Emory Medicine, Summer 1998


When I'm 94
The Emory School of Medicine and Wesley Woods Geriatric Center are inventing new ways to care for the fastest growing and most challenging population in health care.

Photographed in the kitchen of her apartment, where she lives alone, Kendrick, 78, is proof that growing older can mean getting better. A program located at Wesley Woods coordinates her health care, provides household help, and is a resource to help keep Kendrick, and frail elderly like her, out of nursing facilities and in their own homes.

On a recent day at an Atlanta senior center, Sally Roberson (l) and Gladys Kendrick spent the morning discussing their families, health concerns, hobbies, and wondering, "What's for lunch?"

by Rhonda Mullen

When he first saw Gladys Kendrick, she was almost too weak to get out of bed. The 78-year-old had come down with a bad case of flu. She was unable to prepare even a simple meal and had become dehydrated. She barely had energy to get to the bathroom, let alone bathe. "She was on a spiral down," says Dean Kervin, a case manager called in to evaluate Kendrick's situation.

Looking at Kendrick today, Kervin's story seems hard to believe. Seated on a couch in a day center for the elderly in Atlanta, a striped cap jauntily bobbing on her head, she engages in an animated conversation with her friend Sally Roberson. "I came up on a farm in Alabama," Kendrick says.

"I thought you looked like Alabama people," Roberson nods. She lets out a little laugh as she holds her purse close by her side. "Yeah, I've been wondering about that."

Roberson, 83, who lives in public housing in downtown Decatur, comes to the center about four days a week. "My son is always asking, 'Are you ready to move in with me?' I hope I never get ready," she says. "I'll stay here if I live to be 100."

Kendrick, too, lives alone, but in an apartment complex subsidized by public and private funds that staffs two social workers around the clock.

Both women are enrolled in a Georgia Medicaid pilot project that seeks to support frail elderly in their own homes and communities. The pilot, known as Service Options Using Resources in Community Environments (SOURCE), provides an alternative to nursing home placement by offering comprehensive and preventive medical care with in-home support like meals, transportation, cleaning, and nursing. Kendrick, for example, receives her clinical care at Wesley Woods Center on Aging, deliveries from Meals on Wheels on the days she doesn't attend the center, the help of a housekeeper one day a week, and enrollment at the senior center, all funded by SOURCE, which in turn is supported by the state of Georgia's Department of Medical Assistance. Wesley Woods manages the Atlanta pilot of SOURCE through its partner Atlanta Senior Care, a network of medical care, community service, and education organizations that seeks to improve the quality of life among senior citizens. The average monthly cost to support a SOURCE participant ranges between $500 and $900, compared with approximately $3,300 a month for nursing home placement or $1,000 a day for hospitalization due to complications, malnutrition, and falls.

Through programs such as SOURCE, Wesley Woods is redefining the concept of geriatric care, says Margaret Fowler Lesesne, vice president of Managed Care and Network Services. With the fastest growing segment of our population being those over 80, "at this rate, we will be unable to have enough facilities to treat all of our older patients," Lesesne says. "We have to radically rethink our care, making it not only more economical but also better for people. We need to offer continuous rather than episodic care for people as they age. To better serve them, we need to treat them in a holistic manner. We can't just treat their blood pressure, for example, without addressing the problem that caused it."

Marrying into the right family

Wesley Woods CEO Larry Minnix says the merger will allow Wesley Woods and Emory to creatively redefine how they manage the health care of the elderly.

In the geriatric, acute care hospital, it's not just physicians who make rounds. Pets, too, lend their expertise in helping patients.

Redefining is just what William Larry Minnix Jr. has been busily engaged in these days. President and chief executive officer of Wesley Woods, Minnix headed the Chronic Care Special Populations Task Force in the recent strategic planning that took place throughout The Robert W. Woodruff Health Sciences Center at Emory. He compared the task force's job to redesigning an airplane, already in flight, with the assignment of turning it into a space shuttle that will land on a space station that hasn't yet been built.

Previously, in providing medical care to the elderly, "We've had a circle-the-wagons mentality," says Minnix, who holds a doctorate of divinity. "We now need to develop a truly integrated delivery system."

To that end, Emory's School of Medicine and Wesley Woods are strengthening their 50-year alliance with an official merger to form the Wesley Woods Center of Emory University. The new center will bring all of the existing operations on the 72-acre Wesley Woods campus - an acute care geriatric hospital, two nursing homes, an outpatient clinic, residential apartments, and clinical, research, and administrative offices - under the auspices of Emory Healthcare to offer one of the most comprehensive health care systems for the elderly in Atlanta and the region.

The alliance is a natural result of a longstanding association between the School of Medicine and Wesley Woods. Some 150 of Emory's clinicians, researchers, residents, fellows, dietitians, and chaplains already work regularly at Wesley Woods. What the merger brings is a "different sense of commitment," says Minnix. "Previously, we've had a longstanding healthy partnership that was renewed yearly, like a client contracting with a vendor. Now it's more like we're married, albeit with a hyphenated last name and a separate checkbook, but we're going to work it out together."

Minnix sees the merger as a "win-win" situation for both institutions. With the public affiliation with Emory, Wesley Woods elevates its prestige and status. The geriatric center will be able to refinance its debt, receiving more favorable interest rates, and integrate systems such as information and technology, thanks to the merger. And Emory will receive wider access to the elderly and chronic care population Wesley Woods serves, enabling the medical school to strengthen its training base in those areas.

"Wesley Woods has expertise in delivering lower-cost care for people with chronic conditions," says Minnix. "That's our briar patch. We're high-touch but low-tech."

For example, under the new arrangement, a stabilized patient in the intensive care unit at Emory University Hospital can easily be transferred from that unit, which may cost several thousand dollars a day, to the long-term acute care hospital at Wesley Woods for a much lower cost. In return, Wesley Woods gains access for its sickest patients to the specialized, tertiary care available at Emory University Hospital. A trial on the bone marrow transplant program begun this year will put this hypothesis to a test to see if Wesley Woods can help Emory lower the cost of this service.

The partnership offers the two institutions an opportunity "to work together in a different way, to do more together than we could do apart," says Minnix. That becomes increasingly important in the current medical climate with its emphasis on doing more for less. And, according to Minnix, that is essential for staying in the business of health care. "Right now, if we don't think about doing it differently," he says, "we aren't going to be doing it at all."

Needed: geriatricians

Geriatrician Joseph Ouslander believes the interdisciplinary approach at Wesley Woods is well suited for elderly patients, who often have multiple medical problems.

Emory and Wesley Woods are applying this rethinking to training as well. Just this spring, along with the University of Alabama at Birmingham, they established a Southeast Center of Excellence in Geriatric Medicine. The center is supported by institutional funds from Wesley Woods, Emory, UAB, and matching funds for the next three years from the John A. Hartford Foundation. One of only 12 in the country, the center will prepare future faculty members in geriatric medicine as well as offer support for current junior faculty members in that speciality. Because Emory and UAB offer similar programs and share overlapping research interests, they chose to collaborate rather than compete for the grant.

"It is very labor intensive to prepare future academic physicians," says Joseph Ouslander, professor of medicine at Emory and chief of medicine at Wesley Woods. "The combined faculty strengths of the two schools will better prepare young academicians in geriatric medicine."

Training in geriatric medicine, a speciality that has existed only in the past 15 years, becomes particularly important in this age of managed care, Ouslander says. "Geriatricians treat people with very special needs. When young people get ill, for example, their acute medical problem is treated, and it goes away. Many middle-aged people have one chronic problem. But with 80- and 90-year olds, they often have six or seven chronic or active problems. They are on multiple medications. Superimpose on that dementia, depression, or socio-economic challenges. Then they develop an acute medical problem. To help them, you need people trained to provide very complicated care."

This year is the first that Emory fellows could enroll in a one-year program at Wesley Woods that earns them board certification in geriatric medicine. Opportunities are also available for two- and three-year fellowship training. Residents also train at Wesley Woods, both in the inpatient and outpatient settings, and Wesley Woods serves as one of the elective sites for sophomore medical students to gain early exposure to clinical settings.

"I don't know of a geriatric facility with this spectrum of services that is so closely aligned with a major university," says Ouslander, who helped set up a prestigious program in geriatrics at the University of California at Los Angeles before coming to Emory. "Many medical schools are affiliated with geriatric care facilities, but usually they pursue only two medical disciplines: internal medicine and family practice. Here, we offer training and services in medicine, psychiatry, neurology, pathology, and rehabilitation medicine."

The interdisciplinary environment fits the nature of the problems seen here: multiple problems that are not only medical but also neuropsychological, Ouslander says.

Teaming up on the wards

In the rehabilitation area of the inpatient, geriatric hospital, physical therapists use an array of equipment to keep patients' minds tuned and their fingers and bodies nimble.

In Wesley Woods Geriatric Hospital, a group of eight people cluster around a table for a weekly conference to discuss the progress of individual patients. The team includes a resident, two nurses, a respiratory therapist, speech and occupational therapists, a social worker, and the director of the unit. At other times, they will be joined by chaplains, pharmacists, and nutritionists. Today, they are discussing the progress of Josie Nations.

Fellow Anna Thopu starts the discussion. Thopu, now in the third year of her fellowship, elected to do part of her training at Wesley Woods to learn about chronic cases such as Nations'. Her previous experiences had focused on acute-care situations. Nations, she explains, is a 64-year-old female patient recovering from coronary artery bypass graft surgery. After the surgery in the fall, she developed numerous complications: an artery blockage, pneumonia, bronchitis, an infected wound. She is currently on a ventilator, and two previous attempts to wean her have been unsuccessful.

This time, however, the people around the table seem more hopeful. They take turns reporting on their observations. Nations, although still on the ventilator, is receiving minimal support from the machine. Today, she was able to sit up for 30 minutes with the assistance of a therapy device. She is able to communicate through an alphabet board and by mouthing. The speech therapist is concerned that her tongue is still weak but is working with Nations on exercises to strengthen it to enable her to swallow. Nations seems less depressed and is smiling more, the nurse notes.

As the group breaks up, each member going back to his or her own work, speech therapist Amber Scott says, "I've worked in a big hospital before, and people talked about the team approach there. But it really happens here."

Lee Goldman, the social worker says, "Very few of our patients go to nursing homes. Most of them return to their homes."

The average stay in this unit is 30 days. The care team works to restore respiratory and pulmonary status, stabilize patients' nutritional needs, and help their wounds heal. "Some of them come back with cookies," says nurse Susan Jones, the unit manager.

Something old, something new

Psychiatrist Larry Tune divides his time between a clinical practice for patients with dementia and research to provide better future treatments for those patients, including seven ongoing drug trials.

Down the hall, psychiatrist Larry Tune is talking with the family of a dementia patient. "The family has to be intimately involved," he says. "The patient, after all, can't remember anything, so it's pointless to just tell the patient to take this pill."

As professor of psychiatry in the School of Medicine and corporate medical director and chief of psychiatry at Wesley Woods, Tune divides his time between patients and research. Currently, he's engaged in seven clinical drug trials for dementia. Another research study, a pilot he's conducting in collaboration with scientists from the Georgia Institute of Technology, examines how age affects working memory.

"Strategies for treating dementia are finally making inroads," Tune says. "Five years ago, physicians often didn't want to make a diagnosis of dementia because there was nothing that could be done. Now new drugs are making a difference." Cholesterase inhibitors such as Aricept and Excelonce are improving mental status with fewer of the side effects of earlier drugs. Other strategies hold additional promise, says Tune, including anti-inflammatories such as Motrin taken on a daily basis, health food store staples like vitamin E and gingko, even red wine.

In other areas, medical school researchers are exploring equally innovative approaches to improving care for the elderly. Ouslander is interested in better understanding incontinence, particularly when it occurs at night, making falls more likely. Joyce Tenover is at work understanding the role of testosterone in aging. Mario DiGirolamo is tackling obesity and aging. Donald Bliwise, one of only a handful of PhDs certified by the American Board of Sleep Medicine as a specialist in sleep disorders, works in tandem with neurologist David Rye to study how aging affects sleep.

Beyond the campus borders

Horticulturalist Kirk Haines works with a patient in a greenhouse that has been specially designed for wheelchair accessibility. For those inpatients unable to come to the greenhouse, Haines takes plants and potting soil to them, using horticulture to beautify areas of the acute care hospital and to keep patients active in one of the simple pleasures of living.

Not only in training, clinical care, and research is Wesley Woods forging a comprehensive continuum of care for elderly people but also in extending beyond the campus to community resources. An affiliation with Atlanta Senior Care enhances the clinical and research services offered at Wesley Woods. A brain child of Minnix, Atlanta Senior Care is the umbrella organization for many agencies in the metropolitan Atlanta area that serve the elderly, including A.G. Rhodes (which has built a nursing home on the Wesley Woods campus), the Atlanta Regional Commission Area Agency on Aging, Jewish Family and Career Services, Senior Connections, and the Visiting Nurse Health System. The alliance covers transportation, home meal delivery, skilled in-home nursing care, durable medical equipment suppliers, adult day care, senior centers, partial hospital programs, and local chapters of national organizations.

"Extending beyond the campus boundaries into the community allows us to provide a truly integrated health care system," says Minnix. "Using interdisciplinary approaches on campus and with other organizations sets a progressive tone for providing geriatric care in the next millennium."

"We're trying to think outside the box by hooking up with community resources and partnering in different ways," says Margaret Lesesne. "Emory and Wesley Woods working together can generate a lot of energy about geriatric issues as well as chronic illnesses such as AIDS, lupus, and diabetes."

SOURCE is one example that seems to be working. Through that program, one client, who at enrollment was on 52 different medications, now has improved health and mental status. Instead of 12 inhalants, she's down to one. Another client, an insulin-dependent diabetic who had begun stabbing herself with her syringe, was admitted as an inpatient and was treated with new medications. Her family was given counseling about how to better structure her day to lessen stress, and today the woman has returned home to live.

Programs like this translate into a healthier older population leading more productive lives--like that of Gladys Kendrick. "I think I'm doing fine," Kendrick says. "I'm not going to get old."


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