As part of a lifestyle and aging series, we’re working with renowned photographer Terry Lorant to showcase inspirational leaders in the industry. Each month, we’ll feature one or a few inspirational member(s) of the Amazing Care Network community who is using his or her voice to empower others in the collective aging experience. Read, in their own words, what the Amazing Care Network’s efforts mean to them.
This month, we’re proud to feature Warren Wong, a Doctor at Kaiser, a Member of and a Physician Friend of the Family for other Members of Amazing Care Network:
Q: How did you first meet Cora?
A: I’ve been a doctor at Kaiser for 30 years and I came to know Cora when she was in Hawaii, commuting back and forth every week to and from the Bay Area. She was a great leader, one of the best Regional Managers we ever had. I linked up with her and tried to learn as much as I could from her, and we’ve been friends ever since.
Q: What is your background?
My area was geriatric medicine. It was new in the system then, but much more established now. Most of my career was spent thinking about how to improve care for seniors. I’m still doing that now. One of the things that we did at Kaiser that was really good was to develop a home visit program. I retired from Kaiser but am still involved in patient care. I’m planting some seeds for a larger presence of home and community based care throughout Oahu, with the whole concept of evolving health care to meet the needs of the disabled , the very ill, the marginalized and the elderly.
When I first started, if you were the primary care doctor, you did everything. You took care of your patients in the clinic, in the hospital, in the nursing home; you took care of everything. There was a big change about 25 years ago which was the evolution of the hospitalist movement, which is pretty much standard practice now. These days, the PCP who takes care of you as an outpatient really doesn’t take care of you when you’re in the hospital. There are pros and cons to that. The hospitalist doesn’t know the patient as well as the person who knows you when you’re healthier and doesn’t know the nuances of all the issues around how to keep you healthy. On the flip side, the hospitalists take care of very sick patients every day , are very skilled at what they do, and are instantly available if/when anything happens versus the clinic based doctor who is basically unavailable a good part of the day.
Q: How has geriatric medicine changed?
The hospitalist movement evolved over the last 20 years or so. over the next 20 years, home and community based care is going to get bigger and bigger as we have more of an aging population. I absolutely think this has to happen.
Currently, the clinic visit is a one size fits all approach to health care. For most patients, going to the clinic is fine. However for some patients, your 15-20 minute office visit is not the size that fits your needs. .
For a person who is quite elderly, getting to the doctor is pretty much an all day ordeal…from finding somebody to take you to the office, dealing with the fact that you may be in a wheel chair, all for a very brief visit with the doctor that may or may not meet your needs. The home based care for people who are at that stage in their life probably will add a lot in terms of quality and service for older people. For example, let’s say you’re an 85 year old person who’s had a stroke and are somewhat disabled, and you develop a fever. You can call your PCP and say “I have a fever”. Fever in an older person is almost always serious. Most doctors are going to say, “just go to the ER” because they know they’re going to have to do a thorough evaluation. The national data is that for anyone who is 85 or older, and shows up in the ER, there’s a 40% chance that you’ll end up hospitalized. The other data that is very pertinent, is that once an 85 year old is hospitalized there’s only a 40 – 45% chance that they’re going to go home. They’re either going to die in the hospital, 10% chance, or they’re going to go to short term rehab or they’re going to go long term, to an alternative setting aside from their home. So when older people say “I don’t want to go to the ER”, they may not actually know the reasons, but the data is that basically, you go to the ER, you’re not coming home the same day, you may never come home. in a better system of care, a frail person says “I have a fever”, and the response is “let’s come to your house and see what’s going on”. It could be a physician or it could be a nurse practitioner.
Q: What are your thoughts on home care/house visits?
Home visits will become more prominent as we move from fee for service to capitated payment. In urban areas throughout the US, it’s widely accepted that fee for service is going away. Getting paid a certain amount for taking care of a person throughout the whole year, called “‘capitated methodology”, that’s the new reality. It’s a move away from paying physicians for each time they do something, paying for volume. Instead, it is a way to pay a physician to do the right things to care for a patient, paying for value and quality.
The house call could be done by a physician or a nurse practitioner. In the current methodology, the fee for service, there’s no money in that. If you can see 6 or 8 patients in a day on home visits, you’re not going to make money doing that. But in a system of capitated payment, you’re incentivized to do what is valuable. if you have an 85 year old who is sick and you do a home visit, you can do an initial assessment and say this is what I think are the possibilities and these are the ways we can manage it.
What I found out when we started this kind of work at Kaiser was that when people are offered alternatives they may frequently choose alternatives that may be less aggressive than the one size fits all that we have with our current health care system. You can prevent outcomes that are much more costly, and could possibly be a lose, lose, lose, for the patient, for the health care system and the outcome is not high quality
Just like everything, there’s resistance to change. Fee for service used to be considered a revolutionary change. 40-50 years ago people argued that “I shouldn’t get paid the same for my service when I do it a lot better than somebody else”. That was the whole concept of fee for service, you get paid one fee for one service, and all of the services became standardized. I do think that when you start to practice population health, you start to see health from a broader perspective in terms of what’s actually going to improve long term outcomes and make care more cost effective.
I have little expertise in this area but home and community based care makes sense for other problems too. Here in Hawaii we have a relatively large homeless population. Their cost of care is about $100 million per year. And quite a bit of it is at a loss. It’s lose-lose-lose when a hospital takes care of a homeless person and then is seen depositing that person back on the street. All too often, the patient ends up back in the hospital. It doesn’t reflect well on the hospital. But from the hospital perspective, they’re losing money on that person anyway.
It’s a complex issue. A homeless person’s priorities may be, in no particular order, getting their drug fix, getting their addictions taken care of, having a place to sleep even if that’s against the law, having food to eat etc. Most urban settings to some varying degree have organizations that provide for the needs of these patients. Some of them become life buoys for these patients. There’s a trust relationship between these organizations and the marginalized populations. They are extremely important partners for the health care system, which is much less trusted, for a variety of reasons, not the least of which is that health care systems frequently don’t like these patients, and have very strong biases against them. So, home and community based care will mean that when the social issues are what massively impact the overall health care, our health care systems are not going to have to think of these people as just diseases, they’re going to have to say, what are the social issues, and what are the more holistic approaches that may ultimately be better for society as a whole in terms of managing these issues? And I think the most forward thinking systems are starting to realize this.
Q: How did you get involved in Amazing Care Network?
In regards to Amazing Care, I’ve stayed in touch with Cora all these years. When she started Amazing Care, she turned to me partly because I’m in geriatrics and there’s a conundrum which is how to draw males in, how to include the men. I don’t have a good answer for her. Males are definitely overall far less social than females. And Amazing Care is a socialization organization; that’s how it works. It’s pretty consistent throughout the country, at senior citizens centers and so on, there’s always a predominance of women. Partly, there are more women than men in general in this age group. I don’t have any data to support this but I do think that in general, women manage aging better than men do. Men usually have two best friends…their wife and the television. How many women do you know who will tell you…”my husband is a Cling-on. Ever since he retired, he just hangs on to me all the time”. I think there’s a lot of truth to that; I’ve heard it over and over again. The only bit of supporting data is that widowers do more poorly than widows in terms of mortality rate. It might be cultural, but I suspect not.
Men have a lot to offer, but I don’t think they’re offering it. I don’t know how to empower the older man. We need to stand up, and I don’t know how that’s going to happen, but I do have some faith it’s going to happen.
Q: You’ve also become one of ACN’s Preferred Partners. Tell us about that:
I’m a Physician Friend of the Family for ACN. Older physicians are quite familiar with the science and have had years of experience helping patients make the right choices. I do think that it’s ok for a patient to listen to a PCP who gives you good advice, but that advice has to be based on what they know of you, and not advice based just on what they think is right for a disease. When a patient asks for the opinion of a PCP, it’s not just that they want the opinion of what the PCP thinks is right, they also want the opinion of someone who knows who they are, knows what they like, someone who has some real knowledge of them and their lives. Most PCPs will have a lot of experience giving meds or recommending surgery or what have you. But a patient wants to hear what matches up with their priorities and their values. the Physician Friend of the Family can help because the physician friend doesn’t tell a patient what to do. The physician friend can combine expertise with a listening ear and guidance. The Physician Friend can provide reassurance, a thoughtful discussion and sometimes a second opinion.
We tend to see things in a larger context, and to see life and death in terms of all of the issues involved. There’s a lot of grey zone between life and death, a huge amount of grey zone. And the more grey zone there is, the more discussion, the more nuances there are to any decision. Let’s say I get involved with a family where the daughter says, “I just can’t do this anymore”. I’m not going to be the physician who is going to say, “well, you have to”. There’s a lot of nuance to that. And getting to understand the relationship among the people involved and also to find out who they are, they’re not ‘good people’ because they can manage a situation or ‘bad people’ because they can’t. I’ve know people over the years who are just gifted as caregivers and others who I feel, very clearly, I would Not want them to be a caregiver, they’re just not meant to be a caregiver, and would just make matters worse.
Q: What’s next?
I’m starting work in my encore career, digital platforms have a lot to offer seniors, but right now, for the most part, the platforms are too complicated to offer value to that audience. That’s the arena that I’m moving in to; making digital platforms more empowering for seniors to help manage very common issues that people have. One thing I’d like to develop is a community listening and participation post. For instance: “my mom has Alzheimers disease, what is the probability that I’ll get it?” “what’s the difference between dementia and Alzheimers?” simple questions like that that I used to be asked multiple times a day when I was practicing full time. “’How do people die from dementia?”: that’s a very common question. I have a lot of answers to those kinds of questions that I can share and I’d like to share them in ways that can be broadly useful. I’m in the early phase of that kind of work; that’s where I’m heading.
I’m also starting an app for people with mild Alzheimers disease. It’s personalized, and a way to reinforce memories. We’ll be beta testing soon..
I’m fascinated to see what it means as baby boomers become seniors. , The concept of older people being put out to pasture…there’s still a lot of truth to that reality right now, but as baby boomers age, they’re going to stand for that less and less. . There’s actually a lot of good data showing that not only are people living longer, they’re also more able. The average 70 year old today has a higher degree of physical abilities than the average 70 year old did 30 or 40 years ago. So, it’s actually true that 70 really is the new 60.
The world is changing in that regard. A lot of older people have a lot to contribute. The revolution in terms of that is still coming. What it looks like, I don’t know, but I’d like to see older people become much more empowered in society. With age comes wisdom. Older people all realize that there’s only so much they’re in control of, that things happen and everybody goes through struggles and things happen to everybody unless you’re extremely lucky. That’s part of the wisdom that older people have experientially. The best older people have learned from their experiences, learned how to be wiser.
It’s a good question to ask…are older people wiser? The flip side of that is that older people are more set in their ways. There’s some truth to that as well. It’s a bit about how you respond to life experiences. Some people respond to life experiences by becoming more and more rigid and more frightened. Other people respond to life experiences by being a bit more holistic about things. Maybe it’s because I’m in Hawaii, but I see a lot of older people who are just very kind and open minded, holistic and forgiving and realize that life is tough, a lot of mistakes are made. Are we wiser?
Older people also have more disposable income than any other age group. There’s obviously a lot of variation in that. There’s a lot of emphasis on saving enough for retirement. That’s important of course, but there’s also a little bit of a scare tactic involved in that it gets people scared to be generous. And I think that’s problematic. One thing I’ve thought of. There’s a worldwide effort to collect funds locally for worldwide efforts. What if we did that for local efforts? When you personalize your giving, it makes it easier to give. That’s one thing I think is an opportunity…for daily philanthropy in small amounts. In some ways, it’s like in church, making small contributions, it’s a way to create some family. It gets back to the anthropology of aging. How can older people play a valuable role in society?? I think it’s a very interesting time. Change is happening. The notion of ‘it’s time to be put out to pasture’ is just not going to work.
I think older people have it in them to be more generous of themselves. Cora’s work with the Amazing Care Network is a reflection of that…to share.