Maria Torroella Carney, MD, is well-acquainted with the concerns of America’s large and growing aging population. As North Shore-LIJ’s chief of geriatric and palliative medicine, she works to preserve this diverse group’s longevity, wellness, independence and quality of life.
In our newest Leadership Series installment, Dr. Carney touches on the many concerns of aging individuals, their loved ones and their caregivers.
Question from interviewer: Tell me about the North Shore-LIJ Geriatric and Palliative Medicine clinical services and your hopes for growing this further. Why now? And what can it do for the patient?
Dr. Carney: At North Shore-LIJ, we offer clinical programs and multidisciplinary geriatric and palliative care within the Department of Medicine.
Our division has clinical programs throughout the health system. We have outpatient Geriatric-focused medical care, inpatient geriatric and palliative medicine services, sub-acute rehabilitation and skilled nursing facility care. Our division works closely with the North Shore-LIJ House Calls Program, Home Care and Hospice Care Network to provide care to individuals in their home.
Our goal is to provide comprehensive medical care to help individuals live long and healthy [lives] and to help caregivers meet the patients needs and goals.
Q: America has a growing aging population. What are other hospitals across the country doing?
Dr. Carney: There are some excellent hospitals and health systems addressing this, and they are largely known as academic centers. Mount Sinai, NYU, UCLA, and right here in our own community at NORTH SHORE-LIJ , we have all the same services, but many don’t know what we have available to help them.
All of us deal with aging issues with our parents and loved ones. I receive calls on a regular basis from friends and colleagues, about how to help them with these situations... While there are resources already in place, families may not have a way to access these services or the information to know who to call.
For these reasons, North Shore-LIJ is developing a Center for Healthy Aging that will align and integrate the services focused on this fast growing population. An organizing body will help us advocate for, assist with, and coordinate the services for our most complex individuals.
Q: As a society and as a community, are we prepared to deal with the aging population that is coming at us very quickly?
Dr. Carney: We are facing what we often refer to as the “Silver Tsunami.” Baby boomers are now entering the Medicare age range, which is challenging health care systems all around us. We are faced with how to promote longevity, how to keep individuals healthy, how to make sure people are independent and safe in their homes for as long as possible and live with dignity.
We in the health care field have some services, but we need to expand upon them. We must be realistic about the care that can be provided.... Individuals have so many difficult choices to make when it comes to caring for their own health, the health of their loved ones, and all the decisions that they will face with serious illness, chronic illness and even advanced illness.
Q: If you look at some of these issues that we are facing as a society and community, are we ready?
Dr. Carney: We are facing times that are unique. No other generation has dealt with individuals who have lived as long.... If you were born in the year 1900, you were expected to live to about 40 years of age. If you were born in the year 2000, your life expectancy is to about 80 years of age. That is due to public health, sanitation, vaccines, antibiotics and modern medicine. Loved ones need to make decisions about devices, pacemakers, knee replacements, dialysis and other treatments that didn’t exist before.
With longevity comes increased chronic disease.... It can impact our function and as we go on, there are many decisions that have to be made. Every procedure and every medical decision has risks and benefits. Families and loved ones need to help to know how to handle all of these decisions.
We also may not realize that there are community resources available to individuals to help them stay active, healthy and independent. We have community partners and physician partners who are in tune with this aging population. We need to be a resource for individuals and advocate for the needs of the aging population.
Q: As you look at the procedures and other helpful things today and consider the next five to seven years, what will change?
Dr. Carney: We will have more multidisciplinary teams to help complex care situations--individuals with multiple, chronic diseases, who do not have a tremendous amount of support but need some added support to stay independent. We will have doctors, specialists, social workers, pharmacists and chaplains as part of a team to help patients make decisions. Whether it is simple or more complex, a multidisciplinary team will help address this growing, complex, patient population.
Base Care on Need, Not Age
Q: If you look at the elder population, they need different care than you or I. What special training is needed to help providers better serve this population?
Dr. Carney: An aging population presents challenges on two fronts. While some may have frailty, cognitive impairment, functional decline, they need awareness of it and how to maximize their care.
On the other hand, we have 90-year-olds and [almost]-100-year-olds who are independent and healthy, and we have to advocate for them. Maybe they need procedures, devices or advocacy like a 50-year-old [does].
So we need to advocate the needs of the individual. It is not age-based, it is need-based. Whatever the individual needs should to be aligned with the resources available.
Q: Clearly, there will be special issues related to the cost of health care, from government programs and the insurance companies. What are some of those issues and how are they going to be addressed in the coming years?
Dr. Carney: Physicians, nurses, medical teams and community resources are always making difficult decisions for our loved ones and ourselves. These decisions are...based upon diverse [factors]. They are based on religious beliefs, availability of resources, cultural beliefs, and [what patients] want for themselves and their needs.
There is no one answer. Like any other treatment, whether you give antibiotics or provide a surgery, you have to know what the prognosis is. What are the risks and what are the possible benefits?
If we go into a care situation, we need to assess the individual, their current state and a realistic treatment goal. Weighing everybody’s beliefs, we can make decisions appropriately with the use of devices or procedures in the best way possible.
Q: As the aging population increases, will there be a shift in cost and reimbursement?
Dr. Carney: The federal government is starting to look at the cost of health care--how it is reimbursed and how it aligns with quality. Health care facilities and doctors who provide high-quality care with fewer complications and hospital readmissions will be reimbursed better and more thoroughly.
Health Care Proxy
Q: How do you begin the conversation regarding terminal illness?
Dr. Carney: A conversation regarding someone who has a terminal illness really needs to begin much earlier than when they are diagnosed....We need to start, as a society, to evaluate what is important to us at a very early stage with minor issues.
Who do we want to help us make difficult decisions in a complex medical environment? Who knows my values, what is important to me? Who do I want to help me make decisions? That is called the health care proxy....Health care is difficult. It is like entering into a foreign land for some of us. There is another language being spoken; there are a lot of opportunities in terms of treatment options. You need someone to be there to help you. So everyone should have a health care proxy.
Q: How do you begin that process?
Dr. Carney: In our office, with my patients, it is a checklist of questions: What illnesses do you have? What medications are you taking? Do you have other doctors? Where do you live? Do you need assistance with living in your home? Have you been recently hospitalized? Do you have any advance directives? Do you have a health care proxy?
Q: How do you bring up the conversation and who do you turn to, to talk about a health care proxy?
Dr. Carney: It should become a normal part of entering into a hospital, a normal part of seeing your doctor. It could be routine. When you get a voter registration, you should be able to complete a health care proxy. Everybody 18 and over should have a health care proxy.
As a doctor, I routinely ask my patients, just as a standard form like an emergency contact, “who is your emergency contact? Who is your health care proxy? Do you have a health care proxy? Do you know what a health care proxy is? You should complete it. You should hold a conversation with your health care proxy about their role. Here is a form, think about it. We can discuss at a future appointment if you would like.”
Everybody should have one because health care is very complex. It is hard to facilitate and coordinate your care, and when you have more than one chronic illness, it gets that much more complex. The beginning discussion about your values and what is important to you starts with assigning a health care proxy and starting to have this discussion with them.
Q: What is the most difficult thing we are facing over the next couple of years in relation to the aging population?
Dr. Carney: We are approaching difficult health care situations in helping maintain a patient’s autonomy. Patients have the ability to make decisions in their care and we want them to make decisions in their care, if they want to do so. I do not know if everybody wants all of those decisions to be in their hands. We need to help individuals and families make these decisions with information, so it is a partnership.
We need to develop a Center for Healthy Aging in the community that assists individuals, families and caregivers access the care they need and advocate for the care they want.
Older adults can get a comprehensive assessment at North Shore-LIJ’s Ambulatory Geriatric Medical Practice in Great Neck. To make an appointment, call 516-708-2520 Monday through Friday. (Weekend contact number: 516-773-8974.)