Palo Alto Medical Foundation Newsroom

Doctors Honored for Innovations in Geriatric Medicine

Two Palo Alto Medical Foundation (PAMF) doctors recently received awards for their innovative work caring for aging patients in the community.

 California Health Care Foundation Award

Albert Lam, M.D.

Albert Lam, M.D.

Albert Lam, M.D., a doctor in geriatric medicine at PAMF, has received an award from the California Health Care Foundation for his work to strengthen systems of care for aging patients.

His groundbreaking project, “SNF 2.0: Modernizing Skilled Nursing Facility Care for the 21st Century,” strives to create a sustainable model of excellence in caring for patients discharged from hospitals to skilled nursing facilities (SNF).

“We are increasingly seeing people in nursing homes that 20 years ago would have been cared for in a hospital setting,” said Dr. Lam.  “Systemic barriers have made it challenging for many nursing homes to care for patients who are leaving the hospital sooner and sicker. We want to be part of the solution.”

The project incorporates INTERACT, a nationally recognized care system shown to improve the early identification, assessment, documentation and communication regarding medically complex patients in nursing facilities. Dr. Lam has designed a model that further incorporates direct, ongoing mentoring to teach and empower front line team members to embrace INTERACT. “We wanted to create a program that would ultimately allow any facility across the country to implement it,” said Dr. Lam.

“This grant was specially established by the California Health Care Foundation for Dr. Lam,” said Peter H. Cheng, M.D., chief of PAMF’s Palo Alto Center Geriatric Medicine Department.  “Albert’s work allows us to take many of the LEAN management principles being implemented at PAMF out to the community. We aim to impact our patients’ transitions back to their homes, reduce rates of preventable hospital readmissions, and help PAMF deliver superb care outside the walls of our medical offices.”

Practice Change Leaders Aging and Health Program

Steve Lai, M.D.

Steve Lai, M.D.

Steve Lai, M.D., a PAMF doctor in geriatric medicine and palliative care, is one of 10 individuals in the U.S. chosen for the 2014 Practice Change Leaders Aging and Health Program – a national program designed to develop, support and expand the influence of leaders who are committed to achieving transformative improvements in older adult care.

“In the last several years, I’ve focused on advance care planning in our community, including improving the quality of conversations involving POLST (Physician Orders for Life-Sustaining Treatment),” said Dr. Lai. POLST is a form that states what kind of medical treatment patients want toward the end of their lives. Signed by both a doctor and patient, POLST helps give seriously ill patients more control over their end-of-life care.

“This is a unique and exciting opportunity for geriatrics and palliative care at PAMF,” said Dr. Lai. At PAMF we have established the ‘Honoring Your Wishes’ program, aiming to improve the quality of POLST conversations by using professionally produced, research-based videos. Our goal is to educate and support people facing serious illness, so that the medical treatment they receive makes sense to them.  The initial pilot for the program occurred in nursing homes; we will now expand to outpatient settings.”

The Practice Change Leaders Aging and Health Program will provide the support and structure to help successfully implement the program for 2014.  It will also enable Dr. Lai to meet with national leaders in the field and to receive invaluable mentorship and program development guidance.

“It is such an honor and privilege to work side by side with Steve and Albert,” said Dr. Cheng. “There is incredible synergy between the work of geriatric medicine and palliative care here at PAMF. Each day, we strive to work together to deliver the absolute best care possible to our rapidly aging community. Our ultimate dream is for PAMF to be the epicenter of what’s right in caring for older people, by doing all we can to help the organization support patients along their aging journey.”

Learn more about geriatric medicine and palliative care programs at PAMF and Advance Care Planning, Advance Health Care Directives and POLST. To learn more about PAMF’s “Honoring Your Wishes program, attend a free talk by Dr. Steve Lai on Oct. 30 from 6:30 – 8:30 p.m. at the PAMF Palo Alto Center in Palo Alto. Register here.