What's the biggest barrier to practicing medicine today? A lack of adequate hospital discharge planning, education, and follow-up in older adults, Eric C. Rackow, MD, president of , tells 鶹ý in this installment of "10 Questions."
In addition to his position at Humana At Home, Rackow is a professor of medicine at the New York University School of Medicine in New York City.
Prior to his current role, Rackow was president and CEO of SeniorBridge, where under his leadership the company tripled in size to 44 homecare offices and a nationwide network of more than 14,000 care managers coast to coast. Rackow joined SeniorBridge following a career in the hospital industry, where he saw first-hand the challenges frail seniors face in their homes, and the need to provide personalized, ongoing support. There he became passionate about the effectiveness of care management in averting unnecessary hospitalizations and emergency room visits and its power to improve efficiencies in healthcare.
As an expert in critical care and health delivery, Rackow is frequently quoted in national press including The Wall Street Journal and The New York Times and frequently speaks at healthcare conferences on aging, complex chronic care, and healthcare delivery systems.
After earning his MD at the State University of New York, Downstate Medical Center, he trained in Internal Medicine, served as Chief Resident in Internal Medicine, and completed a fellowship in Cardiology at Downstate. Rackow is the author of 184 articles and 40 chapters on the care of patients with complex medical problems.
He has held leadership positions in numerous medical societies.
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1. What's the biggest barrier to practicing medicine today?
An alarming rate of is rehospitalized within 30 days of being discharged from a hospital. Only half recall receiving self-care instructions or seeing a doctor the month after they leave the hospital, suggesting that a substantial number of hospitalizations could be prevented with adequate discharge planning, education and follow-up.
The problem stems from our healthcare system's focus on disease management and a lack of attention to the reality that activity limitation is an independent risk factor for increased healthcare costs.
It is now recognized that when patients with complicated medical, functional, and cognitive conditions receive care management in the home by specially trained geriatric care managers, hospitalizations and emergency room admissions are substantially reduced.
As an industry we must identify patients with these functional limitations as at risk of a rehospitalization and ensure they have the proper support system that goes beyond medical needs to address physical and cognitive function that puts them at risk for adverse events.
Does the patient have food in the refrigerator to ensure adequate nutrition and hydration? Is the patient taking medications or vitamins you don't know about? Are their support limitations preventing them from complying with a discharge plan?
2. What is your most vivid memory involving a patient who could not afford to pay for healthcare (or meds or tests, etc.) and how did you respond?
Financial challenges are serious barriers and are often warning signs that patients could benefit from a holistic care management assessment and care plan. One woman I met virtually quite recently is Margaret, a retired teacher in Kentucky who was unable to pay for her cancer medicine.
Through our Humana At Home service, her Care Manager identified a community grant for which Margaret qualified so she could afford her treatment. However, as is often the case, her care manager discovered that Margaret's financial struggles had been taking a toll on her health in ways that would put her at risk of hospitalizations into the long-run. For example, we learned she considered going to the dentist a luxury and hadn't visited one for years, which put her at risk for infections.
We also learned that to save money Margaret wasn't taking her insulin and was buying her foods in cans -- foods that were low cost but high in salt. Margaret was also feeling lonely and scared about her husband's recent Alzheimer's diagnosis, which was impacting her ability to self-manage.
In addition to helping her afford her cancer treatment, her Humana At Home care manager found her a dentist she could afford, educated her about the role of her insulin, helped her make lifestyle changes with her diet, and connected her to a support group. Margaret reminds me that we need to help our patients afford their care but that we can't stop there.
3. What do you most often wish you could say to patients, but don't?
If people learn how to eat right, exercise, and lead healthy lifestyles, they will be less apt to have chronic illnesses like obesity, diabetes and pulmonary disease. As people age, I encourage family members to be just as proactive in taking care of aging loved ones.
Instead of waiting for your mother to break her hip from a fall, get a professional to conduct a home assessment. If your parent is having memory lapses and taking more than three medications a day, consider having someone manage their medications before medication errors occur.
When you see cognitive impairment warnings signs, ensure bill pay is overseen before parents become victims of financial abuse. Be aware that as we age we are more susceptible to depression. Support your parents' social activities and make sure they don't become isolated. These are the types of services a professional geriatric care manager can provide either through your insurance or through private hire.
We often don't realize what kind of impact the stress of being responsible for a parent or spouse can have on us -- and the stress of being a caregiver can negatively impact your health. That's why it is important to share the responsibilities and perhaps seek professional help.
According to a 2015 AARP report, is a caregiver to another adult.
We often try to engage the family to educate them in terms of how they can help the patient, whether it's their parent or spouse or child. We want to make sure they understand what to do, and we want to make sure that if they need it, they get some rest from constantly being the caregiver.
4. If you could change or eliminate something about the healthcare system, what would it be?
The thing that sends people back to the hospital most frequently is treating diseases, rather than treating the patient holistically. The current healthcare system is built around acute care. Have a problem? Go treat it. Have another problem? Go treat it again... as opposed to looking at people longitudinally and saying, "How can we help this person over the long term? How are we going to support their chronic conditions?"
We wait for a crisis -- for an exacerbation -- and then treat the exacerbation. Then we send them back home from the hospital without any coordination or support and wait until it happens again. So I think the shift from reactive, acute care to holistic, preventive care and support is changing healthcare. I think the shift will mean people will be healthier and be able to stay at home.
5. What is the most important piece of advice for students or clinicians just starting out today?
Albert Einstein is often attributed to have said, "A clever person solves a problem. A wise person avoids it." My advice is to be proactive in helping your patients. Remember that disease management is only part of the problem. Until we address patients' functional needs, we cannot provide them the care they deserve.
Consider a patient's ability to manage their medical conditions and medications, environmental safety, ability to function (Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [IADL]) cognitive issues, financial challenges, behavioral diagnoses, and psychosocial factors. Be proactive in directing them to get the support they need.
6. What is your "elevator" pitch to persuade someone to pursue a career in medicine?
I tell them healthcare is a field in which you can support the people who most need help and make sure they do as well as they can do.
7. What is the most rewarding aspect of being a clinician?
In my role I am so often reminded of the positive impact we have on the lives of the people we serve. Experiencing the impact our team of clinicians has on the people who receive Humana At Home services and their supports is rewarding. I'm also lucky to be surrounded by passionate, dedicated, creative, and smart colleagues I respect and admire.
8. What is the most memorable research published since you became a clinician and why?
Recently Humana published data that showed people who receive support from a Humana At Home care manager not only go to the hospital less, but they also live longer. As a clinician, it's exciting to find evidence of the impact of the work my team and me do.
People who received Humana At Home Care Management improved their 2-year odds of survival . The difference is even more dramatic for sickest and oldest among them. That is rewarding to see.
9. Do you have a favorite medical-themed book, movie, or TV show?
Declined to answer.
10. What is your advice to other clinicians on how to avoid burnout?
Take time to take care of yourself. Remind yourself to take breaks and ask for help to make it happen.