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Long-Term Care

Geriatrics

constituting a small marginal component that each can uniquely call its own. Most importantly, they embrace a common central philosophy of patient-centered commitment to holistic and humane care of individuals who are at particularly vulnerable times of their lives.

Dementia Care

Common Ground

Care of Multiple Chronic Conditions

JAGS

Palliative Care

Home Care

ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by Dr. Pacala and has determined that there is no financial or any other kind of personal conflicts with this paper. Author Contributions: Dr. Pacala is the sole author of this paper Sponsor’s Role: No sponsor.

Figure 2. Building effective partnerships around common ground.

REFERENCES

more education and research directed at this population. We should also reach out to other disciplines and their organizations who share the core of what we do—in essence, extending the Venn diagram as shown in Figure 2. We should be broadening and strengthening coalitions rather than closing our borders. Palliative care is not the new geriatrics any more than geriatrics is the new long-term care or than comprehensive dementia care is the new chronic disease management or than care of multiple chronic conditions and multimorbidity is the new palliative care. All share a core set of principles and processes that constitute the bulk of their disciplines, with specialized knowledge and services

1. Goldstein NE, Morrison RS. The intersection between geriatrics and palliative care: A call for a new research agenda. J Am Geriatr Soc 2005;53:1593–1598. 2. Report of the Geriatrics-Hospice and Palliative Medicine Work Group: American Geriatrics Society and American Academy of Hospice and Palliative Medicine leadership collaboration. J Am Geriatr Soc 2012;60: 583–587. 3. Meier DE. Making the case: 2010. Center to Advance Palliative Care [online]. Available at http://www.capc.org/capc-resources/capc_presentations/ Accessed September 17, 2014. 4. Morrison RS, Meier DE. The National Palliative Care Research Center and the Center to Advance Palliative Care: A partnership to improve care for persons with serious illness and their families. J Pediatr Hematol Oncol 2011;33:S126–S131. 5. Morrison RS. Research priorities in geriatric palliative care: An introduction to a new series. J Palliat Med 2013;16:726–729.

Focusing Together on the Needs of the Sickest 5%, Who Drive Half of All Healthcare Spending Diane E. Meier, MD

WHAT IS PALLIATIVE CARE?

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alliative care focuses on improving the quality of life of individuals and their families through attention to the pain, symptoms, and practical and spiritual stresses of a serious illness. Appropriate at any age and any stage of illness, it is ideally delivered from the point of diagnosis of a serious or life-threatening illness and at the same time as curative, life-prolonging, and rehabilitative measures. Approved by the American Board of Medical Specialties as a medical subspecialty in 2000, it has more than 6,520 diplomats, inclusive of osteopaths, and 301 Accreditation Council for Graduate Medical Education–approved fellowship slots (unpublished data). The annual meeting of the From the Department of Geriatrics and Palliative Medicine, Department of Medicine, Center to Advance Palliative Care, Patty and Jay Baker Palliative Care National Center, Icahn School of Medicine at Mount Sinai, New York, New York. Address correspondence to Diane E. Meier, 55 W. 125th Street, Suite 1302, New York, NY 10027. E-mail: [email protected]

American Board of Hospice and Palliative Medicine, combined with the Hospice and Palliative Nurses Association, attracts more than 2,600 attendees, with growth in attendance every year. The number of hospital palliative care teams has more than tripled since 2000, exceeding 1,900 in 2012,1 and rapid growth in a range of palliative care delivery models in community settings—homes, nursing homes, cancer centers, and doctor’s offices—is occurring in response to the ascendancy of financial risk models. Palliative care specialists provide support to a range of hospital and outpatient colleagues who care for seriously ill people and need simultaneous support for improving or maintaining quality of life. In hospice settings, palliative care teams ideally serve in a primary care (as opposed to consulting) role. The forces driving the ascendancy of palliative care include (but are not limited to) a clear “business case” for palliative care in hospitals and community settings, growing disaffection with fragmented technical and subspecial-

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PALLIATIVE CARE AND GERIATRICS

ized medicine for care of seriously ill and debilitated persons of all ages, and recognition of the concentration of spending and poor quality of care of the sickest and mostvulnerable people in the context of the urgency of better quality and cost containment. Because the demand for palliative medicine specialists far outstrips their supply, salaries are competitive and higher than those commanded in geriatrics. Unlike geriatrics, which was built on support from the National Institute on Aging, the field of palliative medicine has no dedicated institute at the National Institutes of Health (NIH). Instead it focused intensively and early on leadership and model development, testing, and diffusion of innovation through dissemination and implementation strategies. Only recently it has invested in building a research community and research track record with support from private (see npcrc.org) and federal (Veterans Affairs, Agency for Healthcare Research and Quality, and NIH) sources.

WHAT IS GERIATRICS? Geriatrics seeks to improve health, independence, and quality of life in all older people. Recognized as a medical subspecialty by the American boards of internal and family medicine in 1997, practitioners in the field have expertise in a broad range of geriatric syndromes and conditions, providing effective care for previously intractable syndromes such as delirium, dementia, frailty, and delivery models better fit to the needs of multimorbid and functionally impaired older adults. Geriatricians provide consultation to hospital and outpatient colleagues on these syndromes and others such as reducing the hazards of hospitalization in older adults. Beyond teaching hospitals, geriatricians provide some office- and home-based primary care, as well as nursing home care. Ideally, geriatric specialists would provide the primary care of nursing home or otherwise institutionalized elderly adults, especially those with dementing illnesses.2 The number of geriatricians in the United States has not kept pace with the growth in numbers and proportion of older adults and has declined with the retirement of many of the field’s early pioneers. Fellowship slots in geriatrics have gone unfilled in recent years, and geriatricians earn less on average than general internists and hospitalists with less training. There were only 7,356 geriatricians in Morrison RS. JPM 2013

AIDS Gait Disorders Well Older Adults

Cancer Advanced Organ Failure

Stable Chronic Disease Stroke/Neuromuscular Disease Chronic Critical Illness Geriatric Syndromes Perioperative Care

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Focusing together on the needs of the sickest 5%, who drive half of all healthcare spending.

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