A Model Einstein-Montefiore Partnership

A Model Einstein-Montefiore Partnership

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A Conversation with Dr. Joe Verghese on Melding Academic Neurology and Clinical Geriatrics

One impetus for the new partnership between Albert Einstein College of Medicine and Montefiore was to build on “the decades-long synergy among our educational, research and clinical enterprises,” in the words of Allen M. Spiegel, M.D., Einstein’s Marilyn and Stanley M. Katz Dean. A prime example can be seen in the collaborations among Einstein’s researchers in neurology and Montefiore’s clinicians in geriatrics.

Front and center in this effort is Joe Verghese, M.B.B.S., M.S. His Einstein positions are professor and director of the division of cognitive & motor aging in the Saul R. Korey Department of Neurology; professor of medicine; director of the Jack and Pearl Resnick Gerontology Center; and the Murray D. Gross Memorial Faculty Scholar in Gerontology. At Montefiore he serves as chief of the integrated divisions of cognitive & motor aging (neurology) and of geriatrics. He is also director of the Montefiore Einstein Center for the Aging Brain. Dr. Verghese’s investigations focus on how diseases and aging affect cognitive ability and mobility in older adults.

Your training and background are in neurology. Why were you appointed chief of geriatrics at Montefiore?

It was an unconventional appointment, considering that I’m not a geriatrician. However, my work on aging straddles the two disciplines, putting me in an ideal position to build bridges between Einstein’s rich aging-related research in neurology and Montefiore’s extensive clinical services in geriatrics. There had been minimal links between the two sides in the past.

How are you building those bridges?

Regarding education, an early initiative was to start a weekly case conference where our researchers share new findings in the field with our clinicians. We also have a yearly research symposium, which serves as a forum for everyone—researchers, clinicians, fellows, students—to showcase their work.

What about new bridges between research and clinical care?

The most prominent example is the new Montefiore Einstein Center for the Aging Brain, a clinical facility in Yonkers where we’re translating the latest dementia research into practice, such as a tool I developed for assessing cognitive abilities. The genesis of this tool comes from a study in India in which I had to measure cognition. One practical problem was that many people there are illiterate or have a low level of education, and most tests for measuring cognition were based on written words. So we came up with a test that uses only pictures. We tested it at Einstein and then implemented it in the center’s clinics, which serve many patients with low literacy skills. All in all, we want the center to serve as a nidus for research—everything from drug trials to large-scale population studies.

Harry L. Ramos, M.D. (left), talks to a patient about Dr. Verghese’s picture-based tool for assessing cognitive abilities. Dr. Ramos is an instructor in the department of medicine (geriatrics).
Harry L. Ramos, M.D. (left), talks to a patient about Dr. Verghese’s picture-based tool for assessing cognitive abilities. Dr. Ramos is an instructor in the department of medicine (geriatrics).

Are you encouraging research from the clinical side?

Yes. The picture-based tool for assessing cognitive abilities is a great example of the classic loop wherein a clinical observation spurs research, which develops a solution that is fed back to the clinic. We want to encourage that type of interaction, which is why I appointed one of my previous postdocs, Dr. Helena Blumen, to the geriatrics faculty at Montefiore. Her role is to serve as a resource for clinical faculty members who have ideas for research but may not have the expertise to apply for grants, design a study, make presentations or write papers.

Will the Einstein-Montefiore partnership help address the shortage of geriatricians?

That’s a serious issue. It’s estimated that within a decade, we’ll need more than 30,000 geriatricians nationwide to serve our graying population. Today, we have only about 6,000. So while we work to train geriatricians, we’re also trying to increase geriatric awareness—to “geriatricize” the two institutions. I have a clinical faculty of 12, so there’s going to be a limit to how much hands-on care we can actually deliver. But there are other ways to extend our reach.

At Montefiore, we go to various clinical sites to teach clinicians skills such as how to screen for dementia. We’re also working to put screening instruments into the electronic medical record, so that every older patient in the system can get appropriately evaluated. Most older patients with cognitive impairments are seen by a primary care provider, not a geriatrician. But studies show that more than half of these health issues go unrecognized in the primary care setting. There are several reasons—for example, primary care doctors don’t have enough time to fully evaluate older patients—so it will require a multipronged solution. But at least one solution is to give nongeriatricians the right tools to assess older patients.

Are you collaborating with other departments to “geriatricize” healthcare?

We have a co-managed service with orthopaedics, where patients who come for surgery are evaluated by a geriatrician as well as by an orthopaedic surgeon. In a pilot study, Einstein-Montefiore geriatrician Dr. Wanda Horn showed that this partnership resulted in fewer complications and a shorter length of stay, compared to the traditional orthopaedics service. Based on this study, we got a grant from the Foundation for Jewish Philanthropies to set up a similar co-management service at Montefiore’s Wakefield campus. In addition, we’re doing consults with nephrology on general geriatrics issues, including palliative care and advanced directives.

We’re also working in cardiology. Heart failure patients who are frail tend to fare much worse than those who are not, so we’re studying possibly introducing assessments of frailty into the heart failure clinic. And we’re working with Montefiore Care Management to expand dementia outreach and research into the Hudson Valley. Montefiore is going to provide the care management, and we’ll provide the consultative services such as teaching primary care physicians how to recognize cognitive and frailty problems and how to use screening tests.

How many older patients does Montefiore serve?

Montefiore’s geriatrics services reach about 3,000 patients per year in ambulatory care clinics, inpatient services and nursing homes. But in a broad sense we influence the care of all 300,000 elderly people in the Bronx and, increasingly, in Westchester through efforts to promote screening for cognitive issues and frailty, to create new screening tools for older people and by serving as a resource for local primary care physicians.