Navigating Complex Care for Older Adults

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett as she discusses the difficulties of working with older adults in practice including medical complexity, being unsure of where a plan of care is headed, and other interactions that patient may have had or is currently having inside of the healthcare system.

Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

CHRISTINA PREVETTHello, everybody, and welcome to the PT on ICE Daily Show. My name is Christina Prevett. I am one of our lead faculty within our Modern Management of the Older Adult Division, and we are riding on a high right now. If you've been following us on Instagram, we just had our MMOA Summit where 10 of our geriatric faculty descended on Littleton, Colorado, and we just had an incredible time connecting And when you have these cup-filling weekends where you are just eye-to-eye with other clinicians and you are connecting with your team, I always feel like there is a lot of reflection that happens in those weekends, and I was down to meet him. And I was really thinking about where we have gone in the last seven years since modern management of the older adult has been a thing and where the profession has gone. And I thought today we would talk a little bit about the good, the bad and the ugly that we see right now as truly just realities of being in geriatric practice. And I think about, you know, Christina of 2016 and Christina of 2024 and what Christina of 2024 would tell Christina of 2016 as, you know, you get more experience under your belt. You get more clients that you've dealt with. You get how you've worked through really complex scenarios and how you've dealt maybe with some of the heartbreak that can come with really sad stories in geriatric practice. And so I have four things that I wanted to speak to of realities of working in geriatric rehab as a clinician and kind of our thoughts and feelings on them. IT'S NEVER JUST ONE THING The first one is what I tell a lot of my students or individuals who are just getting into geriatric rehab or just counseling or mentoring on getting into the geriatric space is an acknowledgement that sometimes it can be really intimidating because it is never just one thing in geriatric rehab, right? I work in traditionally outpatient and if I am working with younger folks, it's usually that they're coming in for one specific injury, right? Like they have had something happen and their shoulder hurts or they sprain their ankle and you are working on the ankle. Of course, you're gonna zoom out and you're gonna work on the entire person and we're gonna look upstream and downstream if necessary, depending on what joint it is. But we're kind of working on that one orthopedic thing. That's never the case in geriatric practice. And as we get into higher levels of institutionalization, it becomes even less likely that there is only one thing going on. And that is where clinicians can get in the weeds, right? They can get into these interactions where, yes, they have knee pain or yes, they have hip pain, but they've had surgeries that have gone wrong, or they are a lower or a higher surgical risk, lower likelihood of getting surgery because they have unchecked diabetes, or they're having troubles with sensation now because of diabetes, or they've had heart attacks, or they're on 15 different medications, and they all pop up in the BEARS criteria, and they're all having interactions, and you're unsure if their pain is because of the drugs that they are on, or the things that they are experiencing, or mental health concerns, and there is just a lot. And that can almost give us analysis paralysis. And it can also tend to lead us to really conservative management because you're thinking, oh my gosh, there's so much medical complexity here. I don't know what to do. And my advice in those situations is twofold. Number one is the benefits of doing exercise, especially appropriately dosed exercise, far outweigh in almost all scenarios, outside of the absolute contraindications outlined by the American College of Sports Medicine, the negatives of sedentary behavior. I'm gonna repeat that, that benefits, even in medical complexity, of doing appropriately dosed exercise when possible far outweigh many of the harms or any of the harms, especially when monitored, of doing nothing. And that is always a helpful reframe. EMBRACE THE JOURNEY, NOT THE DESTINATION And the second thing is that you don't have to know everything or exactly where you're going you just need to know the next step. And, you know, a lot of times we beat ourselves up in rehab that we don't know the prognosis or the expected end game or what individuals are going to be able to do after our care. As you get to know individuals and as you see how they respond to rehab, as you see their willingness to do things at home and the support that they have, and you get to know a little bit more about them, that picture will become more clear. But when there is a lot going on, know that exercise trumps no exercise, and just know the next step. Because it can. It can be really intimidating when there's a lot of multi-morbidity going on, but that's why they're coming to you with doctoral level education, right? Like, they need that medical monitoring. If they didn't need that medical monitoring, or if they didn't have real barriers like pain, to being able to engage in a physical activity program, they would be going to a gym. And hopefully the goal is that we can transition them there to exercise program or group therapy or whatever it might be. But they need your help at this moment and they just need you to give them the next step. So that's number one. When it's intimidating, we want to think exercise over no exercise and let's go with the next step. BE AWARE OF THE PATIENT'S PAST INTERACTIONS WITH THE MEDICAL SYSTEM The third thing that is sometimes or oftentimes an unfortunate reality of working with older adults is that they've had a lot of time to interact with the medical system. And we know that when individuals start interacting with the medical system, they oftentimes become afraid, number one. And number two is that they've had lots of chances to have communication with providers and that communication can be the good, the bad, the ugly. You know, I had a client just the other day, she was in her mid-60s, and she had had history of compression fracture with osteoporosis, and she was told by her previous PT that, it's all right, just make sure you don't fall, because if you fall, you're gonna be a paraplegic. And that was just one conversation that probably was like, you know, 15 seconds of that PT's day, but she was talking to me five years later, so that had happened to her when she was in her early 60s. She was now in her late 60s. And she remembered that sentence and it stuck with her. And she was seeing me for hip, low back pain, secondary to a lot of deconditioning. And I freaking wonder why that deconditioning happened. And that was one interaction. And so she's had other interactions with other providers as well. that have been able to tip the scale in the I want to do more category or I'm afraid because of what I have or what is a condition that I am experiencing or that is in my body that is making me afraid to move my body. And When we have those types of thoughts or when they've had some of those negative interactions, we talk about it at MMOA as when helping hurts, as when I have to hope, I have a really hard time with the PT one, but I have to hope that people are trying to be helpful. But when we think about the way that our medical providers and our allied health providers are taught, ourselves included, in PT and OT, We are taught to look for dysfunction. We are taught to look for what is wrong and fix what is wrong. But what that means is that is the frame of reference that we go into our conversations. Here, let me outline all of the things that are wrong with you in our next action steps. And I'm not saying this is something that's bad. I'm just acknowledging that when you have a person in their eighties who have now had 30, 40 years, if not more of interactions where every time they see a medical provider, they're being told all the bad stuff. And it's, we're trying to be concise with our, our appointments. We're really trying to get into the weeds of what's wrong and we're trying to get enough time to, to fix it. And people are coming to see us because something is wrong. I'm not saying that these are, these aren't bad things, but Those can chip away at a person's sense of self, a person's independence, or their confidence in what they can do, and can leave individuals, especially when framed through a really ageist lens of now that you're X years old, I don't expect you to ever be able to do this again. It can make individuals either one, very weary, of your interactions. I'm sure many of you listening to this, and I know I've had it, where you have somebody who's very angsty about the medical profession, and you are that representation of the medical profession, and you sit down and you say, hey, tell me what's going on with your foot. I remember I had a client who was in his mid-70s. I was like, tell me what's going on with your foot. He was coming in for ankle pain, and it was like fire was breathing out of his mouth. He was like, rawr, about everything. it was because he had been tossed around from provider to provider because they weren't going to fix his ankle, but then he had too much arthritis to fix with the procedure they wanted before, and they waited too long, and now they couldn't do the first surgery. And so he had been really tossed around from colleague to colleague, and he was really upset, and I was at representation. And so when you have individuals who've had a lot of experiences with the medical field, the first thing is that we have to tread lightly sometimes because we may be going against or counter message to people that individuals are already seeing. This is probably my biggest issue right now or the hardest thing that I am navigating in my practice is when I'm working with an older adult who has other providers who are telling them different things about the same condition. I have a client right now who is working with an osteopath and a naturopath and her family doctor and me and they're all giving her messages about what's going on with her low back. Many that I personally do not agree with. I'm sure they may not agree with me. And I feel horrible because I feel like she's getting so much mixed signaling and many of it is fear-focused messaging. And then it's really difficult for her to navigate when nobody's on the same page. And so just an example of where, you know, things can go awry really quickly in these really complex situations because they are interacting with more than one person and we oftentimes work in silos. And that is just the reality of working with older adults. And so my next step and something that I don't always get this right is that I try to acknowledge where that provider is coming from and then give my two cents that hopefully is adding to or not in completely the opposite direction of the messaging of the other provider. And that is an art. And it can be very difficult when you get really frustrated. Like I've had situations with some of my clients where I'm very frustrated at the other providers because it's creating difficulties for me to be able to get individuals to load appropriately. And right now our medical system is set up in this hierarchy where my doctoral level education is not the same as the medical provider's doctoral level education, but trying to acknowledge those past experiences. leading with kindness, recognizing that maybe kindness has not been given or time has not been given in other interactions, and taking it one step at a time when we are working with individuals who have had the majority of their interactions with medicine being very negative. And that's just the reality of something that we are going to be dealing with more commonly in geriatric practice. So number one is we are working with complex patients. So it can be intimidating when you aren't working on just one thing. There's a lot going on. Number two is that they have had a lot of experiences with medicine and that can bias them or make them jaded or make them upset. And I don't mean that to cast blame on them. I'm pointing that finger at us around why that has happened. The number three, the reality of working with older adults, and this might be able to be extrapolated out to everybody kind of in rehab, is that we have a lot of burnt out people in our healthcare system. And this particularly impacts our older adults because they are the ones who tend to see more multidisciplinary teams, right? When they're in hospital, they're interacting with social work and nursing and medicine and then us, and then they're coming to home health and they have a caseworker and they have, you know, they have more chances to have individuals who are burnt out in care. And we are, in geriatric practice, most commonly working in multidisciplinary teams, especially when we're in higher levels of institutionalization. In outpatient, PTs and OTs, we tend to be in silos where we work with just each other. Maybe we're in a multidisciplinary team where you're sharing with a chiro, or you're sharing with a massage therapist, or whatever that might be, but it's less, and it's less direct interactions with those individuals. And when people are burnt out in care, especially if it's things outside of the patient care, like a lot of clinicians will say to me, well, Christina, it's not my patients that are burning me out. It's everything else around my patients. It's the percentage of productivity. It's the documentation standard. It's fighting with the insurance companies. It's fighting with other not fighting, but having discussions with other parts of our team who are trying to advocate for care for my person because they have so much going on and it would be so much easier if X profession would be able to help with this or, you know, like, and then they're talking with X professional and they're burnt out too. And this is one where this is probably the ugly where We are not in a position right now where we have too many people who are helping. We are in dire need of mental health providers. The demand on our, not mental health, our medical providers, the demand on those medical providers all across the system, like allied health, nursing, medicine, is becoming higher and higher. We have an aging demographic coming, which means that there is even more demand And it is also a business working in healthcare, whether you're in socialized medicine, like I am in Canada, or if you're in privatized medicine, like in the United States, there is a business model and it is a reimbursement game. And that means that we are unfortunately usually understaffed and the mental health of providers is leading to burnout. And so this means, right, when you have a burnt out clinician, it can be difficult to provide the appropriate dose of care because it requires more effort. It requires more effort in our communication with our providers. It requires more effort on our side. And I think my solution, there is no solution because this is a very complex topic, is more just acknowledging where you're at, right? And acknowledging where you're at is the first step of figuring out how that's reflecting in your caseload. And I do not mean this to have any shame and blame. I mean this as burnt out providers. It influences everything. It doesn't just influence their care. It influences their family life. It influences how they interact. It influences the joy and the pride that they experience in their job. And we are in a time, and I think, you know, it started in COVID. It's still experiencing this backlash of it. where we have individuals who are not happy in their setting because of being burnt out, because of the way that healthcare is set up right now. And the first step is the acknowledgement of that. And the second step is trying to figure out, is there a way for you to get yourself out of it? And that might be going to therapy, that might be having conversations about your workload, that might be talking around the culture in your workplace, if that is somewhere that you are staying. And taking that step to work on you as a provider, because when you do that, then you're more likely to dose your care appropriately. Because if you're exhausted, it is a lot easier for you to do C to Therax than it is to do higher level, more supervision required care. And it is okay to acknowledge that some of that under dosage has come from the fact that mentally you are not in the healthiest space right now. And unfortunately that is a reality right now of being in geriatric practice in a lot of settings. And I guess the last extension of that is that coming in to those interactions, acknowledging that that might be where your colleagues are may give us the opportunity to have really fruitful conversations and maybe come in to those interactions with a bit more patience and understanding and trying to come from a place of kindness to hopefully work to repair fences and amend cultures that just need a dose of patience and kindness in combination with all the logistical and administrative stuff. But some of those things are outside of our control. And so these are things in our interactions that are within our control. So I have talked about the good, the bad, the ugly. And I want to finish with the good. So we talked about how, number one, it can be intimidating being in geriatric practice. There's a lot of complexity there. I always say that my caseload is chronic, complicated, and cranky, like cranky joints, not cranky people. Though I guess sometimes I get cranky people. That two, we have had individuals, the older they are, the more likely they are to have interactions with healthcare or decades of interactions that may have not been the greatest. We have a culture right now that is burnt out. And we need to acknowledge where that burnout is and take the steps in our interactions with our people to try and understand that. And number four is I want to leave you with so much hope, so much hope because the tides are changing, right? We have a team at MMA that is in every setting, right? We have PTs, we got OTs, we got people in acute care, in long-term care, in home health, in mobile Part B, in outpatient that are doing the things that we teach in our course around appropriately dosed care. We have been able to show proof of concept across a variety of different settings. And when we first started MMA and it was just a little bitty idea that Dustin and I had, we had people tell us that we have no idea what we're talking about. that I'm wasting their time, their caseload could never do this. And that has changed. And we are seeing that you are not often the only provider who is putting a weight in somebody's hand and doing a deadlift. You are not the only person who is getting Laverne, like Trisha posted about, who is doing 157 pound sled push in long-term care while her tech or her aide is helping carry her oxygen tank beside her. We are seeing that the spread of the ripples in geriatric practice to give our older adults the best possible care is happening. Gosh, it is slow. We have been at this for eight years, eight years. I started my PhD in geriatric practice in 2016, where we were trying to change the dosing schema for working with our older adults. It is starting to change and it's going to take time. It's going to take a concerted effort. It is going to take all hands on deck. But gosh, I left this weekend with MMA Summit and thought it's changing and we are seeing that change. And I feel so blessed and thankful that we have a team now that is working on that change and that They are kind of going forth and talking to clinicians. And I'm so thankful to the clinicians who spent time listening to our messages. And I'm so thankful to the older adults who have been in my care, who have trusted me with their care and seen some of the changes in my practice over the last 10 years as a practicing clinician. I am just filled with so much hope and so much joy that we are going to leave this profession better than how we got it. And you all are such an integral parts of that experience. So if you want to see us on the road, that's all I got for us today. Alan's going to say that I'm just doing 20 minute episodes now. But if you are looking for our last minute content course this weekend, Julie is in Newark, California, and Dustin is in Salt Lake City, Utah. I'm. Then our next course is August 17th, 18th. Jeff is up in Anchorage, Alaska. If you are looking for the kids to be in school and then go to Con Ed, September 7th and 8th, I'm in Mobile, Alabama. That's the first time we're ever teaching in Alabama, which is kind of neat. So super excited to get out there. If you have any thoughts, questions, concerns about any of the stuff that we were talking about today, or if you want to kind of add your two cents, I would love to hear it. Post it in the comments below. I'm excited to continue this conversation, and I hope you all have a wonderful. week.

OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you’re there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.