- Email: [email protected]
Geriatrics at the crossroads: Challenges and opportunities for international collaborations
European Geriatric Medicine 1 (2010) 69–71
Editorial
Geriatrics at the crossroads: Challenges and opportunities for international collaborations
I vividly recall a meeting I attended in Paris in 1999. As a representative of the leadership of the American Geriatrics Society (AGS), I was invited to participate in this meeting of several leaders from Geriatrics societies throughout Europe. The issue at hand was whether to form a union of European Geriatric Medicine Societies. On behalf of the AGS, I strongly advocated for the formation of such a union. My rationale was simple. At the time, Geriatrics was not a well-established or respected field anywhere in the world. Strength lies in numbers and synergy. There are simply not enough geriatricians for societies to duplicate efforts and compete with each other. Basic principles of Geriatrics are the same throughout the world, though the way the same older patient is treated may differ based on health systems issues [1]. Education and guidelines on specific clinical conditions, as well as databases for research and quality improvement initiatives, could therefore be greatly strengthened by a unified approach and sharing of resources. Now, over 10 years later, I am proud to serve as the AGS ‘‘ambassador’’ to the European Union of Geriatric Medicine Society (EUGMS). From the AGS point of view, it is a great opportunity to interact with geriatrics health professionals from multiple countries, and at the same time have an efficient method of communicating and collaborating with the 23 societies currently represented in the EUGMS. The AGS fully recognizes the importance of strong international relationships. As advocates of this interest, my wife Lynn and I hosted a reception for leaders of foreign Geriatrics societies in our back yard during the AGS annual meeting in Los Angeles almost 20 years ago. I first met Professor Jean-Pierre Michel and several other European geriatricians at that reception, and I am glad to say that Jean-Pierre and I are now good friends. We have collaborated on a number of projects, and look forward to doing so in the future in our current roles in AGS and EUGMS. The AGS has a Special Interest Group focused on international Geriatrics, which hosts an international poster session at its annual meeting. About half of the submissions of original papers to the Journal of the AGS (‘‘JAGS’’) are from outside the US. JAGS also has an International Section, and as both Executive Editor of JAGS and the AGS ambassador to the EUGMS, I encourage leadership of the EUGMS and members of its participating organizations to submit descriptions of Geriatrics in their countries, or editorials or other papers that discuss your countries’ perspectives. The importance of these perspectives has also been highlighted by the appointment of a panel of international editors to one of the major textbooks in Geriatric Medicine [2]. I have not traveled extensively in Europe recently, and I do not have a good sense of where Geriatrics is headed in the various
member countries of the EUGMS. In the United States (US), I believe, as do many of my colleagues, that the field of Geriatrics is at a crossroads. On the one hand, the growing elderly population with complex medical, functional, and psychosocial problems is growing exponentially. On the other hand, the number of applicants to Geriatric Medicine fellowships is shrinking, and we are ironically at risk of the field becoming extinct outside of major academic medical centers at a time when we are needed most. What underlies this phenomenon? Like a typical geriatric patient, the causes are multifactorial. First, the number of medical students choosing to enter residencies in internal or family medicine (one or the other is a prerequisite for board certification in Geriatrics) has been going down steadily. In part, this represents the attraction of the high tech aspects of many surgical and other specialties. Among those choosing Internal Medicine, the majority chooses a procedure-oriented specialty (such as cardiology or gastroenterology), or a subspecialty that has attractive working schedules (such as dermatology and hospital medicine). Probably the most important reason for students to shy away from primary care oriented careers is financial. While no one should claim that physicians are poorly paid in the US, subspecialists in procedureoriented surgical and medical fields have average salaries that can be two to four times that of a primary care internist or family physician. For the many medical students who are facing six-figure debts on loans to pay for medical school, the salary differential is a major consideration in guiding their career path. A second and related issue is the fact that while a career in Geriatrics can be very rewarding from a professional point of view, Medicare (the primary payer for physician services for the elderly in the US) does not cover the costs of care coordination for complex elderly patients and their caregivers (e.g. talking to families, reviewing multiple test and consult reports, arranging for and completing documentation for various community-based care services, etc.). Per unit of time spent, Medicare pays much more for procedure-oriented specialists, and makes it almost impossible to have a financially viable primary care outpatient Geriatrics practice. A third factor underlying the declining number of applicants entering Geriatrics fellowships is the lack of incentives to become board certified in the field. In most areas of the US, board certification in Geriatrics does not result in a competitive advantage for leadership positions in health care organizations, or in additional financial remuneration. Moreover, with the recent exception of the current federal administration’s economic stimulus that includes increased funding for biomedical research, obtaining research grants is extremely competitive and requires at
1878-7649/$ – see front matter ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. doi:10.1016/j.eurger.2010.03.008
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Editorial / European Geriatric Medicine 1 (2010) 69–71
least 2–4 years of additional training at the fellowship or junior faculty level to become competitive for grant funding. Many physicians, even the small number who do enter Geriatric Medicine fellowships, are shying away from the extra training and time it takes to become a successful independently funded researcher, and are electing to practice clinical medicine instead. If this continues, we run the risk of not having enough well-trained academic geriatricians to take over the leadership of already successful programs, or to develop new ones. Finally, my view is that the field of Geriatric Medicine in the US has not done a good enough job, despite intensive efforts on the part of AGS leaders and members, to articulate the relevance and importance of what we do to the future of health care in our country. A recent report by the Institute of Medicine highlights the need to strengthen Geriatrics in the US [3], but despite the critical need, this will not be easily accomplished. Some of my concern stems from the first three issues outlined above. But it goes beyond them. Many leaders in academic medicine still do not value Geriatrics as a core component of medical education, research, and clinical care. While some have been enlightened by facing a personal crisis in caring for one of their parents and having a faculty geriatrician come to the rescue (hence the often quoted phrase among academic geriatricians: ‘‘Have you seen the Dean’s mother in your clinic yet?’’), others have not strongly supported the development of Geriatrics beyond the minimum required for medical school and residency education accreditation. Some of this resistance stems from the fact that academic Geriatrics programs do not generate net clinical revenue (some are in fact seen as ‘‘loss leaders’’), and many do not have enough well-trained and experienced faculty to be competitive for research funding (especially federally funded research, which generates the largest amount of indirect cost dollars for universities in the US). Similarly, many physicians and administrators outside of academic medicine do not see the values in Geriatrics. Administrators, like leaders in academic medicine, are currently driven largely by budget concerns, and Geriatrics is generally not a big money maker (though a large primary care Geriatrics practice can generate considerable ‘‘downstream’’ revenue through diagnostic testing and procedures). Physicians still commonly say: ‘‘I’ve been taking care of elderly patients my whole career; I am a geriatrician – why do we need a special field?’’ To be sure, many of these physicians are outstanding clinicians and take excellent care of their elderly patients. But numerous studies in the medical literature, as well as the experience of practicing board certified geriatricians, clearly demonstrate that the recognition and care of many geriatric conditions, such as falls, dementia and delirium, incontinence, polypharmacy, and others is suboptimal. The fields of Palliative Care and Hospital Medicine have been able to articulate a compelling case for their value, and in contrast to Geriatrics, these fields are growing rapidly. At the crossroads, the field of Geriatrics in the US has opportunities as well as challenges. In order to survive and thrive, the field of Geriatrics in the US must work hard to take advantage of the critical need to improve the care of the rapidly growing US elderly population. Here are some of my thoughts about what we need to focus on over the next several years in order to build on our past successes (note that these thoughts do not necessarily represent the views or priorities of the AGS): Academic Geriatrics programs must continue to be supported by academic medical centers and medical schools so that the next generation of geriatricians can be produced. Programs must prove their value for trainee education, clinical care, and research. The Veterans Administration, the National Institute on Aging, the John A. Hartford Foundation, the Donald W. Reynolds Foundation, Atlantic Philanthropies, and other private
foundations have played a key role in supporting these programs by providing support for leadership and junior faculty training, as well as research and education programs, and will hopefully be joined by others in the future in continuing this support. The Association of Directors of Geriatric Academic Programs (ADGAP), currently housed administratively within the AGS, must play a critical role in these endeavors. Geriatrics must take hold of one or more clinical care areas, in addition to building collaborations with our natural partners – the growing fields of Hospital Medicine and Palliative Care. At least two areas are good candidates. First, clinical and administrative leadership roles in transitional care (i.e. the transition of elderly patients between the hospital, long-term care facilities, community-based programs, clinics, physician offices, hospices, and other settings). Efficient and effective management of such transitions, and prevention of complications in the hospital which Medicare no longer pays for (such as injuries related to falls, catheter-induced urinary tract infections among several others) can improve care and reduce unnecessary health care expenditures. Such efforts will be of critical value to the US health care system as it struggles to reform the rapid and unsustainable growth of the Medicare program. Several websites now provide clinical practice tools for transitional care which can assist clinicians in managing these transitions [4–7]. A second clinical area is to continue to build on the role of geriatrics in clinical care and administrative leadership in skilled nursing facilities (SNFs) and other long-term care institutions. The American Medical Directors Association has played a leadership role in this regard. Many physicians in fact now consider themselves (‘‘SNFists’’ - similar to ‘‘hospitalists’’), and spend all of their time in SNF care and medical leadership. A subspecialty certification in this area should be considered over the next several years as the need for institutional long-term care in SNFs, assisted living facilities, and continuing care retirement communities grows [8]. The Medicare payment system must be reformed. Although the US political system is currently deeply divided on how to accomplish this, even bitter political rival admit that to do nothing will result in disaster due to the potential of Medicare to be bankrupt within the next decade. The current Medicare fee-for-service system provides potent financial incentives to perform more tests and procedures, and to hospitalize elderly people. Legal liability concerns reinforce these incentives by forcing health care providers to practice expensive ‘‘defensive medicine’’. But, in many instances, such tests, procedures, and hospitalizations do more harm than good for elderly patients, and result in unnecessary morbidity, as well as potentially avoidable costs. Geriatrics health professionals and other primary care providers can play a leadership role in providing more cost-effective care, and Medicare payment policies must be revised to provide incentives for better quality care (which in the elderly sometimes means less care), rather than financial incentives for more care. Geriatrics is truly a ‘‘team sport’’. We must build on our experience and delegate many tasks to members of the interdisciplinary team, including advance practice nurses, physician assistants, rehabilitation therapists, pharmacists, social workers, and others. Medicare payment reform must also provide financial support for such teamwork. One approach being considered is the ‘‘patient-centered medical home’’ model, which would provide additional reimbursement for care coordination in primary care settings [9]. We must collaborate. The world is growing smaller. As I said earlier, there is strength in numbers and synergistic collaborations. Let’s not waste time reinventing the wheel. Instead, let’s work together to build international clinical practice guidelines for geriatric conditions, clinical practice tools, related educational materials (such as the online repository supported by the
Editorial / European Geriatric Medicine 1 (2010) 69–71
Donald W. Reynolds Foundation [10]) that we can share, and collaborative research and quality improvement initiatives. Indeed, international collaborations present a tremendous opportunity to build on what we have accomplished, and convince our leaders, our colleagues, and the public that Geriatrics is critical to the future of health care in a rapidly aging global population. I look forward to future collaborations between the AGS, EUGMS, and other organizations in achieving these goals. Conflict of interest statement Nothing declared. References [1] Bergman H, Clarfield AM, Ouslander J, Kane R, Burton JR, Gold S. Same patients different systems: Clinical implications for the care of the elderly. J Am Ger Soc 1992;40:1178–82. [2] Halter J, Ouslander J, Tinetti ME, Studenski S, High KP, Asthana S. Hazzard’s Geriatric Medicine and Gerontology, 6th Ed, New York: McGraw Hill; 2009. [3] Institute of Medicine. Retooling for an Aging America: Building the Health Care Workforce. Institute of Medicine, National Academy of Sciences, Washington, DC, 2008.
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[4] http://caretransitions.org (accessed March 7, 2010). [5] http://www.ntocc.org (accessed March 7, 2010). [6] http://www.ihi.org/IHI/Programs/StrategicInitiatives/STateActiononAvoidable RehospitalizationsSTAAR.htm (accessed March 7, 2010). [7] http://interact.geriu.org (accessed March 7, 2010). [8] Katz PR, Karuza J, Intrator O, et al. Nursing home physician specialists: A response to the workforce crisis in long-term care. Ann Intern Med 2009;150: 411–3. [9] http://www.aafp.org/online/en/home/membership/initiatives/pcmh.html (accessed March 7, 2010). [10] http://www.pogoe.org (accessed March 7, 2010).
J.G. Ouslander* Clinical Biomedical Science, Charles E. Schmidt College of Biomedical Science, Christine E. Lynn College of Nursing, Florida Atlantic University, 777 Glades Rd, Bldg. 71, Boca Raton, FL 33431-0991, USA *Tel.: +561-297-0975; fax: +561 2 97 0914 E-mail address: [email protected] Received 6 March 2010 Accepted 8 March 2010 Available online 18 April 2010
Editorial
Geriatrics at the crossroads: Challenges and opportunities for international collaborations
I vividly recall a meeting I attended in Paris in 1999. As a representative of the leadership of the American Geriatrics Society (AGS), I was invited to participate in this meeting of several leaders from Geriatrics societies throughout Europe. The issue at hand was whether to form a union of European Geriatric Medicine Societies. On behalf of the AGS, I strongly advocated for the formation of such a union. My rationale was simple. At the time, Geriatrics was not a well-established or respected field anywhere in the world. Strength lies in numbers and synergy. There are simply not enough geriatricians for societies to duplicate efforts and compete with each other. Basic principles of Geriatrics are the same throughout the world, though the way the same older patient is treated may differ based on health systems issues [1]. Education and guidelines on specific clinical conditions, as well as databases for research and quality improvement initiatives, could therefore be greatly strengthened by a unified approach and sharing of resources. Now, over 10 years later, I am proud to serve as the AGS ‘‘ambassador’’ to the European Union of Geriatric Medicine Society (EUGMS). From the AGS point of view, it is a great opportunity to interact with geriatrics health professionals from multiple countries, and at the same time have an efficient method of communicating and collaborating with the 23 societies currently represented in the EUGMS. The AGS fully recognizes the importance of strong international relationships. As advocates of this interest, my wife Lynn and I hosted a reception for leaders of foreign Geriatrics societies in our back yard during the AGS annual meeting in Los Angeles almost 20 years ago. I first met Professor Jean-Pierre Michel and several other European geriatricians at that reception, and I am glad to say that Jean-Pierre and I are now good friends. We have collaborated on a number of projects, and look forward to doing so in the future in our current roles in AGS and EUGMS. The AGS has a Special Interest Group focused on international Geriatrics, which hosts an international poster session at its annual meeting. About half of the submissions of original papers to the Journal of the AGS (‘‘JAGS’’) are from outside the US. JAGS also has an International Section, and as both Executive Editor of JAGS and the AGS ambassador to the EUGMS, I encourage leadership of the EUGMS and members of its participating organizations to submit descriptions of Geriatrics in their countries, or editorials or other papers that discuss your countries’ perspectives. The importance of these perspectives has also been highlighted by the appointment of a panel of international editors to one of the major textbooks in Geriatric Medicine [2]. I have not traveled extensively in Europe recently, and I do not have a good sense of where Geriatrics is headed in the various
member countries of the EUGMS. In the United States (US), I believe, as do many of my colleagues, that the field of Geriatrics is at a crossroads. On the one hand, the growing elderly population with complex medical, functional, and psychosocial problems is growing exponentially. On the other hand, the number of applicants to Geriatric Medicine fellowships is shrinking, and we are ironically at risk of the field becoming extinct outside of major academic medical centers at a time when we are needed most. What underlies this phenomenon? Like a typical geriatric patient, the causes are multifactorial. First, the number of medical students choosing to enter residencies in internal or family medicine (one or the other is a prerequisite for board certification in Geriatrics) has been going down steadily. In part, this represents the attraction of the high tech aspects of many surgical and other specialties. Among those choosing Internal Medicine, the majority chooses a procedure-oriented specialty (such as cardiology or gastroenterology), or a subspecialty that has attractive working schedules (such as dermatology and hospital medicine). Probably the most important reason for students to shy away from primary care oriented careers is financial. While no one should claim that physicians are poorly paid in the US, subspecialists in procedureoriented surgical and medical fields have average salaries that can be two to four times that of a primary care internist or family physician. For the many medical students who are facing six-figure debts on loans to pay for medical school, the salary differential is a major consideration in guiding their career path. A second and related issue is the fact that while a career in Geriatrics can be very rewarding from a professional point of view, Medicare (the primary payer for physician services for the elderly in the US) does not cover the costs of care coordination for complex elderly patients and their caregivers (e.g. talking to families, reviewing multiple test and consult reports, arranging for and completing documentation for various community-based care services, etc.). Per unit of time spent, Medicare pays much more for procedure-oriented specialists, and makes it almost impossible to have a financially viable primary care outpatient Geriatrics practice. A third factor underlying the declining number of applicants entering Geriatrics fellowships is the lack of incentives to become board certified in the field. In most areas of the US, board certification in Geriatrics does not result in a competitive advantage for leadership positions in health care organizations, or in additional financial remuneration. Moreover, with the recent exception of the current federal administration’s economic stimulus that includes increased funding for biomedical research, obtaining research grants is extremely competitive and requires at
1878-7649/$ – see front matter ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. doi:10.1016/j.eurger.2010.03.008
70
Editorial / European Geriatric Medicine 1 (2010) 69–71
least 2–4 years of additional training at the fellowship or junior faculty level to become competitive for grant funding. Many physicians, even the small number who do enter Geriatric Medicine fellowships, are shying away from the extra training and time it takes to become a successful independently funded researcher, and are electing to practice clinical medicine instead. If this continues, we run the risk of not having enough well-trained academic geriatricians to take over the leadership of already successful programs, or to develop new ones. Finally, my view is that the field of Geriatric Medicine in the US has not done a good enough job, despite intensive efforts on the part of AGS leaders and members, to articulate the relevance and importance of what we do to the future of health care in our country. A recent report by the Institute of Medicine highlights the need to strengthen Geriatrics in the US [3], but despite the critical need, this will not be easily accomplished. Some of my concern stems from the first three issues outlined above. But it goes beyond them. Many leaders in academic medicine still do not value Geriatrics as a core component of medical education, research, and clinical care. While some have been enlightened by facing a personal crisis in caring for one of their parents and having a faculty geriatrician come to the rescue (hence the often quoted phrase among academic geriatricians: ‘‘Have you seen the Dean’s mother in your clinic yet?’’), others have not strongly supported the development of Geriatrics beyond the minimum required for medical school and residency education accreditation. Some of this resistance stems from the fact that academic Geriatrics programs do not generate net clinical revenue (some are in fact seen as ‘‘loss leaders’’), and many do not have enough well-trained and experienced faculty to be competitive for research funding (especially federally funded research, which generates the largest amount of indirect cost dollars for universities in the US). Similarly, many physicians and administrators outside of academic medicine do not see the values in Geriatrics. Administrators, like leaders in academic medicine, are currently driven largely by budget concerns, and Geriatrics is generally not a big money maker (though a large primary care Geriatrics practice can generate considerable ‘‘downstream’’ revenue through diagnostic testing and procedures). Physicians still commonly say: ‘‘I’ve been taking care of elderly patients my whole career; I am a geriatrician – why do we need a special field?’’ To be sure, many of these physicians are outstanding clinicians and take excellent care of their elderly patients. But numerous studies in the medical literature, as well as the experience of practicing board certified geriatricians, clearly demonstrate that the recognition and care of many geriatric conditions, such as falls, dementia and delirium, incontinence, polypharmacy, and others is suboptimal. The fields of Palliative Care and Hospital Medicine have been able to articulate a compelling case for their value, and in contrast to Geriatrics, these fields are growing rapidly. At the crossroads, the field of Geriatrics in the US has opportunities as well as challenges. In order to survive and thrive, the field of Geriatrics in the US must work hard to take advantage of the critical need to improve the care of the rapidly growing US elderly population. Here are some of my thoughts about what we need to focus on over the next several years in order to build on our past successes (note that these thoughts do not necessarily represent the views or priorities of the AGS): Academic Geriatrics programs must continue to be supported by academic medical centers and medical schools so that the next generation of geriatricians can be produced. Programs must prove their value for trainee education, clinical care, and research. The Veterans Administration, the National Institute on Aging, the John A. Hartford Foundation, the Donald W. Reynolds Foundation, Atlantic Philanthropies, and other private
foundations have played a key role in supporting these programs by providing support for leadership and junior faculty training, as well as research and education programs, and will hopefully be joined by others in the future in continuing this support. The Association of Directors of Geriatric Academic Programs (ADGAP), currently housed administratively within the AGS, must play a critical role in these endeavors. Geriatrics must take hold of one or more clinical care areas, in addition to building collaborations with our natural partners – the growing fields of Hospital Medicine and Palliative Care. At least two areas are good candidates. First, clinical and administrative leadership roles in transitional care (i.e. the transition of elderly patients between the hospital, long-term care facilities, community-based programs, clinics, physician offices, hospices, and other settings). Efficient and effective management of such transitions, and prevention of complications in the hospital which Medicare no longer pays for (such as injuries related to falls, catheter-induced urinary tract infections among several others) can improve care and reduce unnecessary health care expenditures. Such efforts will be of critical value to the US health care system as it struggles to reform the rapid and unsustainable growth of the Medicare program. Several websites now provide clinical practice tools for transitional care which can assist clinicians in managing these transitions [4–7]. A second clinical area is to continue to build on the role of geriatrics in clinical care and administrative leadership in skilled nursing facilities (SNFs) and other long-term care institutions. The American Medical Directors Association has played a leadership role in this regard. Many physicians in fact now consider themselves (‘‘SNFists’’ - similar to ‘‘hospitalists’’), and spend all of their time in SNF care and medical leadership. A subspecialty certification in this area should be considered over the next several years as the need for institutional long-term care in SNFs, assisted living facilities, and continuing care retirement communities grows [8]. The Medicare payment system must be reformed. Although the US political system is currently deeply divided on how to accomplish this, even bitter political rival admit that to do nothing will result in disaster due to the potential of Medicare to be bankrupt within the next decade. The current Medicare fee-for-service system provides potent financial incentives to perform more tests and procedures, and to hospitalize elderly people. Legal liability concerns reinforce these incentives by forcing health care providers to practice expensive ‘‘defensive medicine’’. But, in many instances, such tests, procedures, and hospitalizations do more harm than good for elderly patients, and result in unnecessary morbidity, as well as potentially avoidable costs. Geriatrics health professionals and other primary care providers can play a leadership role in providing more cost-effective care, and Medicare payment policies must be revised to provide incentives for better quality care (which in the elderly sometimes means less care), rather than financial incentives for more care. Geriatrics is truly a ‘‘team sport’’. We must build on our experience and delegate many tasks to members of the interdisciplinary team, including advance practice nurses, physician assistants, rehabilitation therapists, pharmacists, social workers, and others. Medicare payment reform must also provide financial support for such teamwork. One approach being considered is the ‘‘patient-centered medical home’’ model, which would provide additional reimbursement for care coordination in primary care settings [9]. We must collaborate. The world is growing smaller. As I said earlier, there is strength in numbers and synergistic collaborations. Let’s not waste time reinventing the wheel. Instead, let’s work together to build international clinical practice guidelines for geriatric conditions, clinical practice tools, related educational materials (such as the online repository supported by the
Editorial / European Geriatric Medicine 1 (2010) 69–71
Donald W. Reynolds Foundation [10]) that we can share, and collaborative research and quality improvement initiatives. Indeed, international collaborations present a tremendous opportunity to build on what we have accomplished, and convince our leaders, our colleagues, and the public that Geriatrics is critical to the future of health care in a rapidly aging global population. I look forward to future collaborations between the AGS, EUGMS, and other organizations in achieving these goals. Conflict of interest statement Nothing declared. References [1] Bergman H, Clarfield AM, Ouslander J, Kane R, Burton JR, Gold S. Same patients different systems: Clinical implications for the care of the elderly. J Am Ger Soc 1992;40:1178–82. [2] Halter J, Ouslander J, Tinetti ME, Studenski S, High KP, Asthana S. Hazzard’s Geriatric Medicine and Gerontology, 6th Ed, New York: McGraw Hill; 2009. [3] Institute of Medicine. Retooling for an Aging America: Building the Health Care Workforce. Institute of Medicine, National Academy of Sciences, Washington, DC, 2008.
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[4] http://caretransitions.org (accessed March 7, 2010). [5] http://www.ntocc.org (accessed March 7, 2010). [6] http://www.ihi.org/IHI/Programs/StrategicInitiatives/STateActiononAvoidable RehospitalizationsSTAAR.htm (accessed March 7, 2010). [7] http://interact.geriu.org (accessed March 7, 2010). [8] Katz PR, Karuza J, Intrator O, et al. Nursing home physician specialists: A response to the workforce crisis in long-term care. Ann Intern Med 2009;150: 411–3. [9] http://www.aafp.org/online/en/home/membership/initiatives/pcmh.html (accessed March 7, 2010). [10] http://www.pogoe.org (accessed March 7, 2010).
J.G. Ouslander* Clinical Biomedical Science, Charles E. Schmidt College of Biomedical Science, Christine E. Lynn College of Nursing, Florida Atlantic University, 777 Glades Rd, Bldg. 71, Boca Raton, FL 33431-0991, USA *Tel.: +561-297-0975; fax: +561 2 97 0914 E-mail address: [email protected] Received 6 March 2010 Accepted 8 March 2010 Available online 18 April 2010