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Featured Researcher: Juliessa Pavon, MD

Medical Instructor, Geriatrics; Senior Fellow in the Duke Center for the Study of Aging and Human Development*

juliessa-pavonToday I find myself immersed in a very exciting time in the field of geriatrics. In the era of Obamacare and ongoing health care transformations, a new spotlight is shining on the field of geriatrics. It is making the future of geriatrics in academic teaching centers and in community hospitals appear very bright. The number of hospitalized patients over the age of 65 is expected to grow in the coming years. Currently, more than 3,400 (per 10,000 population) of adults 65 years and older are discharged annually from nonfederal U.S. hospitals, and account for almost 44% of the national hospital bill. Their hospital stays account for almost 50% of the acute care bed days, and signals the growing presence of hospitalized older adults in the U.S.  Due to ongoing national policy changes to provider payment, such as quality mandates, readmission penalties, and bundled payments, hospitals and health systems are turning to the geriatrics subspecialty to assist them with the increasing responsibility for providing high quality care to hospitalized older adults. As a result, the opportunities for geriatricians to impact the hospital care of older adults has suddenly grown! As an aspiring geriatrics hospitalist, I find the future to be very bright. However, a lot of work still needs to be done to continue improving the care of hospitalized older adults and to meet the responsibility of providing high quality care.

The Duke Division of Geriatrics has enthusiastically taken on these new responsibilities and has already launched several care model redesign initiatives within Duke Hospital to address some of the main challenges impacting the care of older adults. These care initiatives also represent innovative solutions in the clinical areas of peri-operative care and post-discharge care, and they are the following: 1) The Duke Peri-operative Optimization of Senior Health (POSH), which is a collaborative, multidisciplinary peri-operative care model to improve outcomes for older adults undergoing elective abdominal surgeries through targeted outpatient and inpatient peri-operative interventions; and 2) The Duke Health Optimization Program for Elders (HOPE), which is a multidisciplinary clinical demonstration project aimed at improving safe care transitions from hospital to skilled rehabilitation centers. Each of these care models are built on the “quality platform”, and are meant to enhance and revitalize quality care of hospitalized older adults while meeting national health care demands and quality metrics.  Furthermore, the Duke Health System has actively engaged the Geriatrics Division to collaborate and lead health system and population based care changes in relation to new Medicare Healthcare Savings Plans and population based Accountable Care Organization care models.  My involvement in these clinical initiatives has given me the practical experience that I need to expand my knowledge of local and national health care transformation agendas.

For me personally, the national healthcare transformation agendas and the local hospital initiatives have created the perfect arena for me to develop as a geriatric hospitalist researcher. In the same way that quality gaps have been identified in the clinical care of hospitalized older adults, there are also research gaps that exist. There is priority in expanding our knowledge in several areas of care of the hospitalized older adult, including high risk medication use in the inpatient setting, and deterioration of function during hospital stays. To that end, I have worked closely alongside my research mentor, Susan Hastings, MD, MHS (Associate Professor of Medicine in the Division of Geriatrics at the Duke University School of Medicine and Senior Fellow in the Duke Center for the Study of Aging and Human Development; Research Health Science Specialist in the HSR&D Center of Excellence, and Core Investigator in the Geriatrics Research Education and Clinical Center (GRECC) at the Durham VA Medical Center) to complete a project on the association between inpatient medication exposure and readmission risk in hospitalized elders using health system data.  In addition, I am currently working with Dr. Hastings on conducting an evaluation of an inpatient walking program for hospitalized older adults and examining the relationships between inpatient functional status (as measured by gait speed, 2 minute walk distance, and grip strength) and readmission. The purpose of these studies is to identify novel ways for leveraging our health system data to identify high risk individuals at risk for readmission, which is a costly outcome, and reducing readmissions is a current national health care priority.

My overall career goal is to promote the quality care of hospitalized older adults through innovative research that leads to better treatment, reduced risk, and reduced cost to older adults. Therefore, I am currently proposing a research study that focuses on improving the quality and safety of anticoagulant use in medically ill hospitalized older adult, and understanding the role of inpatient mobility in the prescribing of anticoagulants to older adults.  This study will combine the use of health system data and the innovative use of accelerometers to measure inpatient mobility.  In support of this proposal, I was recently awarded the 2014 Department of Medicine Chair’s Research Award.

The integration of geriatrics and hospital medicine at the clinical, educational, and investigational level at Duke University represents significant steps in taking on challenges in the care of hospitalized older adults, and has tremendous potential for improving geriatric care both in local and national hospital settings. With this health care transformation spotlight shining ever brightly on geriatrics, significant opportunities remain for collaboration, care coordination, and research to improve the care quality of hospitalized older adults. Indeed, this is an exciting time!

*Winner of the 2014 Department of Medicine Chair’s Award.