EC: What is your role, and how are you involved in EHR?

PP: My current role is Principle Investigator, Mesa County Frailty Index Pilot. This pilot is funded by the Next 50 Foundation and administered by Colorado Mesa University where I serve as adjunct professor for studies on aging.

We are completing year 2 of the pilot, and, due to the COVID epidemic, and other factors, were granted a third year, to complete the narrative phase of our pilot. Our first two years were exempt under the CMU IRB, as our project was considered quality improvement.

My background in electronic health records is extensive, going back to 1993 when we were the first EHR in Western Colorado, and as the mentor for every Western Colorado counties’ primary care practice implementation.

Starting in 2002, our practice proposed that our community start the second Health Information Exchange in the US, Quality Health Network, serving western Colorado.

I served on the financing, goal setting, recruiting the major health providers, negotiating the diverse provider community, and selecting the platform and executive director of QHN, subsequently serving on
its board as founding provider and chair of the quality improvement committee.

EC: When and how did you first start tracking frailty?

PP: Asked by a family to attend a rehabilitation team and family care conference, I noticed that extensive involvement of a family physician added significantly to framing the care going forward for the vulnerable aging population.

I incorporated this practice for my primary care patients. I attended over 200 of these meetings in post-acute care settings, from 2000 to 2015.
I learned that family therapy technique assisted the inevitable conflicts within families when one member faces frailty. My innovation was to assert that care for the frail should be “Safe, Simple and Respectful” for patients, families and providers. This definition of roles and purpose diffuses conflict and highlights the deficits in care planning.

As the lexicon of frailty as a term directed me to frailty as a condition, a literature search led to a phone call with Ken Rockwood MD, in Canada, who allowed me to start using his scale in 2014. This contact led to bringing Stephen Evans MD to Grand Junction for CME and an introduction to Steven Buslovich and use of his software, Patient Pattern, starting about 2016.

I made three trips to the UK from 2012 to 2018 and had the opportunity to meet with Andrew Clegg, John Young, David Reeves, Steve Pye, Ruth McDonald and Harm van Marwijk and reviewed the UK frailty deployment, narrative assessment of its assimilation, and pearls toward idealized care of the frail. As project manager, I convened at least 50 meetings of the grant partners to enable the flow of frailty data from three data sources (MDS, OASIS, and point of care) as HLA7 messages, scrubbed to Patient Pattern software and back to the Health information exchange (QHN) and on to the primary care practice electronic health record.

EC: How widespread is what you’re describing? We’re aware of Patient Pattern, DGI, and other commercial players. HHS/RAND knows the academic players. In medium-to-small cities where you’re doing your own thing with off the shelf products, in peer organizations, do you see this happening?

PP: In my practice, Primary Care Partners, since 2018, our four family medicine practices (roughly 40 providers) have received a frailty index and geriatric interpretation, on over 1000 patients, derived from the OASIS from Summit West Home Care and the MDS from Larchwood Post- Acute and Long Term Care.

I have performed over 200 point of care health assessments using the Patient Pattern software. I have trained several of our case managers, performing the assessment at a Transitions in Care visit. I have given close to 10 medical education talks on the pilot, both locally and to national audience, covering the interpretation of the scoring, its impact on case management, population health and acute care I have trained the champions of St. Mary’s hospital “Enhanced Recovery After Surgery”, a quality improvement project to minimize post-operative falls, delirium, ICU transfers, death and prolonged stays awaiting complex disposition.

The orthopedic group has used this service to make pre-op decisions on geriatric patients contemplating orthopedic surgery. Gary Knaus MD, a 70 year old family physician in a part time geriatric practice has implemented a parallel workflow in his community. He and I participate in ART2 (Aspen Renaissance Transformation Team), a group of family physicians across the state of Colorado, identified as independent family physicians, who are early adopters and innovators who have agreed to collaborate on practice based research.

ART2 is planning to continue the frailty pilot. Licenses have been funded.
The remainder of the family physicians in Primary Care Partners (about 40 providers) intend to participate in the third year of the pilot. Licenses have been funded by the pilot.

EC: Has this changed outcomes? What are you seeing?

PP: The intent of the grant was to mirror the CPCi mission… to bend the cost curve for the region, but by using a quality improvement goal derived within the catchment area, rather than one directed from an external focus group.

I cannot state that we have met this goal yet. I cannot respond without bias. Our local care has already been described as ideal.

Grand Junction is the most cost effective community for Medicare expenses in the last two years of life. My practice has been in the bottom 5%tile for most of the reporting periods of CPCi. We were the best practice in Colorado for two quarters until the retirement of my senior partner in 2014.

Since 1983, my care has always been in the exemplary range for global cost of care as reported by Rocky Mountain Health plans.

So what can I say? Frailty is an ethical imperative. It leads to honest communication of risk, which leads to alignment of care plan to patient values, which leads to a patient and family narrative of realism, which leads to lower costs and improved perception of good care.

The process improves the completion of advanced care planning. We improved from 10% to over 65%. Care transitions lead to smooth and planned care, fewer ER visits for frailty diagnoses.

More home visits. More hospice referrals. More prompt evaluations of the severely frail when minor acute events arise. Honest discussions of risk prior to elective surgery. Marked improvement in the support of caregivers.
Marked improvement in the understanding of families regarding the true nature of aging and the capacity for harm when curative strategies lead to harm, and supportive strategies lead to patient congruent goals.
Standardization of medication optimization, de-prescribing and documentation on why a guideline is in conflict with a patient’s goals of care.

There is a growing use of the concept of the term frailty. There are still many providers and families who do not understand the paradox of how more care and less cure results in a longer and happier life for the frail, but this tide is turning.

For me, the use of the scale was not sufficient. I needed the score and the process of eliciting the comprehensive geriatric assessment questions in Patient Pattern to migrate my dialogue to a frailty based dialogue. The score alone was not enough for a generalist, hospitalist, rehab doctor.
Meanwhile, in my new position as medical director of New Century Hospice, the documentation of frailty adds information for the subset of hospice patients who benefit from hospice care but do not die, as predicted.
Their national medical director has authorized our use of the frailty score as we contemplate the impact of care on the hospice population who show benefit of care over cure.

EC: Where is the future of this? What you spelled out is, possibly for CMS, a quality metric or an innovation. It could be a fee for service model, too.

PP: I am honored that you asked me to respond.

I would like to complete my project. I intend to address this thoroughly in my final report to Next 50. What is missing is a narrative of these additional providers, so that any future step is not just based on my biased point of view. Without unbiased providers commenting on their experience with frailty workflow, my comments are premature.

But, since you asked, at this point in time, here are my random thoughts.
One of my objectives was to create a state wide care compact regarding frailty and using the ART2 group to give narrative assessment of that as a potential outcome.

Another outcome was to create a billing code as a marker for our intervention, so that outcomes could be measured across the country.
That code would be a procedure code for Advanced Care Planning that is risked advised, by a vetted measure of frailty based on the Comprehensive Geriatric Assessment (i.e. the Patient Pattern software or equivalent). If other products are doing this, but with another data set, then a different code should be used.

For instance, the UK approach is built on the equivalent of a selection of HCC scores. My view of those scores and after viewing the data from Reeves, Pye and van Wijck, is that the data provided is insufficient for care management, whereas the CGA approach is not only adequate but already validated.

How to incentivize good elder care? Who needs to change? ISNPs, DSNPs, and hospice, like FHQs, capture income streams that cover both care and data systems. But these systems don’t seem to pass the shared savings reliably to primary care providers and the array of providers who give essential care to the frail.

For profit health plans, don’t always pass the shared savings to those who must innovate/change to realize the improved outcome.

HHS has had difficulty in innovations outside of the silos. Frailty is the perfect example of a condition that highlights the obstacle of silo based care.

I would like to have an option like UCARE in Minnesota, a not for profit health plan which aligns with primary care providers.

As I collaborate with Julie Riesken, Executive director of the Cross Disabilities Coalition for Colorado (CCDC), I would like to see a pilot work within a community foundation, with board members from the
patient/ disability/ elder care community, and aligned incentives for what brings patients and primary care providers together, which is sustainable and ethically aligned.

For profit health plans and pharmaceutical companies seem to be able to monetize innovations at or above the full value gained by an innovation.
In primary care, we seem to be shackled to a mythology of expected martyrdom. Innovations become mandates that are the equivalent of a tax on the desired innovation. These take decades to be overturned (E&M coding systems, the three day qualifying stay, HCC scoring schemes).

I plan to address this in a planned book on the history of quality improvement in primary care in Mesa County, from WW2 to COVID.

Other areas for frailty:
Care giver support services.
Care navigation services.
Simplified DME and assistive devices pathways.

I recently helped CCDC complete a video continuing medical education video for the American Academy of Family Physicians on disability cultural competency and DME support for the frail). Medicare needs to allow immediate provision of DME for fall prevention of the frail.

A colleague is developing a home monitoring system that is using spy devices for detecting ambulatory sensitive diagnosis symptoms to avert ER visits. This may well be an innovation for a subset of the frail population who do not have caregivers, but should.

Claims data should never be used for this purpose. HCC scores and HEDIS scores do not enhance care management but the financial reward distracts needed attention away from the central focus of frailty. The Adult Wellness Visit data points, if captured, could contribute to create a frailty index.
Another colleague has developed a frailty index for CU Anschutz’ hospitals, but failed to realize how to utilize that opportunity to enhance care, giving up on the project. (Tyson Orbendorfer MD).

I think he gave up too soon. There is a large population of the primary care work force who have the capacity of team building and
systems transformation. I would hate to see another CPCi that was overly prescriptive. Margaret O’Kane, of NCQA, affirmed that quality improvement is a local phenomenon. Motivation, focus, teamwork, and outcome are improved when a community addresses their own perceived priorities voluntarily.

A significant amount of playing in the sandbox is needed before a national mandate.

HHS could assist by encouraging that frame toward innovation.