Bridging the GAP

Everyone benefits from USC’s interdisciplinary Geriatric Assessment Program (GAP): older adult patients, students and care providers from Gerontology, Medicine, Pharmacy, Dentistry and Psychology
By Jonathan Riggs

(l to r, back row) Patricia Harris, MD; Anne Katz, Ph.D.; Piedad Suarez Durall, DDS; (l to r, seated) Bob Knight, Ph.D., Bradley Williams, PharmD Photo by Stephanie Yantz

It’s a common issue all married couples must face: how to stay in sync in the bedroom.

Although the couple knew their bond was strong, they were eager to ask advice when given the opportunity to meet with a unique USC clinic.

One sympathetic counseling session later, the couple was blissfully back on the same page: a romantically harmonious and subsequently very happy 90-year-old wife and 94-year-old husband.

The program this couple took advantage of—Geriatric Assessment Program, or GAP—represents the broad scope of USC’s professional powers. The idea is simple: streamline the often-complicated office visits aging patients may have to make into a single consultation with an interdisciplinary medical team.

Based out of the on-campus Tingstad Older Adult Counseling Center and convening on Tuesday afternoons, the Geriatric Assessment Program (GAP) unites the department of Psychology and the Schools of Gerontology, Medicine, Pharmacy and Dentistry to provide older adults with a convenient and rigorous evaluation performed by a geriatrician (Patricia Harris, M.D.), geropsychologist (Bob Knight, Ph.D.), geriatric social worker (Anne Katz, Ph.D.), geriatric pharmacist (Bradley Williams, PharmD) and geriatric dentist (Piedad Suarez Durall, DDS and Roseann Mulligan, DDS, MS).

“I’ve never had an opportunity like this before to meet so many health professionals who are willing to spend the time with me to talk, give me tips and discuss what’s on my mind,” said participant Barbara Merkel. “In this day and age, where else are you going to get a real live pharmacist or doctor to actually listen to you without checking their watch?”

Origins

That very question was at the heart of what inspired this program: oftentimes, older adults see multiple specialists who work independently of each other and may, at times, have difficulty seeing the forest for the trees in terms of the patient’s overall health.

“We take a bird’s eye view so we can give the client and family a more global picture of how the elder is doing,” said Patricia Harris, M.D., of the Keck School of Medicine. “The interdisciplinary approach we use is rare and worth taking advantage of.”

This approach can help pinpoint dangerous medication interactions as well as identifying underlying functional issues the patient may be experiencing—as well as giving caregivers a safe place to express their own concerns and needs. While GAP is not intended to replace their patients’ primary care physicians, it can offer vital health and diagnostic reinforcement through a specialized geriatric lens.

“Most providers are not experts in the care of older adults, and they can use [the information provided by GAP] as guidance to maximize the benefits received by their patients,” said Bradley Williams, PharmD, of the Schools of Pharmacy and Gerontology. “It is important for older adults who may feel overwhelmed by their health problems to consider the value of seeing multiple experts in one place at one time, working together, to offer them recommendations.”

Speaking with members of the GAP team reveals their shared commitment to offer strong and sympathetic medical support of every stripe to older adults. Just as their professional strengths fold into each other, so did the program’s origins.

When Dr. Harris was named Section Head of the Geriatrics Department, she began a series of conversations with members of fellow health-based Schools about the need for just such a program. She found a wellspring of enthusiasm and creativity in the USC Davis School of Gerontology’s Associate Dean Bob Knight, Ph.D., who had been discussing the importance of starting a similar program with his Gerontology colleague Anne Katz, Ph.D.

“We immediately wanted to add in dentistry and pharmacy,” said Knight, “since we wanted to emphasize the value of interdisciplinary training experiences for all types of health service professionals that work with older adults.”

How It Works

For older adults who choose to take advantage of this free program, the drill is simple. Accompanied by a family member (if they choose), the patient brings in the contact information for their primary care physician, their medical records and all of their medication in its original bottles. (If they are unable or unwilling to locate these items, they are still seen.)

Patients receive the undivided attention of the clinicians for an average of two and a half hours, and then make their follow-up visits with their primary doctor. Although GAP will provide follow-up to the initial assessment, if possible, the group stresses this point: the program is in no way meant to replace all of a patient’s primary care needs.

“I see us as consultants: someone who can lend fresh eyes to a person’s overall condition and offer advice,” Harris said. “It is only advice, not treatment, and as such can be ignored. But if they get just even one tidbit that can improve their daily life, then it’s worth it!”

The team wants people considering using the service to feel comfortable doing so while continuing with their own doctors. Not only can the entire visit be kept confidential, but if patients choose to share the results of the visit with their primary health care provider, the team emphasizes that it should be taken in the light of a supplementary second opinion given from geriatric-focused professionals. In many ways, the team acts as a conduit for patients by providing specialized information and access to potential solutions with a hands-on approach rarely seen these days.

“We get a lot of positive feedback from the patients and have been successful in connecting many of them with ongoing services at USC,” Knight said. “The program has been helpful in getting patients connected with oral health care in dentistry, in adjusting medication, in getting specialized geriatric care and in connecting people with psychological interventions who had not realized that depression or anxiety were part of the total health care picture.”

Along these lines, the team has been able to make a real difference in areas that many older adults may let fall by the wayside as they age, such as oral health. When Roseann Mulligan, DDS, MS, learned of the developing GAP team, she saw a fantastic opportunity.

“More older adults are seeking oral health care, but their overall oral treatment is often complicated by their medical conditions, medications and mental status,” Mulligan said. “Our goal is to have dental students and residents working with other health professional students and practitioners in an inter-professional setting so that they may learn effective teamwork and team-based care for this vulnerable population.”

In fact, GAP was able to help three patients who could not otherwise afford dental treatment receive a complete set of dentures via a grant through the LA CARES Special Patients’ Clinic at the Herman Ostrow School of Dentistry.

“What most of these patients had in common was the fact that due to their multiple medications, they presented a dry mouth, which makes them susceptible to developing caries and fungal infections,” said Piedad Suarez Durall, DDS, of the School of Dentistry. “So it was important to educate them on this topic, reinforce their oral hygiene technique and give them nutritional counseling.”

Social work is another aspect that is crucial to the wellbeing of older adults, who may overlook or fail to understand just how interconnected the field can be to their overall health. In fact, the social worker is the first contact the patient has, and in many ways becomes their virtual lifeline.

“We do a home assessment and complete a bio-psycho-social intake. We work within a systems model to connect the person to various resources in the community,” said Katz, “including in-home help, Meals on Wheels, daycares, legal referrals and individual, family and group counseling, to name a few.”

The Human Touch

Anyone attempting to navigate the health care delivery system can speak to how dehumanizing, impersonal and confusing the experience can be. By putting a friendly group of familiar faces at the center of GAP, the program has gone a long way towards fostering goodwill between patients and care providers, as well as helping participants feel more invested and empowered in their own health outcomes.

Andrus Volunteers John and Betty Sims speak with GAP student interns Photo by Stephanie Yantz

“I became good friends with Dr. Katz—I love her. Every time I come around, she asks for me,” said participant Phoebe Heywood. “I didn’t even feel embarrassed and I learned a lot.”

Positive word of mouth has helped the program grow in esteem not only among participants, but among students as well, and they regularly take part in the GAP examinations.

“The students we have had have been quite impressed with the service and benefit from seeing multiple professional interact directly to care for people,” Williams said. “I’m hoping that we can use GAP to encourage students to pursue geriatrics as a professional focus. There is a great need and too few providers to meet that need.”

The Real-World Effect

Students and patients aren’t the only ones benefiting from this brain trust, however.

“I just love the opportunity to belong to this group: every day that we meet I learn something not only from the patients but from my colleagues,” Durall said. “This interdisciplinary group reflects where health education is going: teamwork to provide more efficient and comprehensive treatment.”

This teamwork more than anything else represents the world-changing goals of GAP, and the success of this program’s clinicians shows just how harmonious the process can be. Ironically, although they are desperately needed, programs like this are rare because of limited funding opportunities—an unfortunate trend that the GAP team aims to buck.

“We’re hoping to find training grant money to expand the program and assure that future health care professionals learn how to work together in collaborative interdisciplinary teams to provide quality care for older adults,” Knight said. “Everyone in the field recognizes the value of interdisciplinary teams in principle, but the practice is lagging behind due to insufficient training experiences.”

With everyone from patient to health care provider benefiting from this sort of approach, many of the participants remain delighted to see traditional attitudes towards older adults’ medical treatment evolving.

Although going to the doctor, the psychologist or the dentist may never rate as one of life’s most fun events, the ability to streamline the process while maximizing its benefit is an admirable goal everyone can agree on.

“It was a fascinating experience with knowledgeable people,” said participant Betty Sims. “There were parts I liked and parts I didn’t like, but the people we spoke with were really interesting and bright and offered suggestions we’d never thought of.”

“As the population ages, we need to take into consideration the complexity of their care, the needs of caregivers and the growing need for support in the community to keep elders safely at home for as long as possible,” Harris said. “We need more emphasis on the aging population if we are going to serve them well as they live into their nineties and beyond.”