Authored by Barbara Brandt

As we approach the holiday season, I reflect on the past three years with the National Center. Many friends and colleagues are aware that my family and I have been intensely navigating the full breadth of the health care delivery system since 2012. Notably, my then spry 91-year old father fell on Christmas Day 2012 as we walked through his apartment door. The 2012 hip fracture and repair were followed by another fall on Easter 2013. On July 4, 2015, he fell again and suffered a severe fracture of his humerus, which is now held together with 11 pins.  Our family now avoids holidays like the plague.
 

After many surgeries, emergency room visits, ambulance rides, transitional care units, two assisted living apartments moves, costly out-of-pocket transports to and from visits, multiple specialists and subspecialists, Medicare and United Health claims and “THIS IS NOT A BILL” statements, and one Social Security interview to qualify me as his representative, I can say that as his only child, I am a practical expert in the U. S. health care delivery system for frail, elderly adults.
 

I am blessed that we are in Minnesota for this stage of his care because today my family has the right team at the right time, and we are on it. Dad’s health care team is now led by a Health Partners geriatrics nurse practitioner who is also a University of Minnesota School of Nursing faculty member and me – not because there is a primary care physician shortage, but because Dianne is the best team leader for his current situation. The other team member, the primary care physician and her residents visit Dad with Dianne in his facility periodically.  As Dad’s health and cognition steadily decline, this team manages his weekly – and sometime daily – needs together, and I participate from where my travel takes me. Dad’s team also includes the phlebotomist, radiology tech, occupational therapist, physical therapist and whichever professional is needed for the situation.  For his own quality of life, they come to him so he has the needed care to manage his acute spells. We are all in this together.
 

What life lessons has this experience taught me?  I’ve reflected upon many aspects of daily life for us and its meaning for my work in the National Center, including:
 

• Atul Gawande’s book, Being Mortal, has had a powerful impact on me this year. Gawande eloquently describes medicine’s failure to set realistic management goals and health care response for aging and dying. My wish is that his next book is about teams rather than physicians.  We need to have that conversation.
   
• I constantly think about the IHI’s Triple Aim — improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care.   My Dad was a child of the Depression, living in foster care. He was very practical all of his life and spent and saved wisely. When he has an acute flair-up and the suggestion is to take him to the Emergency Room, his team has that conversation. It would be very easy to call the $1,000 ambulance, incur ER expenses and have many thousand-dollar tests. It might even make me feel better that I am “doing something.”  We have been there before., and we know all of those tests, costs and wear and tear on Dad have not —and will not — improve his condition. Today, the team stands back together and asks, “What does my Dad need for his quality of life?  And, will spending money on health care contribute to that quality?”  I’m now learning to accept that it is this shared decision-making that makes me feel better.
   
• As caregiver, this is OTJ (on-the-job training). Patients/people and their families are ill-equipped to make these informed and wise decisions. Most of us grew up in the era when only the physician is the expert and knows best. We rarely were exposed to what the National Center is now learning in our research — that the healthcare team can have many situational leaders: nurse practitioners, clinical pharmacists, physical therapists, physicians, students, residentsand so on.  Tremendous work needs to be done in this area to educate the public.
   
• Since July 9, 2015, Dad and I only saw two students – a St. Catherine Occupational Therapy student and a University of Minnesota DNP student. We also saw one Minnesota medical resident.  If this is where health care is headed, the Nexus – aligning interprofessional education with the transforming health care system — needs all of us more than ever.
   
• In Minnesota, nurse practitioners have full scope of practice and are reimbursed for their services.   What would happen if incentives and policy really did support the right team at the right time?  

I could go on and on. . . .and I will in the New Year. I look forward to my family arriving on Christmas Day to help me keep Dad safe on another holiday.. 
 

Best wishes for a healthy new year.