September 2013 by SMCMA

S a n M at e o C o u n t y

Physician

September 2013 | Volume 2, Issue 8

A publication of the San Mateo County Medical Association

Senior Health

Fall Prevention: An Ounce of Prevention for Your Older Adult Patients

The Benefits of Exercise in Alzheimer’s Disease and Dementia

Keeping Older Drivers Safe And Out of the News

POLST Answers to Providers’ Common Questions

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Editorial Committee Russ Granich, MD, Chair; Sharon Clark, MD; Edward Morhauser, MD; Gurpreet Padam, MD; Sue U. Malone, SMCMA Executive Director; Shannon Goecke, Managing Editor

SMCMA Leadership Amita Saxena,, MD .....................................................................President Vincent Mason, MD ........................................................ President-Elect Michael Norris, MD ............................................. Secretary- Treasurer Gregory C. Lukaszewicz, MD ........................... Immediate Past President Manjul Dixit, MD; Russ Granich, MD; Edward Koo, MD; C.J. Kunnappilly, MD; Susan Nguyen, MD; Michael O’Holleran, MD; Chris Threatt, MD; Kristen Willison, MD; David Goldschmid, MD, CMA Trustee; Scott A. Morrow, MD, Health Officer, County of San Mateo; Dirk Baumann, MD, AMA Alternate Delegate

Editorial and Advertising Inquiries San Mateo County Physician is published ten times per year by the San Mateo County Medical Association. Members are encouraged to submit articles, commentary and letters to the editor. Opinions expressed by authors are their own and not necessarily those of the SMCMA. San Mateo County Physician reserves the right to edit contributions for clarity and length, as well as to reject any material submitted. Advertising in San Mateo County Physician is a great way to reach out to the San Mateo County medical community. Classified ads begin at $40 (for up to five lines) for members. Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised. For more information, contact managing editor Shannon Goecke at (650) 312-1663 or sgoecke@smcma.org. Visit our website at smcma.org, like us atfacebook.com/smcma, and follow us at twitter.com/SMCMedAssoc. © 2013 San Mateo County Medical Association

S a n M at e o C o u n t y

Physician

September 2013

Introduction | Russ Granich, MD This issue of San Mateo County Physician is about senior health, and we’ve included several informative articles about keeping older patients safe and helping them thrive. Remember, if you are interested in writing for San Mateo County Physician and/or serving on the Editorial Committee, please contact the managing editor at (650) 312-1663 or sgoecke@smcma.org.

President’s Message | The Parallels Between Pediatrics and Geriatrics. . ................................................................ 5 Amita Saxena, MD Executive Report | Our Second Year of Walk with a Doc................ 7 Sue U. Malone Fall Prevention: An Ounce of Prevention for Your Older Adult Patients.. ......................................................... 8 Gregory Gilbert, MD, FACEP The Benefit of Exercise in Alzheimer’s Disease and Dementia.... 10 Ken Kovinsky, MD Keeping Older Drivers Safe...And Out of the News...................... 12 Linda L. Hill, MD, MPH POLST: Physician Order for Life-Sustaining Treatment Answers to Providers’ Common Questions................................... 14 Coaltion for Compassionate Care of California Upcoming Educational Programs. . ................................................ 16 Photos from the SMCMA 2013 Family Picnic................................ 17 Member Updates, Classified Ads, Index of Advertisers............... 18

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President’s Message | Amita Saxena, MD

The Parallels Between Pediatrics and Geriatrics “Life can only be understood looking backward. It must be lived forward.” From the 2008 film The Curious Case of Benjamin Button For those of you who did not get a chance to see The Curious Case of Benjamin Button when it first came out, I highly recommend renting it for your next movie night. It’s based on a 1922 short story by F. Scott Fitzgerald in which the main character, Benjamin Button, ages in reverse both physically and mentally. As a moviegoer, I could appreciate the nuanced emotions Brad Pitt and Cate Blanchett brought to their roles in the film. As a pediatrician, I couldn’t help but notice how many parallels there are between the seemingly unconnected worlds of geriatrics and pediatrics. Both fields represent the “bookends” of life: they each have their share of unique ailments, evolving physiology, and age-related health challenges. In 2011 the World Health Organization calculated the average life expectancy of men in the U.S. to be 76 years for men, 81 years for women. Those decades between pediatrics and geriatrics result in significant changes that require the distinct medical expertise of a specially trained clinician. At first glance, one might assume that pediatrics and geriatrics must be very different, with patients at opposite ends of the life span. The fact is, pediatrics is more related to geriatrics, and vice versa, than either is to adult medicine. Both specialties require a thorough understanding of their respective developmental physiology, attention to agespecific details, and the willingness to serve as an advocate for patients. Children are no more “little adults” than the elderly are “old adults,” and both age groups can have metabolic needs and organ physiology that differs significantly from the “adult” benchmark.For example, a six-year-old has double the minute ventilation of an adult. Seniors, on the other hand, experience a loss of lung elasticity and respiratory muscle strength, resulting in a decrease in vital capacity and slower expiratory flow rates. Additionally, children and seniors both have unique dietary needs. Kids are always moving and need to consume more calories and

water per unit of body weight than adults. Seniors, on the other hand, are often less active than adults due to a reduction in lean body mass and reduced energy levels. They need to cut calories and/or increase exercise in order to maintain a healthy weight, and need to do so without losing out on vital vitamins and minerals. A frail 95-year old is no more similar to an active 70-year old than a teenager is to a newborn. A specialist needs to understand the whole gamut of issues affecting their patients, from the first vaccinations through puberty, from reduced energy and endurance to hospice care. Both groups face health risks that are specific to their age. Congenital diseases such as hemophilia, cystic fibrosis, metabolic disorders or sickle cell disease can have a profound impact on both the quality and quantity of a child’s life. Toddlers love to put everything in their mouths, which increases their exposure to bacteria, parasites, environmental toxins, and so on. Senior adults can struggle with complications from diabetes, cardiovascular disease, cancer, dementia and Alzheimer’s. For some of these illnesses, the seeds may have been planted at a very early age, so prevention has become a buzzword in both pediatrics and geriatrics. Both age groups can spend significant time in group settings, which facilitates the transmission of infectious diseases: children in daycare, seniors in convalescent homes or hospitals. This can make them key players from a public health standpoint. Environmental factors such as second-smoke or exposure to toxins in utero may have a lifelong health impact on a child, whereas seniors can experience more complications with multiple compounded problems from a seemingly “simple” illness such as influenza. The flu can lead to a fever, the fever can aggravate confusion, and confusion leads to a fall which results in a broken hip. Another trait that children and seniors share, though for different reasons, is a limited understanding of danger. With children, they might be too young to read a warning label, or too cognitively immature to recognize dangerous behavior. In seniors, sensory changes, neurological disorders, or interactions from multiple medications can september 2013 | SAN MATEO COUNTY PHYSICIAN 5

President’s Message | Amita Saxena, MD cause them to miss the danger signs and take risks that can end up hurting them. Both age groups are vulnerable to abuse, neglect, and may have little control over the type of dangers they are exposed to. Both age groups also present unique legal and ethical challenges for a practitioner: who has the legal right to make medical decisions for an individual who may not be competent to make those decisions for him/herself? In closing, I’d like to touch one of the most important similarities, in my opinion, between pediatrics and geriatrics: the need for advocacy on behalf of patients. You need to be able to communicate clearly and compassionately with patients, as well as their parents, caregivers, adult children, and so on. There can be a lot of emotion surrounding both end-of-life and beginning-of-life issues, which makes it even more difficult to have those crucial conversations. There is no foolproof template for this kind of dialogue; for most of us it is a skill we have to work at over time. But this is important work: it establishes trust and can help ensure that our patients receive quality medical care that is both safe and ethical.

Please join us on: October 2, 2013 8:00 - 10:00 am The City Club 155 Sansome San Francisco

Keynote speaker Bernard J. Tyson Chief Executive Officer, Kaiser Permanente

honoree Dava Freed Legacy Award Recipient Generously underwritten by the McKesson Foundation To RSVP please e-mail OA20@operationaccess.org

6 San Mateo county physician | september 2013

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Last but not least, I hope I’ve convinced you to watch the movie. ■

Noridian Meet-and-Greet with Bernice Hecker, MD, MHA, FACC, Executive Medical Director, JE With the second change in Medicare Administrative Contractors (MAC) in five years, physicians are understandably anxious about how potential changes may affect their practice and even cause interruptions to their cash flow. To help you understand the changes ahead, the SMCMA is hosting a presentation with Bernice Hecker, MD, MHA, FACC, of Noridian Healthcare Solutions, the new MAC for California. Dr. Hecker is the Medicare Medical Director for Parts A and B in Jurisdiction JE (California, Hawaii, Nevada, and the Pacific Islands). Don’t miss your chance to hear from an expert and get answers to your specific questions.

Tuesday, October 15, 2013 6:00 p.m. San Mateo County Medical Association 777 Mariners Island Boulevard, Suite 100 San Mateo This program is free to SMCMA members, but space is limited and you must pre-register to guarantee your space. To register, please call (650) 312-1663 or email sgoecke@smcma.org.

Executive Report | Sue U. Malone

Our Second Year of Walk with a Doc Our SMCMA Community Service Foundation started its Walk with a Doc program in 2012 after hearing that the Ohio physician who had started the program was encouraging groups across the country to initiate local programs. Ironically, shortly after we started our program, we learned that the CMA Foundation had received a substantial grant from Anthem to commence these Walks throughout California. CMA utilized a portion of these funds to provide funding for approximately five pilots in various areas of the state. Unfortunately, we were not the beneficiaries of any of that grant money and went forward on our own. We faced two challenges: recruiting physicians to lead the walks and attracting members of the public to participate in the walks. The latter turned out to be much harder than we’d expected. As attracting large turnouts was no easy task. In the first year we printed posters that were displayed at local businesses and distributed to local hospitals, civic organizations, schools, and so forth. We learned first-hand that communicating with the pubic is an uphill battle. We did get an article in the San Mateo Daily Journal, but it wasn’t enough. Enticing physicians to participate was also a challenge, but somewhat less so. Also, during the planning process we had envisioned the Sawyer Camp Trail as an ideal site for the walks, only to discover during that summer that the people who frequented the Trail are seasoned walkers, runners, and bikers—not the audience we were trying to attract. At the end of the summer of 201,2 we were pretty dejected. It was a learning experience, to say the least. When spring of 2013 rolled around, we could either face defeat or make a renewed effort to make the Walk with the Doc program successful. First, we took a lesson from past mistakes, we scheduled the walks at city and county parks located in urban areas throughout San Mateo County. The local parks enabled participants to walk over to the park to meet up with the group rather than driving.

We were fortunate to have the participation of several enthusiastic physicians this year, but we still had to put forth a significant effort into attracting members of the public. We turned to a non-profit advertising agency that secured billboards for us along Highway #101 from the San Francisco border south to Menlo Park. It was not inexpensive, and we have yet to determine whether it was an effective way to capture the attention of drivers. Also, even though billboards are huge, they don’t really lend themselves to including a lot of text about walk dates, locations, or where to get more information and register. Most of the physicians we asked said that they never even saw the billboards, so I am afraid that the cost may not have been all that effective. We did find, however, that the community centers in the parks were very helpful about posting our notices on their bulletin boards and in their newsletters. We continue to learn better approaches to targeting participants. Our outreach did not attract young people or those most in need of a physical activity. We did attract seniors who were most pleased to participate. They loved the doctors and came ready with their questions. We ended the summer with an outstanding group of physicians who volunteered their time, talking to walkers aboutthe benefits of physical activity, leading them in stretching exerices, and, of course, answering their health questions. I need to give special note to Venkateshwar “Eshwar” Kapur, MD, and Mike Norris, MD, both of whom made it to almost all eight walks. Other physicians I wish to thank are Lynne Bartels, DPM; John Carbone, DPM; David Goldschmid, MD; Eva Liu, MD; Sharon Ou, MD; Aileen Shieu, MD; Kristen Willison, MD; and Wendy Zeng, MD. We are also grateful for the sponsorship of NORCAL and the Magnolia of Millbrae. ■

september 2013 | SAN MATEO COUNTY PHYSICIAN 7

Fall Prevention An Ounce of Prevention for Your Older Adult Patients Gregory Gilbert, MD, FACEP

An ounce of prevention is worth a pound of cure. In the dollars-and cents-world of fall prevention, that means that for every $1 spent, $20 is saved. As San Mateo Countyâ&#x20AC;&#x2122;s population of 65 years and older steadily grows, so does the incidence of falls and subsequent injuries, and associated medical and social service costs. In 2011, falls accounted for 44 deaths, 1,481 hospitalizations and 4,114 emergency department visits of older county residents. During that time period, the Office of Statewide Health Planning and Development (OSHPD) reports that the average cost of a fall-related hospitalization was more than $90,000. In a community the size of San Mateo County, the cost benefit of providing fall prevention strategies quickly enters into millions of dollars. An estimated one in three of your older adult patients (65 years and older) will fall each year. A history of prior falls in this age group is the single greatest predictor of future falls. Other risk factors to look for are muscle weakness, poor gait or balance, visual impairments, arthritis, functional limitation, depression and use of psychotropic medications. The Centers for Disease Control and Injury Prevention (CDC) recommends a multi-faceted approach that includes: 1) medical management including medication adjustments and vision care, 2) home safety review and modifications as indicated, and 3) participation in a routine exercise program that includes strength and balance training. The best thing a physician can do is to assess their patientsâ&#x20AC;&#x2122; risk for falling, manage their medical conditions

and medications that may contribute to their fall risk, and refer them to appropriate resourcesâ&#x20AC;&#x201D;a local fall prevention program, physical or occupational therapy, or a community exercise program. Studies have shown that many people in this age category will not seek out this help on their own, and referral from a physician or advanced care practitioner is imperative. Locally, we are fortunate to have the San Mateo County Fall Prevention Task Force, a collaborative of healthcare providers and community advocates dedicated to reducing the incidence of falls among older community-dwelling adults living in San Mateo County. The Task Force, which has been in existence since 2003, annually provides educational outreach to more than 4,000 older adults,

Participating in a routine exercise program that includes strength and balance training is one way seniors can help avoid falls.

8 San Mateo county physician | september 2013

caregivers, and healthcare providers. They have developed resource materials (including referral checklists for physicians/advanced practitioners), provide speakers for professional or community presentations and have an excellent website with links to additional resources for older adults, caregivers and healthcare providers. While preventing falls may not have an easy treatment course, and might not seem to be as rewarding as treating strokes, heart attacks and cancer, it is certainly a disease process that is too often overlooked in our daily practice. Fall prevention is our responsibility as physicians to address with our patients. Taking a proactive role of assessing our patients’ fall risks and making appropriate referrals could mean the difference between life and death, or a life of independence versus dependency.

About the Author Gregory Gilbert, MD, FACEP, is Assistant Clinical Professor, Emergency Medicine, Stanford Hospital and Clinics; EMS Medical Director, San Mateo County Health System; and President, California Emergency Medical Directors Association. The San Mateo County Fall Prevention Task Force, developed in 2003, brings together a coalition of more than 25 different community provider agencies, hospitals, nonprofit organizations, senior centers and private service providers with the mission of decreasing falls amongst older adults through advocacy, resource development and community education. To learn more, call (650) 573-3039 or visit www.smcfallprevention.org.

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september 2013 | SAN MATEO COUNTY PHYSICIAN 9

The Benefit of Exercise in Alzheimer’s Disease and Dementia by Ken Kovinsky, MD

Alzheimer’s Disease and other dementias have impacts far beyond cognitive function. Alzheimer’s patients also experience steady declines in physical function. Over time, these patients lose the ability to do basic activities of daily living such as getting dressed or bathing, becoming dependent on family caregivers. Walking ability also steadily declines. For this reason, patients with Alzheimer’s disease fall frequently. A landmark study published in April 2013 in JAMA Internal Medicine demonstrates that a patient-centered exercise intervention administered by trained physical therapists can slow the physical deterioration of Alzheimer’s Disease. The investigators randomized 210 patients (average age= 78) with moderate to severe Alzheimer’s Disease to either usual care or one of two exercise intervention groups as follows: •

•

Home Exercise: A physical therapist visited the patient’s home for one hour twice a week for one year. The treatments were goal oriented and tailored to the patients problems in physical functioning and mobility Group Exercise: Patients attended a day health center for 4 hours twice a week for one year. Exercise sessions, which lasted for about 1 hour, were administered by two physical therapists to groups of 10 patients. Exercise focused on endurance, balance, strength training, as well as cognitive exercises

It is important to note that this type of exercise program is far different from what a patient in the United States would receive with a physical therapy referral. The intensity and duration far exceeds what is generally

10 San Mateo county physician | september 2013

available under the Medicare benefit. In addition, the Finalex study used therapists with particular expertise in dementia. Was this intensive exercise intervention worthwhile? The answer is a resounding yes! The key results are as follows: •

The exercise program slowed declines in physical function. Patients getting usual care declined an average of 14 points over 1 year on the functional independence measure. Patients getting home exercise declined 7 points and patients in the group exercise declined 10 points. (The difference between both exercise groups and usual care was statistically significant. The difference between the exercise groups was not significant)

•

The exercise groups had far fewer falls. The group exercise subjects had 40% fewer falls, and the home exercise subjects fall rate was more than cut in half. This impact makes this study one of the most effective fall intervention programs ever devised

•

Even when accounting for the cost of the intervention, the health costs in the exercise groups were not more expensive than the costs of usual care. The cost of this intensive intervention was compensated by lower rates of health service use in the exercise groups. This goes to show that the best things in life sometimes really are free.

Based on this study, it would be reasonable to offer a similar exercise intervention to most patients with moderate to severe Alzheimer’s disease. Since the group and home exercise interventions both worked, the choice between the two approaches can be guided by the needs of individual patients. Unfortunately, it will be nearly impossible to make these types of intervention available to patients with dementia in the United States. Structurally, our health system seems incapable of providing such intensive patient-centered services on a long-term basis. Also, the intensity of physical therapy considerably exceeds that which is typically approved by Medicare. Its not that the US health system does not spend a lot of money on Alzheimer’s Disease. We pretty much can get as many MRIs as we want. We can also spend as much as we wish on the repeated hospitalizations that are often related to the physical deterioration that exercise interventions may prevent. It is the nature of the US health system that we are often able to spend vast sums of money on stuff that does little to help our patients, but are unable to spend much less on the stuff our patients really need. If these exercise interventions were drugs, they would be on the fast track to approval. But they are not drugs and there will be no special interests with the resources needed to fight for their availability.

Can you imagine the uproar that would occur if CMS announced that it would it no longer pay for dementia drugs such as donepezil (Aricept) because their marginal benefits do not justify their costs? Surely, there would be screams of rationing. But the inability to

provide patients these types of exercise interventions, as well as other multidisciplinary caregiver focused interventions that have been proven to improve outcomes in Alzheimer’s disease, is rationing just the same. Why is there no uproar?

About the Author Ken Kovinsky, MD, is Professor in Residence at UCSF School of Medicine. He completed medical school at UCSF, residency in Internal Medicine at Johns Hopkins, and fellowship in General Internal Medicine and Health Outcomes Research at Beth Israel Hospital. His research interests focus on understanding the determinants of health outcomes in older persons. This essay was originally published in geripal.org, a geriatrics and palliative care blog. Reprinted with permission.

september 2013 | SAN MATEO COUNTY PHYSICIAN 11

keeping older drivers safe ...and out of the news

by Linda L. Hill, MD, MPH

Seventy-four-year-old driver with health problems plows into an El Cajon Carl’s, Jr., killing a man inside. ***** CHP Officers spend forty minutes pursuing elderly motorist from Encinitas to University City. Driver did not notice six squad cars and police helicopter following him the entire way. ***** Seventy-five-year-old driver with a bad hip mistook the gas for the brake and drove off a cliff at Cabrillo National Monument, resulting in his death. On average, men outlive their ability to drive safely by six years, and women by ten years. With individuals sixty-five years old and older the fastest-growing demographic in the United States today, the problem of elder driving safety is exploding. By 2020, there will be more than 40 million licensed drivers over the age of sixty-five in the United States. Our challenge is to identify—before tragedies occur—when alternative transportation options should be employed. The age at which driving becomes unsafe is variable, with many individuals continuing to drive safely into their ninth decade. Older adults have positive driving attributes such as experience, being more likely to follow the laws and less likely to take risks; however, as a group, they have rates of death per distance driven and per population as high as that for teenage boys, due mainly to declining vision, impaired cognitive function, general frailty, and chronic diseases with their associated medications. In addition, in crashes of the same intensity, older adults have three to four times the risk of death as twenty-year-olds due to decreased muscle mass and osteoporosis. AMA has recognized the role of physicians in identifying which older adults should no longer be driving and has developed guidelines that provide tools and practice management aids, including sample letters, screening tests, management guidelines, and charting aids. The screening tests suggested by AMA are blunt but identify three areas of concern: vision (acuity and fields), frailty (gait speed, range of motion, and strength), and cognition (Trail-Making B and Clock Drawing). The bluntness of these tools stems from the paucity of data 12 San Mateo county physician | september 2013

linking failure (as a group) on these tests directly to the outcomes of interest: citations, crashes, injuries, and deaths. There is, however, more than sufficient evidence on each of these tests with the relevant outcomes to support their inclusion. In addition to the seven tests, the screening process should also cover targeted history to include a history of loss of consciousness, seizures, dementia (all reportable to the California Department of Motor Vehicles), medication history to include drugs that interfere with cognition, and especially patient or family concerns about the ability to drive safely. Since driving involves rapid decision making, especially under stressful conditions that cannot be duplicated in the doctor’s office, family concerns remain the most effective screen. For patients who pass all seven screens, management should focus on restricting medications to their lowest necessary doses; on strict avoidance of alcohol while driving; and on counseling on safe driving. Seniors should be retested periodically or with health changes. These screening tests may identify problems associated with temporary or correctable changes in function. In those cases, referral and evaluation, with treatment, may result in enough improvement in function to resume driving. If the vision or frailty tests are failed, assess whether the diagnosis has been made and whether there is a reversible component. If the deficit is permanent and the patient wishes to continue driving, consultation with an occupational therapist with advanced training in driver assessment may help in deciding whether this is

a safe option. Known as certified driving rehabilitation specialists (CDRS), these health professionals can take drivers on the road and provide both safety assessments and rehabilitation of driving skills. Currently, CDRS programs exist at Sharp Memorial and Tri-City hospitals. The failure of the dementia testing requires further evaluation to confirm the diagnosis and determine the level of dementia. The DMV feels that some individuals with early dementia are able to continue driving safely; however, they want to be aware of these individuals and conduct testing and monitoring. As with patients exhibiting frailty and impaired vision, a CDRS can be helpful in providing guidance for patients with mild dementia. The DMV mandates reporting of drivers with dementia, a loss of consciousness, or seizures. Reporting can be done through the Confidentiality and Morbidity Report (CMR) form or through the DMV’s DS 699: Request for Driver Reexamination. Physicians can also report drivers with other health issues—such as substance abuse, vision deficits, frailty, and medication side-effects—that may potentially impair their driving. Physicians who report are protected from liability by Health and Safety Code 103900. Especially once families have expressed concern, physicians who choose not to report could face potential liability in the event of an accident. Lawsuits by third parties injured in an accident are often not covered by malpractice policies. Once the DMV has been notified, whether by an emergency department, the treating physician, or law enforcement, a detailed medical questionnaire (Driving Medical Evaluation, or DME) is sent to the patient. Physicians traditionally dread filling out these forms, but irrelevant sections may simply be lined out rather than completed in detail. The legal consensus is that no liability attaches to filling out the DME, unless deliberately and provably false statements are made. The most helpful questions for the DMV hearing officer are, “In your opinion, does your patient’s medical condition affect safe driving?” and, “Do you currently advise against driving?” Physicians may hesitate to answer these questions, but no liability attaches to answering them. Our medical opinion carries great weight, but the ultimate decision and liability rests with the DMV. Patients may be reluctant to bring driving concerns to their physician’s attention. Driving is a sensitive issue for many older adults who depend on driving for

independence. Driving cessation in this population has been associated with a threefold decrease in out-of-home activity and a two-and-a-half-fold increase in depressive symptoms. Thus, ARDDS (age-related driving disorders screening) should be conducted in a supportive environment where options for continued mobility can be given to patients who should no longer be driving. U.C. San Diego has been training professionals on ARDDS since 2004 through funding from the California Office of Traffic Safety. Our team is a unique partnership of preventive-medicine physicians in the Department of Family and Preventive Medicine, led by Dr. Linda Hill, and trauma surgeons in the Division of Trauma, led by Dr. Raul Coimbra. More than 1,000 patients have been screened for ARDDS in both in- and outpatient settings. We have found both settings to be valuable: Outpatient settings capture the majority of older adults, and primary care physicians are ideally suited to screen and counsel on this issue. Inpatient settings provide access to persons whose health may have suddenly changed and where driving is either temporarily or permanently unsafe. Screening is well accepted, and satisfaction levels are high in both settings. Addressing driving retirement requires effort on many levels. The availability of alternative transportation methods for older adults is a problem that must be addressed by society through increasing public transportation options. The government has a role through the DMV in helping to identify unsafe drivers during relicensing; however, the health care system must also play a crucial role as physicians screen and identify patients. Society, older adults, and their families depend on physicians to help them through this transition.

About the Author Linda L. Hill, MD, MPH, is a professor in the Department of Family and Preventive Medicine at UCSD, director of the UCSD/SDSU General Preventive Medicine Residency, and the director of TREDS (Training, Research, and Education for Driving Safety).

september 2013 | SAN MATEO COUNTY PHYSICIAN 13

POLST – Physician Orders for Life-Sustaining Treatment

Answers to Providers’ Common Questions POLST (Physician Orders for Life-Sustaining Treatment) is a form that states what kind of medical treatment patients want toward the end of their lives. Printed on bright pink paper, and signed by both a doctor and patient, POLST helps give seriously ill patients more control over their end-of-life care. One difference between a POLST form over an Advance Directive is that the POLST form is designed to be actionable throughout an entire community. It is immediately recognizable and can be used by doctors and first responders (including paramedics, fire departments, police, emergency rooms, hospitals and nursing homes). What is the POLST form? POLST is a physician order that helps give seriously ill patients more control over their end-of-life care. Produced on a distinctive bright pink form and signed by both the doctor and patient, POLST specifies the types of medical treatment that a patient wishes to receive towards the end of life. As a result, POLST can prevent unwanted or medically ineffective treatment, reduce patient and family suffering, and help ensure that patients’ wishes are honored. What information is included on the POLST form? The decisions documented on the POLST form include whether to: • • • •

Attempt cardiopulmonary resuscitation, Administer antibiotics and IV fluids, Use intubation and mechanical ventilation, and Provide artificial nutrition.

Why was POLST developed? POLST was developed in response to seriously ill patients receiving medical treatments that were not consistent with their wishes. The goal of POLST is to provide a framework for healthcare professionals so they can provide the treatments patients DO want, and avoid those treatments that they DO NOT want. Is POLST mandated by law? Filling out a POLST form is entirely voluntary. However, California law requires that the physician orders in a POLST be followed by health care professionals, and provides immunity from civil or criminal liability to those who comply in good faith with a patient’s POLST requests. Who should have a POLST form? POLST is designed for seriously ill patients, or those who are medically frail, regardless of their age.

14 San Mateo county physician | september 2013

Does the POLST form replace traditional Advance Directives? The POLST form complements an Advance Directive and is not intended to replace that document. An Advance Directive is still necessary to appoint a legal health care decisionmaker, and is recommended for all adults, regardless of their health status. If someone has a POLST form and an Advance Directive that conflict, which takes precedence? If there is a conflict between the documents, the more recent document would be followed. Who should discuss and complete the POLST form with patients? Having a conversation with a patient about end-oflife issues is an important and necessary part of good medical care. The law allows anyone who is a health care provider* to assist with the completion of a POLST form. In many cases, physicians will initiate conversations with their patients to understand their wishes and goals of care. Depending on the situation and setting, other trained staff members—such as nurses, social workers, or chaplains—may also play a role in starting the POLST conversation. However, physicians are responsible for signing the POLST form. *The term “health care provider” is defined by law as “an individual licensed, certified, or otherwise authorized or permitted by the law of this state to provide health care in the ordinary course of business or practice of a profession.” Can a POLST form be completed for patients who can no longer communicate their treatment wishes? Yes. A health care professional can complete the POLST form based on family members’ understanding of their loved one’s wishes. The appointed decisionmaker can then sign the POLST form on behalf of their loved one.

POLST – Physician Orders for Life-Sustaining Treatment

Answers to Providers’ Common Questions What should be done with the form after it is completed and signed? The original POLST form, on bright pink paper, stays with the patient at all times. If the patient is transferred to another setting, the POLST form goes with them. In the acute care or long-term care setting, the form should be kept in the patient’s medical record or file. At home, patients should be instructed to place the form in a visible location so it can be found easily by emergency medical personnel – usually on a table near the patient’s bed, or on the refrigerator. Can a patient’s POLST form be changed? Yes, the POLST can be modified or revoked by a patient, verbally or in writing, at any time. Changes may also be made by a physician, or requested by a patient’s decisionmaker, based on new information or changes in the patient’s condition. When should a patient’s POLST form be reviewed? It is good clinical practice to review a patient’s POLST form when any of the following occur: • The patient is transferred from one medical or residential setting to another; • There is a significant change in the person’s health status, or there is a new diagnosis; • The patient’s treatment preferences change. How can I obtain copies of the POLST form to use with patients/clients? Health care providers may download the California POLST form at www.caPOLST.org. In order to maintain continuity throughout California, the form should be copied or printed on 65# Ultra Pink card stock, available at most office supply stores. POLST forms may be purchased in bulk from MedPass at www.med-pass.com. Are faxed copies and/or photocopies valid? Must pink paper be used? Faxed copies and photocopies are valid. Ultra Pink paper is preferred and used to distinguish the form

from other forms in the patient’s medical record; however, the form will be honored on any color paper. Is the POLST form available in other languages? Chinese and Spanish translations of the form are available to assist healthcare providers in explaining the form. However, the English version of the POLST form must be completed and signed so that emergency medical personnel and healthcare providers can follow the orders. Where is POLST being used now? POLST was originally developed in Oregon. There are a number of states which have established POLST programs or are currently developing programs. For more information on the national POLST effort, including published research and a complete listing of states using POLST, visit www.POLST.org. When was POLST authorized in California? California State POLST Legislation (AB 3000 (Statutes 2008, Chapter 266)) went into effect on January 1, 2009. Will a patient’s POLST form be valid when traveling to another state? The California POLST form is valid in California. If patients are traveling outside California, it is a good idea for them to take both their Advance Directive and POLST form with them. Both documents, even if not legally binding, will help health care providers know and honor their wishes. Who is leading the POLST initiative in California? The Coalition for Compassionate Care of California (CCCC) provides leadership and oversight for POLST outreach activities in California, with support from the California HealthCare Foundation. How can I find out more about POLST? Visit the California POLST website at www.caPOLST.org for additional information and resources.

This information was provided by the Coalition for Compassionate Care of California, a statewide partnership of regional and statewide organizations and individuals dedicated to the advancement of palliative medicine and end-of-life care in California. For more information, please visit www.coalitionccc.org.

september 2013 | SAN MATEO COUNTY PHYSICIAN 15

Meaningful Use Workshop Series This three-part series will take you through all steps of EHR adoption, including the basics of Meaningful Use, how to attest for the incentives, what is needed for a security risk analysis, and how to avoid or prepare for an audit. Our goal is to enable providers to receive the federal incentive payments outlined in the HITECH Act. Presenters include Lori Hack, the principal and CEO of Object Health LLC, a management consulting group that helps health care organizations and communities improve operational efficiencies and clinical health outcomes. Learn more at www.objecthealth.com. MEANINGFUL USE BASICS AND ATTESTATION REQUIREMENTS Tuesday, October 1, 2013 Check-in/buffet: 6:15 p.m.; Program: 6:30 - 7:45 p .m. 365 DAYS OF MEANINGFUL USE AND AUDIT PRECAUTIONS Tuesday, November 5, 2013 Check-in/buffet: 6:15 p.m.; Program: 6:30 - 7:45 p .m. STAGE 2 MEANINGFUL USE, PREPARATIONS, AND NEW CRITERIA Tuesday, December 3, 2013 Check-in/buffet: 6:15 p.m.; Program: 6:30 - 7:45 p .m. LOCATION All programs will be held live at the SMCMA at 777 Mariners Island Boulevard, Suite 100, in San Mateo. COST SMCMA Members & Staff: 1 Course: $99 / 2 Courses $190* / 3 Courses: $275* Non-Members: 1 Course: $199 /2 Courses: $380*/3 Courses: $550 * *Please note: Advance payment in full is required to receive discounts. Prices include dinner and course materials. REGISTRATION Please return your completed registration form (available at smcma.org) and payment to fax (650) 312-1664, email sgoecke@smcma.org, or mail to SMCMA, 777 Mariners Island Boulevard, Suite 100, San Mateo, CA 94404.

16 San Mateo county physician | september 2013

Charting a Path to ICD-10 Implementation Orientation Session for Your ICD-10 Champion ICD-10 is one of the most daunting regulatory requirements imposed on physicians. Understanding the changes required throughout your practice and the impact those changes will have on your practice and staff will prepare you for a smoother transition. It is essential that every practice, no matter the size, select an ICD-10 “champion” to drive this process. This program consist of three essential components: 1. Three-hour in-person ORIENTATION session in October 2014 2. Five PLANNING WEBINARS that walk you through creating an ICD-10 implementation plan (commencing in late 2013) 3. Access to CODING WEBINARS on the ICD-10 codes and documentation requirements for clinicians (commencing in 2014) The in-person orientation session will be an overview of the planning process for each medical practice’s ICD-10 Champion, including the internal tasks and the work with external entities that must be done. Completion of the orientation seminar is required to register for the follow-up planning webinars. Completion of the planning webinars is required to register for the coding webinars. Date and Time You must attend ONE of the two sessions: Thursday, October 24, 2013 - 5:00 - 8:00 p.m. OR “ Friday, October 25, 2013 - 9:00 a.m. - 12:00 p.m. Location San Mateo County Medical Association 777 Mariners Island Boulevard, Suite 100, San Mateo Cost SMCMA members and staff: $149/Non-members: $299 Cost includes refreshments and all materials. REGISTRATION Please return your completed registration form (available at smcma.org) and payment to fax (650) 312-1664, email sgoecke@smcma.org, or mail to SMCMA, 777 Mariners Island Boulevard, Suite 100, San Mateo, CA 94404.

smcma family picnic August 25, 2013 - Huddart County Park, Woodside

september 2013 | SAN MATEO COUNTY PHYSICIAN 17

Tracy Zweig Associates

NEW SMCMA MEMBERS

INC.

REGISTRY

PLACEMENT

FIRM

Physicians

Nurse Practitioners Physician Assistants Alexander Ding, MD R/Novato

Karin Molander, MD EM*/Burlingame

Hayes Gladstone, MD D*/Palo Alto

Thuy Nguyen, MD PTH*/Burlingame

Ami Kapadia, MD IM*/Daly City

Scott Selinger MD IM/Redwood City

Hemal Mehta, MD PD*Menlo Park

Karen Wetz, MD PD*/San Mateo

Locum Tenens Permanent Placement V oi c e : 8 0 0 -9 1 9 -9 1 4 1 or 8 0 5 -6 4 1 -9141 FAX : 8 0 5 -6 4 1 -9 1 4 3 t z w ei g@t r ac y z w ei g. c om w w w. t r ac y z w ei g. c om

Office Space for Rent in Burlingame Nice office available for rent, approximately 1,500 square feet, at 1828 El Camino Real, Suite 707, in Burlingame. Available November 2013. Direct inquiries to Carol Hiroshima at customercare@peninsulasleep.com or (650) 697-7079.

Index of Advertisers Dementia Therapeutics.......................................................Inside Back Cover The Magnolia of Millbrae.........................................................................................4 Marsh............................................................................................ Inside Front Cover Office Space for Rent: Burlingame..................................................................18 NORCAL.................................................................................... Outside Back Cover Sutter Care at Home................................................................................................15 San Associates..........................................................................................18 Mateo Co. Medical Association Tracy Zweig

06-18-09 correction In the July/August issue of San Mateo County Physician, the caption for the photo below from the SMCMA annual meeting was incorrect. The two gentlemen pictured are Michael Norris, MD, left, and Beatty Ramsey, MD.

in memoriam

Richard McLaughlin, MD August 10, 2013

18 San Mateo county physician | september 2013

Introducing Dementia Therapeutics:

The First In-Home, Non-Pharmacological Solution for Alzheimer’s and Dementia. • Dementia Therapeutics interventions are designed by experts. The program consists of over 300 research-based interventions targeting various cognitive as well as non-cognitive domains. Interventions were developed by a fully qualified research team led by Dr. Samuel T. Gontkovsky, Psy.D. • Dementia Therapeutics intervention is performed one-on-one at home. Each client works with an interventionist who tailors the intervention plan to accommodate their individual needs. Providing personalized, one-on-one care within the home facilitates a sense of familiarity with the environment, helping clients remain at higher levels of independence for longer periods of time. • Dementia Therapeutics focuses on more than just memory. The program targets the five primary cognitive domains: executive functioning, attention, language, visual-spacial perception in addition to memory. Interventionists also teach and promote lifestyle changes to positively influence the aging process and overall health. • Dementia Therapeutics provides consistent care. Consistent participation in the program over time is key. Since our program is designed and led by experts, we are able to provide consistent, continuous care that meets the evolving needs of the client.

Call now for a free brochure:

650-213-8585

www.DementiaTherapeutics.com

777 Mariners Island Boulevard, Suite 100 San Mateo, California 94404

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NORCAL Mutual is owned and directed by its physician-policyholders, therefore we promise to treat your individual needs as our own. You can expect caring and personal service, as you are our first priority. Contact your broker or call 877-453-4486 today. Visit norcalmutual.com/start for a premium estimate.

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