Conversations with Leaders in
the Field of Patient-Centered Care
One of the ways Picker Institute supports patient-centered care is by recognizing people in healthcare who have made significant contributions to achieving patient-centered care worldwide.
“Conversations with Leaders in the Field of Patient-Centered Care” is a regular feature that highlights people who have promoted patient-centered care in their work or through their organization.
This Conversation is with Dr. Mary Jane Koren.
Dr. Mary Jane Koren
Mary Jane Koren, M.D., M.P.H., a geriatrician, is vice president for the Commonwealth Fund’s
Long-Term Care Quality Improvement Program. Prior to coming to the fund she held faculty appointments at the Albert Einstein College of Medicine and the Mt. Sinai School of Medicine and later served as the director of the Bureau of Long- Term Care Services, New York’s state nursing home survey agency. Since coming to the fund in 2002, Dr. Koren has given invited testimony to congressional committees, serves on numerous advisory committees and expert panels for CMS and other federal agencies and chairs the national steering committee for the Advancing Excellence in America’s Nursing Homes Campaign. In 2010 she was the recipient of the Terrence Keenan Leadership Award in Health Philanthropy from Grantmakers in Health.
You manage the Long-Term Care Quality Improvement Program for the Commonwealth Fund. The program used to be called the Quality of Care for Frail Elders Program. What distinguishes frail elders from their colleagues?
I think the best explanation of what that term connotes can be found in a terrific article called “The Bridges to Health,” written for CMS by Joanne Lynn, Barry M. Straube, Karen M. Bell, Stephen F. Jencks and Robert T. Kambic and published in the Milbank Quarterly in 2007. The authors divide the entire population into eight groups: healthy; maternal and infant health; acutely ill, with likely return to health; chronic conditions, with generally “normal” function; significant but relatively stable disability, including mental disability; “dying” with short decline; limited reserve and serious exacerbations; and long course of decline, from dementia and/or frailty. Everyone falls into at least one of those categories throughout her or his life. The article sets the healthcare goals for the last three categories as “coping with illness at the end of life.” These are frail elders.
You have been interested and active in geriatrics since you were a student in medical school. What is it about the field that compels your interest?
I am a child of the ’60s, and social injustice resonates with me. I am concerned by inequality, discrimination, disparity in income and education—and particularly by the way older people are undervalued in this country, and how very vulnerable they are. Let me give you an example: My mother called me the other day, in tears. She wanted to donate to National Public Radio, but she didn’t have a credit card or a computer. For her a contribution meant mailing a check. But the fund drive didn’t offer that option, so she was prevented from doing something that was meaningful to her. That is ageism, and it’s everywhere.
How do you think the United States rates in its attitude toward and service to its aging population?
I am very aware that we have a problem in this country with aging demographics, and with the fact that too often older people with viable medical conditions are dismissed just because they are old. I’m starting to see a change in the way some aging issues are addressed, but I don’t see a real change in attitude or the way services are delivered. As our population increases, there will be more and more intergenerational competition for scarce resources—and I don’t see elders winning.
Elders will never outnumber the rest of the population, but they do represent a very large proportion of the general population. And the elder generation covers a wide range of ages. There’s a lot of difference between someone who is between 65 and 75 and someone in her or his 90s, and as you get older you are less and less likely to be regarded. Older people tend to count on others to advocate for them, and it is younger people who most often take on the role of advocating for an older person’s interests.
Why do we recognize and attend to catastrophic events in hospitals but not in long-term care facilities? It goes back to undervaluing older people, to dismissing them as not worth treating just because they are old.
You said you’re starting to see some changes. What kind of progress do they represent?
Let’s look at physical restraints. When I was the director of long-term care services for the New York State Department of Health, at least 50 percent of the residents in state institutions were physically restrained. It wasn’t meant to be punitive—it was to keep them from falling, and families and insurance companies were in favor of it for that reason. Now the national rate of physical restraint in that population is down to 3.5 percent. The Commonwealth Fund was active in bringing that about. In 1973 a campaign got underway to “Untie the Elderly,” and that resulted in a demonstration that using or not using physical restraints made absolutely no difference as far as the law and liability were concerned made physical restraint illegal. Actually, getting the law passed was one thing; getting long-term care staff and the people who conducted the surveys of LTC facilities to pay attention to it has been a lot more difficult.
If advances have been made, are you satisfied with the speed at which they are moving forward?
The United States is in massive denial of aging. Everything that we see and hear—movies, television, style, fashion, transportation, advertising—is focused on the young or on people who want to stay young. But I am starting to see some businesses using older models and some manufacturers producing clothes that are styled for older people, and I think the real change will develop when the baby boomers start becoming elders. If we can make a compelling case to the baby boomers about why it is so important that we pay attention to the elderly—call it “just-in-time learning”—they could become a potent voting bloc, and that could have some very significant results.