Watching her parents struggle to care for her ailing grandmother in rural Kansas, Alicia Arbaje, MD, MPH, discovered the passion that would shape her career. “My grandmother was the backbone of our family. Watching her suffer through repeated trips to a hospital 30 miles away, without hope of getting better, made such an impression on me,” she recalls.
As her professional parents (a gastroenterologist and a psychiatrist) found even their skills inadequate in the face of a health care system ill-equiped to care for older adults, Arbaje decided that she would one day do everything in her power to change that system.
“I decided to work with people with complex health problems. I wanted to help families and patients who really did not have a voice,” says Arbaje, a geriatrician, 2003-2005 Robert Wood Johnson Foundation (RWJF) Clinical Scholar and 2007-2011 RWJF Harold Amos Medical Faculty Development Program scholar.
Arbaje has made great progress toward achieving her goal. Her research has produced new evidence on how to keep older adults out of the hospital, healthy and in their own homes.
Little Things Mean a Lot
Arbaje’s research began during her RWJF Clinical Scholar term at the Johns Hopkins School of Medicine. Working with Chad Boult, MD, the father of Guided Care—a model program for caring for older adults—Arbaje says, “my initial project was teaching nurses how to deliver coordinated care across the health system.”
“My Clinical Scholar project was a national study, ‘Post Discharge Environmental and Socioeconomic Factors and the Likelihood of Early Hospital Readmission Among Community-Dwelling Medicare Beneficiaries,’ [published in the June 2007 issue of The Gerontologist] that analyzed the environmental factors that were most likely to cause older adults to be readmitted to the hospital within 60 days of discharge. We found that the most important issues were very simple things. Older people who lived alone, for instance, or who had unmet functional needs, such as the ability to bathe, dress themselves or prepare meals were most likely to land back in the hospital.”
Next, Arbaje became an RWJF Harold Amos Medical Faculty Development Program Scholar to prepare for the next phase of her research. “Becoming a Harold Amos Scholar really helped me to launch my career and build on what I learned as a Clinical Scholar. I expanded my research skills and learned how to implement my findings. Mentors Bruce Leff, MD, and Sandy Schwartz, MD, also helped me make the critical transition to becoming a faculty member,” she says.
New Evidence: Best Practices
For her Amos project, Arbaje took a look at the availability of quality geriatric care in the nation’s hospitals.
“I wanted to identify the characteristics of hospitals that provide services relevant to older adults and give older patients a guide to choosing the best institution,” Arbaje explains. “Our team talked to nurses, physicians, social workers, therapists and others to take a 360-degree look at the challenges of providing elder care to produce a senior-friendly hospital index.”
The senior-index research is under review for publication, but key findings from Arbaje’s studies reveal important new guidelines for older patients and their caregivers. “There are at least five key things to consider,” she says.
- Identify and address patient’s unmet functional needs. “This may seem obvious,” Arbaje says, “but it’s unusual for physicians to ask these questions because it’s not what they learn in medical school. Yet, these issues are vital to recovery.”
- Work across disciplines. “Interdisciplinary collaboration is important in all medical practice, but for older people with complex illnesses that may have several providers, it’s critical for nurses, physicians and other caregivers to work together. Our work confirms that no physician can provide comprehensive care to these patients all by him or herself,” Arbaje says.
- Test cognition. “Again, this seems obvious, but many providers shy away from this for fear of stigmatizing patients. But cognitive impairment—that may not be obvious during routine visits—puts people back in the hospital,” Arbaje notes.
- Closely monitor medications. “This is a very significant problem. It’s very common for over-medicated older patients to land back in the hospital because of medication-related complications. Physicians should constantly re-evaluate all of the medications geriatric patients are taking,” Arbaje advises.
- Provider, patient and caregiver must work together. “Discuss care goals, advanced directives or whether patients want palliative care. Many physicians are uncomfortable with this conversation, because they are not trained to pull back on care, but these issues and caregiving decisions must be addressed,” Arbaje says.
Keeping Seniors at Home
Now working with a grant from the National Patient Safety Foundation, Arbaje has formed a uniquely creative partnership. “I’ve teamed up with engineers who are experts in how humans interact with their living space to figure out how to apply the lessons from my research to home environments. We are going to follow older people through the transition from hospital to home to identify red flags that may occur as they go home. The goal is to help people stay healthy in their own homes for as long as possible, even with multiple health challenges.”