and makes available lists of many San Diego resources. “We often work with out-of-state family members who are trying to manage care for a loved one long-distance,” says Terry Tolley, senior care specialist. “It is very convenient to refer them to our Web site where they can access current information and services for the San Diego area. The most frequently needed services include in-home care, transportation, meals, counseling, senior legal services, support groups and emergency alert systems.”

Kaiser even works with its senior members and families when they consider nursing home placement, details and referrals to homes, which are also available online. Its Web site lists homes Kaiser physicians work with.

Assessing The Future

UCSD Medical’s Dr. John Daly confers with Carmen Contreras, medical assistant.

Head of the training program in geriatric medicine at UCSD, Daly says there is no doubt a great need for senior resources. “This is a problem that is growing and is continuing to grow,” Daly says. UCSD addresses inpatient and outpatient issues through its Senior Behavioral Health Program in Hillcrest, which offers a combined psychiatric and medical approach for seniors older than 65. Seniors admitted to the inpatient unit are evaluated for medical or biochemical problems, as well as mental health disorders. At the acute psychiatric unit, patients are admitted because they are having behaviors or symptoms, like severe depression, aggression, agitation and difficulty sleeping, that cannot be controlled as an outpatient. Each patient receives a comprehensive assessment by a number of professionals including a geriatric internist, a registered nurse, a social worker, an occupational therapist and a board-certified geriatric psychiatrist. A neuropsychologist also evaluates patients with memory concerns. Outpatients may obtain a complete geriatric assessment through the SOCARE program, which provides general medical care to senior citizens including primary care, internal medicine, health maintenance, diagnostic evaluation, acute and chronic care and medical consultation.

Seniors Only CARE is the clinical portion of UCSD’s Alzheimer’s Disease Research Center. It provides a multi-disciplinary, team approach evaluation and data is collected for the research center. “It’s a comprehensive program for seniors who have concerns about memory,” Daly says. Initially patients are examined by a geriatrician. Then baseline laboratory work will be performed and they see a specialist in geriatric psychiatry and a neurologist and undergo a battery of cognitive tests. After the process is complete, a conference is held with the individual and their family and/or caregivers during which an evaluation and recommendations are presented.

“This is a field where the need is there and we are only seeing the tip of the iceberg,” Daly says. “I think San Diego stands in a pretty good place for providing services.”