Interview with Kathleen Hall

Interviewer: So how did you get interested in geriatrics?

Kathleen Hall: I started out in exercise physiology, working in sports medicine for three years, and found that I did not really want to work with athletes. I felt like someone that was chronically ill with everything, and acutely dying of nothing, was far more interesting and rewarding than competitive athletes.

And I just didn’t feel like it was very rewarding. But every time someone came in with Parkinson’s disease, or lower back pain, or a limb amputation, I felt like I was making a bigger difference. I was making the difference between them being able to live in their own home, versus being institutionalized. I just decided that was a more meaningful role for me.

And then, so when I switched into nursing, I went into nursing with the intention of doing geriatrics. Because I knew that that’s what I wanted.

Interviewer: What are some of the biggest challenges that you’ve ran into in geriatrics?

Kathleen Hall: From within the field, or external to the field? Because we have internal barriers and external barriers.

Interviewer: Let’s talk about both.

Kathleen Hall: Okay. Internal barriers are the failure to recognize geriatrics as a sub-specialty. So that healthcare providers treat older adults as if they’re just older adults, and not as a sub-specialty population.

And that’s a mistake because older adults do have different responses to health and illness, than say, a 30 or a 40 year old. And so the drugs, the diagnoses, the presentation of symptoms, are different. And to not appreciate that, means that older adults oftentimes get really bad care.

Interviewer: Right.

Kathleen Hall: That, and I think that our health care system prefers the sexy subjects of trauma, and emergency room, and that sort of thing. I mean, we watch TV shows about that kind of stuff. Because it’s exciting to us as a culture. And we don’t seem to be as excited about needing to immunize an entire community full of older adults against pneumonia or the flu.

We wouldn’t watch a TV show on that because it’s not exciting. You know what I mean? There’s this ambulance chasing fascination that our culture has, that doesn’t value to the same extent, or isn’t fascinated by aging.

And yet, you have older adults that are the best storytellers alive, and they teach me way more than I teach them. And so, I feel lucky to be in their
presence. But I don’t think that that is shared within our culture.

Interviewer: Right. It’s the storytelling, and the things that they have to say can be incredible.

Kathleen Hall: And we find out how their perspective isn’t ours. And they’ve been around the block more than us, and yet we demean them with baby talk and ageism. And, when really, they know more than we do.

And they certainly know more about what it means to be old than we do. Because they are living it.

So, without getting too academic, there’s anthropological terms that I refer to a lot in my teaching. And that is the emic, and the etic perspectives. And the emic perspective is the lived experience. Whereas, the etic perspective is the outsider’s view of what’s going on.

And sometimes as outsiders, we look at a population and say, “Oh, I understand what their problem is and I know how to fix it.” And a lot of times, we miss what’s really important to them, because we fail to get their perspective.

And that’s the emic approach. We really need to be gleaning from them what their problems are, and include them in the solutions.

Interviewer: And what are some external challenges in geriatrics?

Kathleen Hall: Funding is a big one. And the main reason is, because if you think about our healthcare system, it really was designed, originally, as hospital-based care.

That’s what Medicare was. And as our systems became more complex, then we created other funding sources for the poor, or the imprisoned, or the vets, or the employed, or the unemployed. And across all of those systems, there is very little interest in doing what has been deemed a non-medical. And a lot of things that the aged need are deemed by insurance companies as being non-medical.

And the problem is, that when you don’t support the non-medical needs, they become medical needs. And the medical needs are far more expensive than if we had just helped them with grab bars in the shower, or an elevated toilet seat, or a ramp in the front porch. And we don’t cover any of those things.

Interviewer: Right. Those are some examples of the non-medical?

Kathleen Hall: Right. None of those are covered. And so when people say, “Oh, I have great insurance.” I have to say, “I hate to break it to you, but none of this is covered.” Because the insurance companies deem it non-medical. Whether it’s care-giving, or reminders to take your medicines, or assisting with home modifications so that you improve the lighting for example, or the grab bars or remove the trip hazards. None of that’s covered. But the hip fracture is.

I worked at University of Vermont before coming here, and I was working with a group of nursing students to do a community-wide fall prevention campaign. And it was for the whole county. And I told the students, I said, “So calculate the cost of what it would take to do this county-wide fall prevention campaign.”

So, you’re going to pay for the printing of the fliers, and you’re going to pay for the public health nurses’ time, and you’re going to buy all your props, and you’re going to feed the people that show up at your sessions, and all this kind of stuff. And they calculated out what they thought would be about $65,000, for the county-wide campaign.

And then I said, “Now look up the cost of one hip fracture.” And it was $65,000. So I said, “So all you’ve got to do is prevent one and you’ve broken even. You prevent two and you’ve doubled your investment.”

But our culture doesn’t think in that way, and certainly insurance companies don’t. They think, “these are the finite lists of things that I’m covering. And if it falls out of this finite list, it’s not our problem.”

And then we also underfund public health, so that if insurance companies aren’t going to fund it, we also underfund our public health systems. So, whether it’s transportation, or sidewalks, or streetlights, or all of those things contribute to healthful living in a community setting.

And those are usually the first things on the chopping block. And the cost of all of the community’s programs is not even the cost of one helicopter for the Department of Defense. And yet public health is the one that get cut.

We’re looking the other direction when it comes to prevention, and then spending a whole lot at the end of life, or once things really get bad enough to be called medical.

Interviewer: Okay and then explain the types of bias in research when research happens on things like this project. What bias is out there?

Kathleen Hall: Oh, that’s a long question. I mean, there’s internal sources of bias. Did you use it correctly? Did you go in with an open mind, or did you already have a decision about the product before you even started to use it?

Interviewer: Right.

Kathleen Hall: And that’s what I’m doing everything I can to resist. And then there’s also the external bias of the pressure to use or not use something. It could even be the cost of using something, or not using something. I mean there are free tools

This is not a free tool. So, the tool may be a perfectly good tool, but maybe it’s not worth the cost, depending on the health system that’s deciding whether or not to adopt it. Sometimes if something is more complex, then less people want to buy into it.

Interviewer: Understandable.

Kathleen Hall: So, usually simple tools have the easiest adoption, because they make sense to pretty much everybody who tries to use it. And so, just this being kind of a web-based tool might be a disincentive for some to use it, and others might say, this is what I’ve been looking for all my life.

Interviewer: Now, how is quality improvement different from research?

Kathleen Hall: The purpose of research is to produce generalizable knowledge. So I’m going to take a representative sample that has sufficient statistical power, and I’m going to test a new idea only under those circumstances, to see whether or not I produce generalizable knowledge for, or against, something.

Quality improvement means that I’m going to take an internal organization’s baseline, and see if I can move that baseline in an improved direction. I’m not going to try to draw inferences to any other system, or any other setting.

So, in research, I would be making a statement that “this should work in all similar settings.” Quality improvement means “I’m not saying anything about anything other than the setting that I used it in, and I’m not trying to produce statistically significant results as much as I’m seeing if I can move the benchmark from baseline to an improved direction.”

Interviewer: Describe your work at the TJ housing authority.

Kathleen Hall: I go to each of their four senior housing sites once a month and do health promotion screening, and also do a fair amount of triage with people that come in and say, “I have this rash.” Or “I have this mole.” Or “My knee hurts

And then, I try to plug them into where ever I think they need to go within the system. Sometimes it’s a 911 call. Sometimes it’s an urgent care visit with their primary care provider. Sometimes it’s setting people up with a primary care provider, because they don’t have one. Sometimes people prefer more of a complimentary, or alternative approach, and then I try to plug them in that direction.

A lot of times it is education on chronic disease management, medication management and what health promotion measures they might take. So whether it’s fall prevention, or dietary recommendations for the management of chronic disease like hypertension, that sort of thing.

Interviewer: Does this usually take all day? Is this once a month or do you go to a different housing site each week?

Kathleen Hall: Each Friday I go to one site. So there’s four Fridays in a month, so one Friday is at one site, the second Friday is at the next site. Third Friday is at the third site, and fourth Friday’s at the last site.

Interviewer: And explain the silos of care, versus collaboration of care.

Kathleen Hall: Okay. The silos of care, which falls under the same thing about what I do at the housing authority. A lot of the people that I see are low income. They are chronically ill, and they have multiple medical needs. And a lot of primary care providers won’t take them. Because they are the squeaky wheel.

And so, I end up trying to plug them in where I can get them in, because it’s the right thing to do and all human beings deserve it. And the siloed care is a little bit, and this is certainly not unique to Grand Junction, but it’s a little bit like a hot potato, where people spend as little time as possible before they can pass the potato to somebody else. Without really connecting the pieces, and doing what we call a warm hand-off.

Making the referral really quickly, rather than calling to whom you refer, to say, “This is what I’m wondering, this is how I need your help.” And there’s a hot potato syndrome, where I spend as little time as I can, and I only do that piece of the problem that I’m being asked to do, even though I might know more on more than I’m being asked.

And then so you get, basically, the people that say, “I’m a pulmonologist, what do you want me for to do?” Okay, I’ll look at the lung, but maybe the patient has asthma and maybe I should be talking to them also about allergic triggers. But they might think, “Well that’s for the allergist to do. I’m not doing their job.”

Maybe there’s a person who is falling a lot, and maybe the falls are a side effectof medicine. But does the pharmacist get involved to say they’re on 20
medicines and 15 of them have a side side effect of falls or dizziness? To what extent are we just trying to hurry up and do our piece, without considering the communication among all of the pieces.

And then how are those pieces connected. Often they’re not connected. And if they’re connected at all, they’re connected very loosely with a referral process, which is not necessarily communicated well. It’s a piece of paper that I send through an electronic system. It’s not a phone call where I say, “I’ve got a problem. Can you help me?” You know what I mean? And I get it, because that way takes more time. I get it.

Interviewer: Yeah.

Kathleen Hall: And it’s not reimbursed. But if we’re there to do the right thing, it is the right thing.

Interviewer: So how might this community, or the QHN Catchment area, overcome these obstacles?

Kathleen Hall: The easiest way is to create funding streams, to capture. Because people do what they get paid for.

Interviewer: Right.

Kathleen Hall: And when I worked in Vermont, they tried to implement something called the Vermont Blueprint for Health, which was basically a statewide system of primary care medical homes, and then supportive services delivered at a community level. And the project, which was a perfectly good idea, had problems because there were no funding streams.

And I remember at the time saying, “The problem is the safety net facilities, whether they’re the long-term care place that takes Medicaid, or they are the home health agency that does indigent care, or they’re the FQHC that bills people on a sliding scale, or the free clinic that doesn’t charge anybody at all.

They’re trying to catch all of these people that the rest of the system is letting fall through the cracks. And it’s falling through the cracks because there’s no funding stream to fill the crack. Because, I mean, they’re businesses, and they have to stay in business. And to do the work that takes a long time, and has no reimbursement, will put people out of business.

Interviewer: Absolutely.

Kathleen Hall: Everything’s got a price tag, and the complex patients can’t get a doctor because it takes a lot of time. And once they’re your patient, now you need to spend the time to address their problems. And these are patients that often have low reimbursement. Because they either are poorly insured, or uninsured, and they’re chronically ill with everything, and acutely dying of nothing. And there’s no funding stream for that.If you’re familiar with FQHCs. You’re familiar with FQHCs?

Interviewer: Go ahead and tell me.

Kathleen Hall: Okay. They’re federally qualified health centers. And they basically get a little bit of an extra stipend from the federal government to be this safety net place. And so for example, in Grand Junction it’s Marillac.

Where they take people on a sliding scale, based on their ability to pay, and it’s the last stop before you go to nowhere. And they are miracle workers, because they don’t have a choice not to be.

The truth is, if we could figure out a way to have stable funding streams that would cover basic primary care then, to me, a lot of this would get better.
Because then people wouldn’t be chasing the funding. Right now, everybody chases the funding.

Interviewer: Right. And people aren’t getting taken care of before major issues arise.

Kathleen Hall: Right. I don’t know how long you’ve been with your eye on healthcare, but in 1997 when the federal government balanced the budget, it balanced the budget on the back of Medicare. By creating what’s called the prospective payment system. And what that did was, it said that for diagnosis X, you’re going to get payment Y.

So it doesn’t matter what care you need for your diagnosis X, your payment’s the same. So unless you can give me a different diagnosis code, you’re going to have a standard payment for each diagnosis. But every body, every human being, isn’t a robot. And that same amount doesn’t cover the needs of everybody that has a single diagnosis. And yet that’s all that the payment is.

And so, one of the things that happened was a lot of people that went to the doctor’s office to get, for example, screenings, because it didn’t have a well
reimbursed diagnosis code, a lot of providers stopped offering those appointments. Because they couldn’t get reimbursed very well for their time.

Which is exactly the opposite of what we want people to do. We want you to come in and learn how to eat well. We want you to come in and learn safe exercise. We want you to learn how to get a good night’s sleep and manage your stress, and how to self-manage whatever chronic conditions you happen to have. But all of those stopped happening, because they weren’t billable.

Or if they had a reimbursement code, it was really awful. And it wouldn’t reimburse the provider for the amount of time they were spending. And it put a lot of people out of business. And particularly, a lot of home health agencies out of business. Because if I went into home health with congestive heart failure, it didn’t matter if I got discharged from home health on day two, or on day 10, the payment to the home health agency was the same.

But if you’ve got somebody that has no social support, and no ability to get their shopping done, or they have no caregiver, then it takes more time to get them on their feet.

Interviewer: Of  course.

Kathleen Hall: Than it does somebody that has family all over the place, and adequate income to hire a taxi to get to where they need to go. And It takes a system of care, and we don’t have that system of care. And if we do, it’s siloed and underfunded.

Interviewer: Or catering to different, specific populations and ignoring others.

Kathleen Hall: Exactly.