Ep 17: The Next Round of Age-Friendly Care

Terry Fulmer  0:02

There was a riff in that book that talked about frail older adults. It talked about tying bows and people’s hair, making fun of them. And I was disgusted. A system that starts at your kitchen table takes you, perhaps, to the emergency room, maybe to the ICU, back to rehab, back to your kitchen table. Every point of care has to be age-friendly.

 

Lan Nguyen  0:26

That was Dr. Terry Fulmer, President of the John A. Hartford Foundation, a philanthropic organization dedicated to enhancing the health and wellbeing of older adults.

 

Terry Fulmer  0:37

I might submit ten papers before one gets accepted to share moments of failure if you want to call it that. I don’t call it failure. I just call it next round. I would tell the younger Terry that it’s going to be alright, that there are multiple paths. And if you get on the wrong path, you can get off it. 

 

Lan Nguyen  0:57

In this conversation hosted by Dr. Joanne Conroy, President, and CEO of Dartmouth Hitchcock and Dartmouth Hitchcock Health, we learn about Terry’s career path, from bedside nursing to academia to leading the national conversation around age-friendly health systems. So let’s jump into Her Story, a program where we explore the intersection of women in leadership and healthcare.

 

Joanne Conroy  1:24  

Welcome to Her Leadership Story. My name is Joanne Conroy, and I’m President and CEO of Dartmouth Hitchcock and Dartmouth Hitchcock Health. It is my great pleasure to have Dr. Terry Fullmer, Ph.D., RN, who’s president of the John A. Hartford Foundation and a member of Women of Impact. We are here to talk a little bit about her life story, as well as some of her perspectives on where we need to go in terms of aging in America. Welcome, Terry, it’s great to have you here. 

 

Terry Fulmer  2:00  

Joanne, thank you so much. I’m just honored to be with you today. 

 

Joanne Conroy  2:04  

Let’s start with how your career in nursing started. How did you determine your direction?

 

Terry Fulmer  2:11 

I’m going to call myself one of the lucky ones because, from the time I was five years old, I knew I was going to be a nurse. I was inspired by my mother, who was a cadet nurse and she had these incredible capes when she was in the army and she seemed to be so knowledgeable. She knew things, she inspired me – her twin sister was a nurse, several of my aunts were nurses, my sister’s a nurse, my nieces are nurses. There is a temperament that goes with that, and I have always been so blessed to say that I picked the right profession.

 

Joanne Conroy  2:45  

There were probably some decision trees somewhere in your career, though, where you move from bedside nursing to actually nursing leadership and nursing research.

 

Terry Fulmer  2:57  

Yes, and I will tell you that I continue to do my bedside nursing as an attending nurse at Mount Sinai Medical Center in New York City, where I go on service twice a year to ground myself in the essence of the profession. As I began my career at the Beth Israel Hospital in Boston, Massachusetts, one of the great moments was when I determined that I was going to be working for the one and only Joyce Clifford. Joyce Clifford was an iconic nurse leader who inspired all of us to be primary nurses, to own our practice, to be responsible and accountable for our practice. Trish Gibbons was the Chief of medical nursing, a woman who stayed in my life until she died, too early, at 70, of cancer. But Trish was a person who always gave you a platform to run with and would say to you, “Terry, you care about improving the well being and care of older adults. What do you want to do here?” That’s how we started NICHE. “Terry, you are very worried about elder abuse. What do you want to do? Go ahead and start the Beth Israel Elder Abuse Team.” And we did. And so it’s about leadership, and it’s about women empowering women.

 

Joanne Conroy  4:06  

When you were at Beth Israel, your paths crossed with a young physician that was an author that wrote a book that was very popular when I was going to medical school. And I understand they still sell between one and 2 million copies a year. Talk a little bit about that. 

 

Terry Fulmer  4:24  

The context: the 70s, women’s liberation movement, unrest on campuses, black power, all these things going on. And a general upheaval about medical education, by the way, as well as nursing education. And Samuel Shem had written a book called House of God, I read the book, and I was never more offended in my life. It’s probably one of the reasons I became so passionate about geriatrics. There was a riff in that book that talked about frail older adults, they talked about tying bows and people’s hair, making fun of them, and I was disgusted and it set my path. If you don’t want to give good care to older people, get away from them. I was able to tell them that later. 

 

Joanne Conroy  5:09  

But experiences like that galvanized people, and it obviously galvanized you to go into geriatric care. Talk a little bit about your path to the Hartford Foundation, which arguably is an organization in the U.S. is doing the most to really advance the care of the elderly. Getting older is an area of medicine that is rife with opportunities to really change things. 

 

Terry Fulmer  5:34  

It really is. I was at the Beth Israel, and I saw that we could improve care for the geriatric patients. And it turned out that there was a person named Jack Rowe, who’s coming back from the National Institute on Aging and setting up the Division on Aging and Department of Geriatrics at the Beth Israel, and I saw the opening. I knew that he would need an interdisciplinary team and nurses. We began working together, and every time there was an opportunity within that constellation of experts, we had just extraordinary faculty in the Harvard Division on Aging, and I just stepped up and said, “yes,” because there was always something that would advance my career be interesting and would help me improve care for older adults. So why do I say that in this context, when I was at the Division on Aging, the John A. Hartford foundation trustees came to visit to do a site visit and I was there and watched as the foundation talked about funding work on delirium very early on. I was recruited next, as my husband got a job opportunity in New York City, to Yale, and when I got there, again, there was the John A. Hartford Foundation. Talking with Leo Cooney, the endowed chair and chairman of geriatrics at Yale. And I watched and listened and already had a little sense of the Foundation and they launched something called the HOPE Project, Hospital Outcomes for Patients who are Elderly, and I was able to embed my thinking that I had begun to evolve around the NICHE program at the Beth Israel, and embed it into that work at HOPE and at Yale. And the John A. Hartford foundation funded that work again, I got to know them a little bit better, embed them. And subsequently, after a wonderful period of time at Yale, I was recruited to Columbia. And when I got there, I continued my conversations with the Foundation and they made the first grant ever to a nurse–to me at Columbia along, with my co-P.I. Mathy Mezey, at NYU. And that’s where we really began in earnest, the full-fledged development of NICHE: Nurses Improving Care for Healthsystem Elderly. So from there, moving from Columbia, got recruited to NYU, and there, Mathy and I led the Hartford Institute for Geriatric Nursing. I got recruited to Northeastern University in Boston, which was just another one of those fairy tale places where it was up and coming, scrappy and restless, moving very beautifully into the forefront of higher education. There, I was at Northeastern, and I got a phone call from the search firm that was looking for a new CEO for the John A. Hartford foundation. And to my great delight, I was successfully selected. And I’ve been there for now going into my sixth year.

 

Joanne Conroy  8:23  

I know that one of your favorite quotes is a quote from Gloria Steinem, that says, “Without leaps of imagination or dreaming, we lose the excitement of possibilities.” Did you dream you were going to be a college president and then had to shift it to be president of a National Foundation?

 

Terry Fulmer  8:42  

What I know about me is I love to beat my personal best. I’m not competing with you, I’m competing with me. When I move my career ahead, I like to beat my personal best and say to myself, “I could do that.” Very often. You’re looking at people in roles, and you say, “I could do that.” And so if you could, then do it. It’s the “Talk is cheap, watch what people do.” Yeah. So if you think you can do it, try. I might submit 10 papers before one gets accepted. I might put my name in for three jobs before I get that next one. And to share the moments of failure, if you want to call it that. I don’t call it failure, I just call it next round.

 

Joanne Conroy  9:08  

Talk a little bit about your first 100 days at the Hartford Foundation. I mean, you were a known entity, they knew you. But it’s different to be known by an organization and to come in and really make an assessment of how you actually make that organization better. 

 

Terry Fulmer  9:27  

It’s all about understanding the trustees, mission, vision, and goals, what they want, and making sure you mesh with them. And that you don’t compromise what you think is right, but you listen carefully. When I joined the Foundation, they were in transition with chairs. We had been very devoted to developing the next generation of leaders in geriatrics, so we were funding centers in geriatric medicine, geriatric nursing, geriatric social work, and funding models of care, as well as doing our Health and Aging Policy Fellows Program. When I joined, they said that they wanted to shift downstream to the point of practice. Music to my ears. I was in higher education as a Dean or a Professor for 37 years, I loved every minute of it. But at my heart, I’m a clinician, and in my essence, I’m a clinician, and so I could translate that for them. And I knew I was going to be able to do that. First 100 days–when I took the position, I presented my first 100 days–and they were very pleased with that. One of our trustees said, “So Terry, what’s your big idea?” And I kind of knew, and I said, “My big idea is age-friendly health systems because there is no such thing.” And we moved very rapidly from there. And what I needed to do was work with our remarkable staff at the Foundation, who are very smart and very knowledgeable. And say to them, “This is what I’m thinking, Are you with me? Can you improve it with me? Can you get on board with me?” And I looked in the eyes of each of them, and they have been my most passionate supporters. 

 

Joanne Conroy  10:59  

When you talk about age-friendly health systems, especially around COVID, we have seen a lot of gaps that we’ve got to make priorities and to address. How has that shifted your thinking about age-friendly health systems, and maybe the priorities that we need to address?

 

Terry Fulmer  11:16  

I would say for all of us in geriatrics, it was a galvanizing moment. All of a sudden, we were seeing the numbers out of nursing homes, we made an emergency grant to the Institute for Healthcare Improvement, to work on a National Nursing Home Huddle that took place every day to really get out there and support the frontline nursing home personnel.

 

Joanne Conroy  11:34  

Yeah, I think for all Americans that have family members in nursing homes and haven’t been able to see them, but have been able to appreciate the strains on our nursing home system right now in order to deliver the care that we would expect to receive as an older person. Think 10 years ahead or 20 years ahead, and what do you hope elder care will look like in the frail elderly?

 

Terry Fulmer  12:00  

Twenty years would be unacceptable, and ten years seems kind of slow, as well. But what you’re describing, Joanne, is an age-friendly health system. A system that starts at your kitchen table, takes you, perhaps, to the emergency room, maybe to the ICU, back to rehab, back to your kitchen table. Every point of care has to be age-friendly, whether you’re in a CVS MinuteClinic. So no matter where you are–point of care, quality of care–an age-friendly health system causes no harm, is responsive to what matters to the older individual and is reliable. What we have is a lack of reliability that is shocking to you and to me, and it can’t continue. When I try to get people’s attention on this, I say, “Let’s close all nursing homes.” Why would we do that? Because incremental, tedious, little tinkering and change will not do what we need to have ready for the baby boomers.

 

Joanne Conroy  12:56  

Who will be out in force, looking for some support as they age? Let’s talk about you personally, when you were talking about your journey, you’ve actually moved to a bunch of different cities, and you have a professional spouse. How did you and your husband actually manage that?

 

Terry Fulmer  13:12  

That’s a negotiation that’s ongoing from the time you decide that you’re a couple. Keith and I met, actually, in third grade. And we started dating when I was 15. So we’ve known each other and one of the beauties of that is I knew his mom and dad, he knew my mom, my dad had since passed, but we knew a lot about each other, and we sort of had a way of understanding each other, which does not mean that our negotiations were any easier. We graduated college, and there was a first negotiation where Keith got a scholarship to St. Lawrence, I got a scholarship to Skidmore. These were incredible schools, very generous scholarships, or we wouldn’t have gone. He got a position in grad school at Northeastern, so that decided Boston. So each turn along the way. It’s like, where are we going to live? How are we going to do this? We were married several years before we had our first adorable baby, Nina, who’s now 36. And at that moment, Keith turned to me and he said, “You’re not really going to work, are you?” And I said, “Keith, I’m a tenured professor, I tend to think of this as a career.” Even your own husband–and in my community, people would say to me, “Do you have to work?” It’s a career. I think that we are not past that curve. Yet, young women tell me it’s still there. We have to support them and help them with language.

 

Joanne Conroy  14:29  

You and I both know that healthcare has been historically very hierarchical, very male-dominated, and it’s permeated every aspect of delivering care. And I think we’re breaking barriers subtly. But there’s a lot more work to do. So talk a little bit about some of the interesting observations you had as a nurse leader.

 

Terry Fulmer  14:53  

I mentioned briefly that I worked at Harvard, Yale, and Columbia. One would notice that those are pretty traditional, male-dominated–particularly if you’re in a medical school organization. Whenever I came to any table, any meeting, any discussion, extremely well prepared with science in my back pocket, with the clear message that I was ready to lead and take on any responsibility to get the work done that we needed to move ahead. And that was very helpful in terms of having me being brought in as a colleague, and as a trusted partner in the work we were trying to accomplish. I think the Harvard Division on Aging was actually very well-rounded. Again, it was the 70s, and there was a lot of momentum around women’s rights. And we spoke about it. And one time, we’re in a meeting. And I remember there was a person who was talking about caregiving. And one of the people in the room made the comment, “Well, we really have to help women with caregiving.” And I said, “I don’t want you to help me, I want you to do it. I could double the number of caregivers tomorrow if I could double the gender.” And what happened in that moment is, everybody laughed, and they changed the topic. Fast forward. If I say the same thing today, about the same thing happens. So until we seriously look at the way that we share those responsibilities or decide that we’re going to, in any family unit, have them be unequal for reasons that we expressly understand, we won’t make the progress we need.

 

Joanne Conroy  16:24  

It’s interesting that as a medical student, and even as an attending physician, I would walk into patients’ rooms and they would assume I was the nurse.

 

Terry Fulmer  16:33 

I love that example of when female physicians are immediately considered nurses. When I was applying to colleges–and there was a lot of pressure on me from my parents to go to medical school. That was the 70s, things were opening up. Prior women could be secretaries, nurses, or teachers. They felt it was in my best interest to free myself up and go for those new opportunities. And I knew I wanted to be a nurse. And so I had to argue a lot about that. And I would never change that. But it was stressful. Then, as I moved up my career ladder, people would say, “Oh, but you’re not really a nurse.” “Yes, I really am a nurse.” “No, no, you’re a Ph.D.” “No, I’m not. I am a nurse.” And then they say, “Well, why didn’t you go to medical school?” And what I found was helpful is, I would say, “You wouldn’t ask a lawyer, why they are not an accountant.” So it’s a good idea not to ask a nurse why they’re not a physician, two fundamentally different roles. The other thing you have to guard against, is this “me versus them”. Because people immediately riff into the, “Well, it’s the nurses who do all the work.” No, nurses do nursing work, physicians do physician work–and explain to them, because that othering and that pitting is not a useful narrative. 

 

Joanne Conroy  17:48  

You mentioned Joyce Clifford, who actually my nursing executive here says is one of the legends in nursing. And actually, B.I. was a legend in nursing for years, the best in the country. So talk about mentors that you’ve had, and sought out to give you advice.

 

Terry Fulmer  18:12  

You’re right, it was a Camelot moment in nursing to work at the Beth Israel because everything was possible. And we were empowered. We were accountable and responsible, which was the key to our success. And it was really the partnership of Joyce Clifford and Mitch Rabkin, the CEO of Beth Israel, that made that possible. I think that there are people who are just inspiring. And so Trish Gibbons was one of those inspiring people, she would always say, “Always start your conversation around what’s going to make it better for the patient, and the conversation will go well.” And that’s true instead of me versus you or: Whose work is it? Whose fault is it? What’s in the best interest of this patient right now? And Trish was fun and funny and smart and challenging and brave, and I loved her bravery. She would cross lines sometimes that others would fall short of. And other mentors, certainly Jack Rowe. Jack, who was a legendary Chief Medical Resident, and he went to NIH, and then he came back to start the Division of Geriatrics in the Harvard Division on Aging. And he was tough, but fair, and he would welcome you as long as you could hold your own. And then he would open doors for you. And he’s opened so many doors for me.

 

Joanne Conroy  19:24  

Oh, serving as a sponsor. 

 

Terry Fulmer 19:26

Yeah, he is a sponsor. 

 

Joanne Conroy 19:27

And we all need those. Will we think about leadership, are you an accidental or an intentional leader?

 

Terry Fulmer  19:35  

And I am a very intentional leader. And I think of careers as–think of it as sport. What’s your next play? And do you see the opening? And do you know where you’re going to pass the ball to or where to skate to where the puck is going? And watch, because if you just keep your head up, oh my goodness, the options are remarkably broad, diverse, and deep. And you touch base with people, you call Trish, you call Joyce and say, “What do you think of this one? And what do you get that?” and get some feedback. And sometimes you make mistakes, and you go, “I should not be here.” And then you have to get out of it.

 

Joanne Conroy  20:08  

You’re right. People are very willing to give advice, and it can be incredibly helpful from somebody that’s actually walked that path before. I’m sure there were a lot of people that have applied for every single job that you actually were recruited and hired for. What do you think it is about you that has allowed you to move forward?

 

Terry Fulmer  20:28  

I’m very, very tenacious and driven in what I consider the best sense because we only have one life and we want it to be very purposeful and we want to make sure that at the end of the day, we spent our days well and made a difference in the world. So that guides me. And I think that, for me, when things don’t go, you have to have a sense of humor and have a great sense of humor and have a great ability to laugh at myself. And I will also say, for me getting from A to Z, I have a husband of 45-plus years and three unbelievable kids. And sometimes, on your worst day, you come home, and your kid asks you something or complains about something, and it just puts everything in perspective. There’s always somebody who has a more important question than you do.

 

Joanne Conroy  21:15  

That’s a great perspective. What would you tell Terry who is 21 years old, given the wisdom that you have accumulated over the last 40 years?

 

Terry Fulmer  21:27 

I would tell the younger Terry that it’s going to be alright, that there are multiple paths. And if you get on the wrong path, you can get off it. And that if you find yourself in a place where you don’t believe that your capacity is doing the best for the most people, then you probably need to rethink what you’re doing. One of the trite phrases I use–and I’ve used with nursing students–says, “Everything’s reversible, except death.” So just remind yourself in these moments that we’re going to get there. This is slower, this is harder. We’re feeling some pain around this one. But we’re going to get there and to get around a corner to where we’re going to be able to laugh at this. 

 

Joanne Conroy  22:15  

You know, we have all done a faceplant at some point in our career. And we do get up and brush ourselves off and keep going. Terry, I have just incredible enthusiasm about the future of elder care because you’re at the helm of the Hartford Foundation. Thank you so much for your time, and you will inspire many nurses and physicians and people from all walks of life. 

 

Terry Fulmer  22:40  

Thank you so much for this wonderful conversation. 

 

Lan Nguyen  22:44

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