Purpose and Need

Vision: The Middle Tennessee GWEP addresses Tennessee’s poor health rankings and health profession shortfall by integrating geriatrics into primary care delivery systems while increasing the pool of quality geriatric providers. The program will enhance training for providers, healthcare professionals, patients, and caregivers in 6 CMS-MIPS measures:

  1. Dementia Caregiver Education and Support
  2. Evaluation for Risk of Opioid Misuse
  3. Advance Care Planning
  4. High Risk Medication Use
  5. All Cause 30-day Hospital Readmissions
  6. Falls Risk Assessment.

Demographics and Older Adult Health in Tennessee: The 2019 State of Aging in Tennessee report predicts the number of Tennesseans 65 years of age or older will grow by 33% to 1.7 million individuals, or 22% of the population, by 2030.  Currently Tennessee ranks 42nd in overall health, with over 280,000 uninsured individuals of whom 10% are between the ages of 55–64, and 10% are veterans. Tennessee also ranks in the bottom 10 states on most health and well-being measures.  Although family caregivers provide over 1 billion hours of care, they are frequently ill-prepared for their role.  The 2014 Tennessee Governor’s Task Force on Aging emphasizes the need to improve education and support for family caregivers.  With most caregivers working part or full-time, employers are concerned about the reduced productivity and health of employees who are family caregivers, but few currently offer eldercare information and support.  The 2017–2021 Tennessee State Plan on Aging indicates that low-income minority residents make up 20% of the state’s elders. In Middle TN there are 87,046 residents age 65 years and older, among which 60% are female and 40% male, 78% are white 19% African-American, 2% Asian, and 2% Hispanic or Latino. In 2013 the inflation-adjusted household income was $43,306 with 19% of the population at or below 149% federal poverty level. Approximately 20% have less than a high school education only 30% completed high school or GED.

Health Status Indicators: Tennessee ranks low in the 3 biggest health problems: including 42nd for smoking, 35th for obesity, and 49th for physical inactivity. Tennessee also ranks 47th for hip fractures among older adults, 45th for teeth extractions, 40th for preventable hospitalizations, 43rd for food insecurity, 42nd for nursing home quality, 36th in health status disparity, and 44th in number of geriatricians. In the Middle TN area among residents over age 65, there were 21% preventable hospitalizations, 7% visited the emergency room for fall related injuries, 31% live alone, 9% are at less than 100% of the federal poverty level, 20% are veterans, and 37% have 4 or more chronic illnesses. 

Caregiving and Healthcare: Approximately 85% of the long-term care to older adults and persons with disabilities nationally is provided by unpaid family caregivers and friends. The 2015 National Caregiver Survey conducted by the National Alliance for Caregiving in partnership with the American Association of Retired Persons estimated that 43.5 million unpaid caregivers provide assistance to at least one adult and the average caregiver spends over 24 hours per week in this role.  Almost 22% of caregivers report their health to be worse because of caregiving strain, 60% of caregivers are women, and 20% take care of two or more people, and only 53% report another unpaid caregiver assists them in their tasks. Tennessee ranks 48th in support for family caregivers.

Implementation Plan - Background:

The Middle Tennessee GWEP plans to improve health outcomes by engaging a broad coalition of stakeholders focusing on developing a health care workforce that utilizes patient and family engagement and improves health outcomes for older adults by integrating geriatrics and primary care. The aging of the population requires an increased amount of primary care physicians.  Nationally, primary care shortage areas defined as a population-to-physician ratio greater than 3000 to 1 has increased The American Association of Medical Colleges (AAMC) predicts that by 2030, demand for physicians will exceed supply by 42,600 to 121,300, including a 14,800 to 49,300 primary care physician shortage, with the greatest shortage in the Southern US.Addressing the shortage will require a multi-pronged approach, including innovation in care delivery, greater use of technology including telehealth, efficient use of all health professionals on the care team, and increased collaboration with advanced practice nurses and physician assistants.    

ADRD Caregiver Education and Support:  Alzheimer’s disease and related dementia (ADRD) affects 47 million individuals worldwide, including 5 million individuals in the US. In Tennessee, the number of persons with ADRD is estimated to increase to 140,000 by 2025. Patients with ADRD are increased utilizers of health services, with a 57% increase in healthcare costs in the last five years of life.Progressive disability and higher mortality associated with ADRDs require supportive and proactive healthcare models to address these issues. Proactive medical and psychosocial care management improves quality of life and other health outcomes and increases quality of care by adherence to guidelines and referrals to community long-term care services and supports (LTSS).  Distress is common among caregivers of patients with ADRD generating a great need to engage and support them.  New models of care delivery to enhance access and person-centered care for individuals with ADRD and their family caregivers are desperately needed. Direct care providers and family caregivers need to be trained to address care needs of family members with ADRD and provided optimal practical strategies and solutions.

Evaluation for Risk of Opioid Misuse: The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that from 1999-2010 there has been a 4-fold increase in narcotic overdose deaths in the US, and uninsured patients have twice the risk of prescription opioid misuse. Tennessee ranks 38th in overdose deaths with 6,900,000 pain medication prescriptions and 1776 overdose deaths in 2017, representing a 52%, 5-year increase. In 2014 the Tennessee Department of Mental Health and Substance Abuse Services launched Prescription for Success: Statewide Strategy to Prevent and Treat the Prescription Drug Abuse Epidemic in Tennessee.  This comprehensive multi-year program has been implemented by the Tennessee Department of Health and includes promotion of the Screening Brief Intervention and Referral to Treatment (SBIRT) a primary care tool to assess for substance use disorder. In 2018 the Governor and State Legislature with the support of the Tennessee Medical Association launched the Tennessee Together Program, which has declared Tennessee’s opioid epidemic as a number 1 public health priority. 

Advance Care Planning:  Advance care planning documents detail a patient’s wishes with respect to a choice of life-sustaining treatment and/or surrogate decision maker, when they are unable to communicate on their own behalf. However only 36.7% of US population have completed an advance directive. Historically, embracing hospice and palliative care has been slower in the Southeast than other US regions.Having an advance care plan alleviates anxiety among patients, and [surviving] family members report improved satisfaction with the quality of care received. Patients are also more likely to receive care according to their preferences, have fewer hospitalizations and less costly care. Surveys and focus groups of patients have demonstrated that there is an overwhelming preference for opportunities to plan for the end of life. Public education on advance care plan conducted at various settings, including the workplace, is important to promote intergenerational discussion and completion of advance directives.

High Risk Medication Use: Patients over age 65 comprise approximately 25% of the US population but are prescribed over 50% of all medications. Potentially inappropriate medications (PIMS) use is a serious problem particularly for older adults with poor health status, multiple chronic conditions, and dementia About 50% of elder patients experience iatrogenic complications during hospitalization often related to medications. With polypharmacy, the potential for drug-drug interactions, medication errors, and medication side effects rises. Medication reconciliation is a complex task which can consume a large portion of a geriatric primary care visit especially after recent discharge from a hospital or skilled nursing facility. Thus, there remains an enormous challenge to improve the overall quality of prescribing practices, medication use and reduction of PIMS, with many points of intervention including provider education and individualized feedback for practice changes in the ED and primary care.
All Cause 30-day Hospital Readmissions: The cost of unplanned re-hospitalizations to the Medicare program is estimated at over $12 billion yearly. Beyond economic implications, suboptimal care transitions increase the risk of adverse events resulting from poor care coordination among providers and health care facilities.  Repeat hospitalizations are tied to poor transitions of care and many existing barriers. Suggestions for improvement have been advanced by the National Transitions of Care Coalition which recommends shifting the discharge paradigm from discharge from the hospital to transfer with continuous management. Practice changes that could potentially impact readmission rates include emerging strategies to improve coordination, communication, and cooperation among healthcare professionals across healthcare settings.  There is a great need to improve transitions of care and a patient centered medical home is a promising model which enhances team based care, communication and coordination and thus may reduce hospital readmissions.

Falls Risk Assessment: Approximately one-third of community dwelling older adults experience a fall each year with10–20% of these falls resulting in serious injury. Complications from falls are the leading cause of death from injury in adults aged 65 years and older. Thus, screening for falls and fall risk is an important component of geriatric primary care. Based on the results of systematic reviews, most successful interventions for fall reduction have been multifactorial interventions which suggest a 30–50% reduction in subsequent fall risk.Thus, provider training in falls risk assessment and evidence-based management of patients identified as high fall risk is needed to reduce future falls.