Our Geriatric Assessment Clinic
Dr. Ryan Chippendale shares information about the Geriatric Assessment Clinic, the services they offer and how the GAC is different from a regular Geriatric Clinic.
Ryan Z. Chippendale, MD
Ryan Chippendale, MD is the new director of the Geriatric Assessment Clinic (GAC) and an attending physician in the section of geriatrics at Boston Medical Center (BMC). She, along with the team at the GAC, provides care to vulnerable older adult patients in home, clinic and geriatrics inpatient service settings. She is also a core faculty member for the Primary Care Training Program and the geriatrics subspecialty education coordinator for the Internal Medicine Residency Program at BMC.
Melanie Cole (Host): Welcome. There are so many ailments and issues associated with aging and here to tell us today about the Geriatric Assessment Clinic at Boston Medical Center is Dr. Ryan Chippendale. She’s the new Director of the Geriatric Assessment Clinic and an Attending Physician in the Section of Geriatrics at Boston Medical Center. Dr. Chippendale, such a pleasure to have you with us. As I said in the intro, there are so many ailments and issues associated with aging. What are some of the most common that you see?
Ryan Z. Chippendale, MD (Guest): That is an excellent question. Thank you so much for having me as well. It is a great pleasure to speak with you this afternoon. We see a whole host of different issues with aging in our Geriatric Assessment Clinic. It is anywhere from issues with mobility, balance, gait disorders, to issues with memory that are either diagnosed in the past or a new issue that a family member or caregiver becomes concerned about or the patient themselves has noticed recently to issues with medication management and also sometimes with new diagnoses that they’ve received from their primary care doctor that just may benefit from a geriatrician’s touch.
Host: Well I couldn’t agree with you more. There are so many things. So, let’s raise awareness about this new Geriatric Assessment Clinic at Boston Medical Center. Tell us about your program and why did you see the need for this type of a program?
Dr. Chippendale: So, we have had the Geriatric Assessment Clinic running for quite a number of years now. I recently took it over in May and we’re trying to increase awareness so that really the docs and the family members and caregivers in the Boston Medical Center and surrounding Boston community have more of a sense of what we do and what services we can provide. So, the visit usually encompasses about a two to three hour comprehensive assessment. It’s usually one time so we try to fit a lot into that two to three hour period. And it entails working with both a geriatrician like myself as well as an interprofessional team. And the typical interprofessional team member that is with me in the clinic is a geriatric nurse specialist who is very well versed and an expert in community resources and trying to connect patients with the appropriate resources, whether it be skilled nursing care or any kind of resource from some of our aging agencies and partners in the community and Boston and elsewhere to make sure that our patients are getting the best care that is tailored to their particular needs.
Host: Well thank you for that explanation. How is this Geriatric Assessment Clinic different from a regular geriatric clinic that might be anywhere? What do you do differently? What makes it unique?
Dr. Chippendale: Yes. So, this is a consultative clinic meaning that as I said before, they just see us one time and what’s very unique about it is the time that I’m able to spend with patients. So, I am a primary care physician as well. I used to see patients within our geriatrics clinic as well as in our homecare program. And because of productivity requirements, with a lot of primary care physicians, especially those that are practicing in just adult medicine practices like general internal medicine or family practice; typically they get 15 to 20 minutes to spend with their patients. And that’s just not a lot of time to delve into the complex issues that we see in our older adults.
So, I have the luxury and this is one of the reasons that I was most excited about getting involved with this clinic; is that I can as I said before, spend hours with these patients and really try to unpack some of these really complex issues that even if their primary care doctors have been able to identify them, have not really had the time or resources or expertise in order to best diagnose, treat, educate patients and family members with these types of conditions.
Host: And as you’re discussing this with us today, Dr. Chippendale, what type of providers are involved. Tell us about your team and does this require management of several aspects of multidisciplinary care as you mentioned medication management, and then there might be memory issues and fall prevention and there’s so much to think about.
Dr. Chippendale: Yes. So, our interprofessional team within the clinic, we are so fortunate as I said before, have very expert nurse partners who have expertise in the area of geriatrics and community resources. We do have a social worker who is very skilled in behavioral counseling. She’s not necessarily part of every geriatric assessment that I do but it’s definitely a referral that I can make for patients that are in need of that resource. We also have a geriatric pharmacist who is able to help with any complex medication management and we also use our community partners quite frequently. So, those are skilled nursing type requirements for patients like visiting nurse, physical therapists, occupational therapists, social workers out in the field working with agencies such as Central Boston Elder Services, Adult Protective Services because we are so well versed in this area and we have a lot of connections out in the community; we are not shy to connect patients and are well supported in being able to do that because we partner with these programs so frequently and have contacts there.
Host: So, then let’s talk about the patient for a minute. What is the criteria to go to the Geriatric Assessment Clinic and when you are telling us that, talk a little bit about patient outcomes and why this continuum of care is so important for success and the family members involved and tell us a little bit about the patients.
Dr. Chippendale: I think that’s a great question. So, we do not have specific criteria for referral other than the patient has to be over the age of 65. This is not an opportunity for a primary care doctor to transfer over care although sometimes we do make a decision with the primary care doctor after the consultation that that might be appropriate for the patient, for the individual, if they are interested in transitioning over to geriatrics primary care but that is not the primary reason for referral.
Usually, the patients that are best suited for referral to this type of clinic are patients that have a myriad of geriatric syndromes and what I mean by that are things like dementia, mobility disorders, urinary incontinence, sleep disorders, mood disorders like depression are facing diagnoses that may be nearing the end of life so that we can talk about advanced care planning and we can talk about goals and preferences and really spend a lot of time on that to make sure that the care that’s being provided to the patient is in line with their goals.
So, the patients that are referred I will tell you the spectrum is so wide, and I always say that whether it’s a very defined question or whether it’s something much loser like help, the patient is just becoming too complex for me to manage and I would love a geriatrician’s perspective on this which I have gotten many consults like that before. That we are able to really make a difference in the lives of these patients and hopefully reduce some of the stress both for the primary care doctor that’s trying to manage all of this complexity in such a short period of time in clinic but also as you said, for the patients and specifically the caregivers.
So, we spend a lot of time at the end of the visit after we’ve done a very comprehensive assessment which I can talk more about and we spend a lot of time educating, providing resources and really able to move the needle in terms of connecting these patients with care that would be most appropriate to keep them functional in their homes for – because that’s most of their preferences is to stay home and to stay as functional as possible as well as to promote quality in their lives.
Host: What a wonderful program and so that leads me very well so once someone has come to you, what can the patient and family expect. Tell us a little bit about the assessment.
Dr. Chippendale: Absolutely. So, as I said, many times the referring provider, one of the primary care docs or a primary care nurse practitioners or even specialists, both at Boston Medical Center and many times through our community health centers or outside facilities also refer patients. Many of them do have a defined question which of course if that’s in the referral, I will start there to make sure that we tackle it appropriately. But I actually have adopted a 5-M approach which I will define for you, which was first described by a very well known famous geriatrician at Yale that is a framework for addressing all of the multiple complexities that many of our frail older adults present to us with.
So, I will try to hit at least a piece of each M and I’ll walk you through my M’s to ensure that we are not missing anything major that maybe the referring provider didn’t even have the time or scope to be able to address. So, those 5 M’s are mind and as I said before, many of the patients that are referred to us whether diagnosed or not do have some component of memory loss. Also under the mind category I will address things like mood and sleep and how that may be affecting patient’s quality of life or function.
The next M is mobility where I’ll ask about falls, I’ll ask about unsteady gait or balance issues, whether they are using assistive devices or whether I think that they could benefit from that. Barriers for getting out of the home or getting to appointments is that seems to be an issue with frequent no shows or if I notice caregiver stress around getting the patient out of the home. And then addressing overall function and reliance on caregivers and how I feel like that’s going thus far in their lives and whether we could tackle some resources to help support the caregivers especially in those situations.
The third M is medications. So, we talk about things like polypharmacy’s, so are they on so many medications that it’s becoming difficult for them to manage them or to adhere to those medications. Are they on any what we call “inappropriate” medications that could be contributing to issues with things like mood or sleep or memory and whether or not something that I can help advise the primary care clinician to maybe remove from their medication list if that’s appropriate. And then I’ll address things like systems for administering medications like prepackaged medications if that tends to be a big stress for caregivers. Again, adherence to medications. Affordability. I mean in the medications category I could probably spend three hours alone just doing a very thorough medication reconciliation and making recommendations on them.
Then I will move on to what we call multimorbidity which is the fourth M. And this is looking as I was talking about before about chronic medical issues that may be impacting their function. So I wont go through every single diagnosis because it’s just not possible in the time that we have. But if there’s active conditions like congestive heart failure or COPD, that’s affecting the patient’s function because they are having difficulty sleeping because of their breathing. Sometimes I will address or make recommendations based on how I think that we can enhance their quality by maybe making adjustments in medications or transitioning to a more palliative or symptom based approach. I talk about things like their bowels, their bladder, sensory deficits, appetite, weightloss and just overall frailty or decline that may be caregivers or the patients themselves have identified.
And finally, you can see how comprehensive this is. Just by talking about it for a few moments. We address what matters most to the patient. So, that’s the fifth M is matters most and I actually think this is the most important and oftentimes, I will lead with this even though I’m mentioning it last. And this is addressing things like patient’s goals and preferences. As I said before, advanced care planning so do they have a healthcare proxy? Have they discussed their goals with either their primary care doc or nurse practitioner or provider or have they discussed things like advanced directives or how they’d like to be treated if they were to become sicker in the future. And many times like I said before, this is to no fault of anyone on the care teams that are providing their primary care, it’s just very challenging to find the time to bring these issues up in a very condensed visit where there is a lot going on medically so I’ll have the time if this is something that’s important to the patient and that we prioritize in the visit to really again unpack some of that and at least lead the conversation so that the primary care provider can then finish it up later or continue on with the discussion.
Host: Wow, well that certainly is a comprehensive assessment and as you say, we definitely don’t have enough time to go over all of them but, that really is an amazing program. As we wrap up, and as the new Director of the Geriatric Assessment Clinic, what’s your vision for the program and what would you like listeners to know about it so that we can increase awareness because it’s such a wonderful program?
Dr. Chippendale: Yes. So, my vision moving forward is to be able to service our geriatric community as best as we can. So as we know, the population is aging and it’s aging at a very fast rate with our baby boomers now coming into the older adult category. And it’s just not possible for trained geriatricians to touch all of these patients. And many times just one visit with the lens of a geriatrician looking at a case that we can provide so much in terms of recognition of geriatric syndromes and issues to provider and make recommendations to them as well as to patients and families and caregivers.
And that I want folks in both in our Boston Medical Center community as well as our surrounding community to recognize that this resource is out there. These patients can be very overwhelming to care for even as a geriatrician, a trained geriatrician who has been doing this for many years, even I get overwhelmed sometimes when I’m trying to manage these patients. So, really, the message is that you’re not alone that we are here to help support. We’re here not necessarily to drive the ship but to help guide the ship in the right direction in order to make sure that we are helping older adults maintain their preferences, their goals and their function and independence as long as they possibly can in the community.
So, the more referrals, the better. We are always happy to see patients. There’s never a wrong referral. And like I said, even very open ended referrals, we can really take the time to make a difference in these patients lives and to help the providers and the families feel less overwhelmed taking care of these very complex wonderful patients that we have the privilege to see in the clinic.
Host: Wow, what a great segment. Thank you so much Dr. Chippendale. Really such a comprehensive program and if you’d like to find out more about the Geriatric Assessment Clinic at Boston Medical Center; please call 617-414-4639. And that concludes this episode of Boston MedTalks with Boston Medical Center. Please visit our website at www.bmc.org for more information and to get connected with one of our providers. Please also remember to subscribe, rate and review this podcast and all the other Boston Medical Center podcasts. For more health tips and updates follow us on your social channels. I’m Melanie Cole.