Delivery of Care

Change in demographics, a change in care

New outpatient primary care practice launched with older adults as the target population

Photo courtesy of Care New England

Dr. Ana Tuya Fulton, MD, FACP, AGSF, the executive chief of geriatrics and palliative care at Care New England.

By Richard Asinof
Posted 10/14/19
An in-depth interview with Dr. Ana Tuya Fulton, who is directing a new outpatient primary care practice focused on providing care to older adults in a patient-centered fashion.
What is the current census of patients in skilled nursing facilities and assisted living facilities, according to age and according to diagnosis? How many outpatient primary care practices dedicated to serving older adults are there in Rhode Island? What is the current waiting time for a new patient to be seen by a primary care provider? Do the metrics for tracking outcomes for older adults need to reflect differences for men and women? Is there a measurement related to “connectedness?”
One of the economic statistics that often seems to be lacking in looking at employment in Rhode Island and the nation are the number of older adults, many of whom are over 65, who are working but not as a full-time employee for a firm, but rather as a participant in what is known as the gig economy.
In a similar fashion, as a result of the current drug overdose epidemic, many grandparents find themselves serving as “parents” for their grandchildren, without the benefits or social supports needed to help them with their unanticipated role.
A third part of the equation where there seems to be a large data gap is the growing role that skilled nursing facilities play in rehab for patients following surgery, with hospitals seeking to free up inpatient beds and insurance paying for roughly three weeks of care. In turn, many of these facilities provide a ready-made employment opportunity for newly minted RNs and CNAs.
Up-to-date economic data on all three sectors might provide more insightful economic analysis of what is happening in the state’s economy.

WARWICK – In July, Care New England launched a new outpatient primary care practice focused on providing care to older adults, as part of a continuum of care that is patient centered, integrated with the health system’s accountable care organization, Integra, as well as coordinated with an inpatient hospital 10-bed unit for frail older adults at Kent Hospital.

The creation of such an outpatient primary care practice focused on older adults clearly reflects the demographic trends in Rhode Island, with a growing population of older adults, many with chronic disease management issues.

The new practice, still in its infancy, currently has about 35 patients, but expects to grow to serve several hundred patients in the near future. In turn, it has sought to create a primary care practice that caters to the needs of older adults, scheduling longer appointments and being focused on delivering care that matters most to the patients.

In a recent news release, the new practice was described as providing daily access to geriatrics clinicians; having a 24/7/365 nurse call system; same-day availability for appointments; and transportation services available through Uber Health.

The new outpatient primary care practice for older adults, which is located in a first floor suite at 215 Toll Gate Road in Warwick, will soon feature a community room with a full schedule of activities, in partnership with numerous community groups.

To learn more about the dimensions of the practice, the rationale behind its creation, and the ways that it fits into the “age-friendly” health system that Care New England is creating, ConvergenceRI recently spoke with Dr. Ana Tuya Fulton, MD, FACP, AGSF, the executive chief of geriatrics and palliative care at Care New England and medical director of Integra Community Care Network, and the principal clinicians directing the new outpatient primary care practice.

[The current clinical team includes: Drs. Michael Ross, DO, and Lidia Vognar, MD; Rachel Roach, APRN-CNP; Courtney Soares, office coordinator; Meibel Vivanco, medical assistant; and Linda Zabbo, RN, nurse care manager.]

ConvergenceRI: How many patients are currently part of the practice?
The last time I ran our list it was around 35, and that was a few weeks ago.

ConvergenceRI: What is your capacity in terms of being to expand the practice?
Right now, we are looking to continue to enroll new patients as they present. We have a part-time geriatric nurse practitioner and a part-time geriatrician. But we are also actively hiring for an additional physician to join the practice.

We’re probably talking about at least a few hundred patients for the providers we have now. And, then, once we have an additional provider, probably growing even further.

We are taking it carefully and thoughtfully, because one of those things that make this practice different, is that we allow for longer visits, because older adults often have more complex medical needs and complex social needs.

We are not a traditional primary care practice that has 15 or 20 minute visits. We give every patient at least 30 minutes for a follow-up visit and an hour for a new patient visit.

We are not going to grow [in a way that] overwhelms the providers; we want them to have lots of time [to sp;end] with the patients they have.

ConvergenceRI: Are there other examples of similar practices in Rhode Island, Or is your practice unique?
There are other geriatrics practices that exist in Rhode Island that may have similar staffing and a multidisciplinary team.

You try to pull in social work, you try to pull in nursing, you connect with pharmacy, so there are other geriatrics practices that I’m sure have that same multi-disciplinary focus.

We are working to add the community room to also provide opportunities for socialization, classes, care-giver support, things like that.

That is unique to our practice. From what I’ve heard, I’ve not physically been there or seen it, the new Oak Street vendor practices brought in by Blue Cross [and Blue Shield of Rhode Island] also have a similar sort of community room aspect to the primary care practice.

ConvergenceRI: The response by your program and others seems as if there is a recognition that there is a growing demographic – that there is a need to serve this growing demographic from a clinical point of view, trying to merge a lot of different aspects of care together
Yes, there is definitely an aging demographic. And there is an imperative to better serve their needs.

We are coming at it from a geriatrics perspective, which is a clinical perspective. This is a population that Care New England has really devoted a lot of resources to caring for in a more patient-focused, higher quality way.

We have an entire service line in geriatrics devoted to both the inpatient and outpatient needs of this population. So, this is something that was the right time for us. We had built out the inpatient services first. We’ve built out our programming at our ACO, Integra Community Care. We have some home-based primary care and some home resources for our frail older adults.

So, this is really just the next step for us to fill out the continuum of care with all the right services.

We are looking at Rhode Island and our aging population as a clinical need that exists, and we really want to show that we are devoted to this population and dedicating the resources to provide them the care that they need. So, the outpatient primary care practices are a natural next step.

ConvergenceRI: Have you developed your own unique list of questions to ask patients beyond the pain scale or whether or not you’ve fallen recently, and beyond asking about depression?
Yes. As geriatricians, we [follow] a standardized approach to older adults to get to know them better.

So, when they come in for their first visit, when they come to our inpatient unit at Kent Hospital, we use an age-friendly focus geriatric assessment model.

We ask about four big areas: we ask about what matters, what is important to them in terms of goals of care, what is important to them in terms of treatment decisions, and who are the people that they want involved in their care and in conversations around decision-making.

We also focus heavily on mobility. How are they getting around? Do they have any issues? What is their functional level? What is hard to do at home? What do they need help with? What do they no longer do, such as driving? Or meal prep, things like that?

We really try to get to know them from every perspective. So, it is not just about a list of medical problems or a list of medications. It’s also about who is involved in their life, what is their living situation like, what supports do they have, what supports to they need.

We really try to provide a more whole person-focused approach; we embed that into the primary care practice as well as into our inpatient unit at Kent.

We have a 10-bed unit there where we provide that same approach.

ConvergenceRI: As I understand the inpatient approach at Kent with the 10-bed unit, you are primarily dealing with a population of what was called “frail” older adults. Is that the same population with the outpatient primary care practice, or is there a broader definition for the people you see in your practice.
It is definitely broader in the practice. We have, by virtue of being geriatricians, people are often referred to use because they are frail, they are older, they have multiple issues that make it harder to manage them in traditional settings.

But we also have older adults whose families, or the older adult themselves, who self selected and said, “I’m 80, I really want this as my primary care. As I grow older, I [want to be] in the right place.”

[Some patients] are anticipating that things may get more complex.

They self-choose to join a practice like this, to have those supports in place, even before they necessarily need them. We do have some more independent, older adults who live on their own. They drive into the practice, they’re doing fairly well.

And, then we have our population of frail older adults who are coming in with family members, who are coming in from assisted living facilities, and who [represent] more of the traditional frail elder.

ConvergenceRI: In terms of insurance, is this a Medicare-population that you are serving? Do you take all forms of insurance?
We have not set any restrictions. I believe our providers are credentialed in all plans. We have commercial patients, we have Medicare, we have Medicare Advantage; we have a little bit of everything.

Anyone who refers in or who wants to come in is welcome to come in.

ConvergenceRI: There are some interesting new projects that you may have heard about. Healthcentric Advisors is piloting a program to facilitate blood pressure screening for adults in their home in real time, using mobile technology.

Which seems like an interesting effort to change the way that patients and clinicians deal with high blood pressure, and how long it may take to get seen by someone.

Does your practice have similar kinds of outreach and interactions with your clients to improve the time between when you call for an appointment and when you are seen?
We are integrating a lot of what we are doing in the practice with our Accountable Care Organization, Integra Community Care, which allows us to provide a more streamlined continuous coverage for 24/7 care.

So, if a patient is enrolled in our practice, if they were to call the practice, during business hours, they would reach our practice coordinator and our medical assistant and they are generally coming in for a same-day visit.

Our providers have flexibilities to do that. We also have coverage built in. Even though one of the geriatricians, or one of the geriatric nurse practitioners might not be in the practice today, we try to fill in and cover, so if something comes up, we can get a patient in to be seen.

We also utilize Integra’s access to community paramedicine partners, and our home-based nurse practitioners and physician assistants. We provide visits for a patient in the home who might need something and might not necessarily feel good enough to come in.

We send a PA or an NP out to the home to do a home visit, and then that person will discuss it with the geriatrician or the geriatric nurse practitioner that knows the patient.

We also cover “on call” ourselves. If it is a patient in our practice who is calling in at 10 p.m. with a question, or a concern, we have a nurse 24/7 call line and our nurse will triage, and if they need to have provider call, we call that patient back, and interact with them, and do what we need to do to screen for their issues.

We’re trying to be very available to patients of this practice, so that they always have one of us to reach out to when they have a question or acute medical concern.

We also have access to Integra’s hospital at home program, which we developed for some of our older adults who choose to get treatment in the home when they acute exacerbations of their chronic illnesses. That program has been really successful for some of our patients and families, who know that hospitalizations can be very stressful or often fraught with complications.

We try and manage some of their issues in the home. We’ve really integrated our practice into the ACO because we can provide more for our patient.

ConvergenceRI: I saw in the news release that you were using Uber Health for transportation for patients.
We are. That service is available to anyone who would like to use it.

We have a contract that Care New England has done, through Integra.

We typically have had patients come in either on their own, or with a family member. If they were to call us and say, “Hey, my daughter can’t bring me, or I need to come in for a sick visit, and I don’t have anyone,” we have that contract available, so that they can utilize that service to get in.

ConvergenceRI: In what ways do you see the practice growing?
I see it growing in size. We’re very new; we’re just beginning to enroll patients. I think we’re very focused on bringing in community partners.

For example, we’re in conversations with the Alzheimer’s Association. They were looking for a new site to provide some of their caregiver workshops. So, we want to see if we can integrate with them to have those services available to patients of our practice – or, just to the local community around our physical location that might benefit from some of those services.

We’re also looking to partner with other agencies such as the R.I. Geriatric Education Center to provide workshops to patients and family members within our practice. And, we are also looking to partner with Spaulding Rehab as part of our Care New England network to do things like fall prevention workshops.

We’re also looking into hiring and partnering to do things like Tai Chi in the community room.

We really want, in the next year, for that community room to be filled with a very robust schedule, to have something there every day of the week that is easily accessible to our patients as well as patients from other practices within our network that could benefit.

ConvergenceRI: Is there a waiting list for patients? One of the biggest complaints that I have heard consistently for people trying to get into see a new primary care provider is that it can take up two or three months to be seen.
We have pretty good access right now. We still have capacity. Someone could call today and get in very quickly. I would say definitely within a week or two weeks.

ConvergenceRI: How are you tracking datapoints, being that you are a new practice?
That’s a very good question. We are clearly part of an accountable care organization. We are tracking all of those quality metrics that we would otherwise track. Cancer screenings, blood pressure screenings, falls, depression scales, all those traditional things we track and make sure that we are doing.

For us, one of the big things that we focus on from the geriatrics perspective is the “what matters” question. Have we addressed what is important to that patient? What’s the most important goal for them? Is it maintaining function? Is it staying independent in their apartment? What’s important to them? Have we addressed that? Have we documented that, so that someone can find that information if they need it.

We are also very focused on making sure that all of our patients have their advanced care planning wishes documented.

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