Our society is facing one of the greatest health challenges—the growth of the population of older adults. In less than 10 years, the number of persons over the age of 65 in the United States will exceed the number of people under 21 for the first time in history.
The recognition of this profound change in our society led to the founding of Mount Sinai’s Brookdale Department of Geriatrics and Palliative Medicine 38 years ago, and the Department’s focus on clinical care, research, and education has guided its growth ever since.
The Department’s vision and a commitment to innovation meant it was uniquely positioned when the COVID-19 pandemic hit New York City early this spring. In this Q&A, R. Sean Morrison, MD, the Ellen and Howard C. Katz Chair of the Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, explains how the Department responded and how its efforts helped save lives in New York and around the country.
The Mount Sinai Hospital Ranked Among Top in the Nation by U.S. News & World Report; Brookdale Department of Geriatrics and Palliative Medicine Claims No. 1 Spot in Specialty Rankings
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But challenges remain. Dr. Morrison says older adults face unique concerns, as many must continue to live in isolation, while Mount Sinai and other health systems face concerns of their own, as health care workers continue to cope with the difficult demands of the pandemic.
R. Sean Morrison, MD
“Our Department is working very hard to identify ways to bring a social connection to our older adults who need to be physically distant. Their feelings of isolation are real, and those emotions are ones that we don’t yet have a good solution for,” says Dr. Morrison. “Also, as we emerge from the COVID-19 surge in New York City and, hopefully, avoid another surge in the fall, we need to think about the emotional health of our health care workers, because long after we have a vaccine for COVID-19, the after-effects of caring for people will be with us and with our health care workers.”
What is unique about the approach of your Department?
In 1982, the first Chair of this Department, Robert Butler, recognized that if health care in this country was going to match the needs of its citizens, the focus needed to be on developing leaders who could care for the special needs of older adults. This Department was founded on the principle that health care must meet the needs of the society, and it must adapt as the demographics of that society changed. Over the past 30 years, this Department has led innovations in health care for older adults, developing models to find age-friendly health care for people in hospitals and in ambulatory clinics, training the leaders who have gone out throughout the United States to establish divisions and departments focused on the needs of older adults. Our research has led to fundamental changes in how we think about care for our most vulnerable patient populations.
How did this track record help you respond to the COVID-19 pandemic in New York?
The work that this Department had done under the leadership of its founding chair Robert Butler, and my predecessor, Albert Siu, positioned us to respond to the needs of New York City in a way that I don’t think any other institution could. The data that we had from China, from Italy, and from other earlier hot spots made us realize that the population at highest risk for severe COVID, and indeed for mortality, was the group of people that we care for, those over the age of 65. From the time that first case was reported, we put together a plan to ensure that our population would be cared for, that they would be safe. And that we would have a plan in place to provide the medical care, the added layer of support to families, and the security that the New York City population needed as COVID ravaged through our city.
What specific steps did you take and how did that help?
First of all, we put in place a system to ensure that we touched every single patient in our ambulatory clinics, that we contacted every single patient to talk to them about their wishes for care, to talk to them about how to avoid COVID and how to stay safe, and what to do if they developed symptoms. We rapidly developed a system of telehealth so that we could care for our patients in their homes, without them having to leave that safety, and so that they didn’t have to have health care providers coming in to see them.
How did that work?
We provided telehealth through something as simple as a telephone call, through video conferencing, and over a number of different platforms. For those people who needed face-to-face, in-person care, we expanded our home-based medical care so that we could go to see them, and keep them safe, rather than have them come to the hospital.
What other steps did you take?
In our hospitals throughout the Health System, we embedded our clinicians into the teams that were responsible for caring for the incredible numbers of patients who were coming into the programs. We embedded our clinicians in the emergency departments. We embedded our clinicians in the intensive care units. We embedded our clinicians within hospital medicine. Wherever patients with COVID were treated within the Mount Sinai Health System, a member of our Department was there to ensure that their special needs were met. We developed some very new and innovative models of care delivery that we took from concept to innovation to scale in a matter of days, rather than a matter of months.
Can you give an example?
We created a 24-hour telephone hotline that allowed overextended and overwhelmed emergency physicians and intensive care unit physicians to refer patients to us, so we could discuss their goals of care with them. We could advise around symptom management, and we could provide support to their families who could not see them, because no visitors were allowed in any New York City hospital during this time.
How was the Department able to scale up so quickly?
I think it was really three key elements that this Department has been doing since its founding, namely our focus on clinical care, research, and education.
A key part of our mission is to create leaders, not just in the care of older adults, but leaders in health systems, leaders in hospitals, leaders in community centers. For example, the senior vice president of the Mount Sinai Health System, who was responsible for coordinating clinical care throughout the pandemic, was a graduate of our fellowship program. He knew the importance of high-quality care for older adults during this pandemic and made sure that the patients in the Health System received that care, and that our Department was on the front lines. It was leadership within the Department, graduates of our training program, who developed the innovations, who developed the care models, who understood the need, throughout the Health System, for high-quality care for older adults.
Our research has focused on how do you deliver high-quality care to people outside of the hospital, outside of doctor offices. That allowed us to create new models of care that met the needs of the population.
And it was our educational efforts. We knew how to train, very quickly, other clinicians who may not have had training in the appropriate care of older adults, or the special needs of older adults, and be able to put that on the ground, right away, when patients and families needed it most. This Department trains 1 in every 10 geriatricians in the United States. Our graduates are in hospitals and health systems throughout the country.
What was the result?
The models of care that we have developed at Mount Sinai have been implemented in hospitals and health systems throughout the country. The work of our educators, providing high-quality technical support for the care of older adults, have been disseminated throughout the country. As other parts of the country wrestle with the challenges of COVID and, unfortunately, as the number of cases rise in other cities, as our experience this spring is being repeated elsewhere, the work of this Department, I believe, will save many, many lives throughout the country because of what we did in New York City.
So what are you focused on now?
As New York City has emerged from the surge of COVID, I worry about a number of challenges that we are facing and will continue for us. These challenges affect our patients, and our health care workers.
For patients, there is a sense of isolation. In order for our patients to stay safe, they have had to remain in their homes, often alone or with very few visitors. There is a sense of loneliness, indeed, the sense of purpose may seem limited, given how much of their time is spent isolating at home. We must ensure that we recognize their mental health needs, identify when isolation and distress becomes major depression, and provide support that helps our patients through the next six to nine months before we have a vaccine.
And what about health care workers?
The second challenge that I think we all face is that of the emotional health of our health care workers. My faculty experienced and saw more death in three months then many clinicians will see in entire careers. They were often the person holding the iPad so that their patient could say goodbye to their families and loved ones, or could have a conversation, not knowing what was going to happen to them and not being allowed to have their family there. Our faculty, our clinicians, our staff became patients’ families. They did that every single day, hour after hour, minute after minute. And it takes its toll.