New Delivery Models

Building an Age-friendly Health Care System

Changing demographics are forcing new attention on health care for seniors

By Lola Butcher

Seven primary care physicians at Providence St. Joseph Health recently tried to serve themselves food while blindfolded. They put their hands in mittens and tried to get dressed. They used wheelchairs to get from one floor of the hospital to another.

They were learning what it feels like to be a frail, elderly person navigating a world that is set up for the young, strong and speedy.

“The main reaction I heard was ‘Oh, I had no idea,’” says Ruth Johanson, executive director of the Senior Health Program for the health system’s Oregon region, based in Portland.

But the physicians — and their administrative colleagues who joined them in the exercise — are gaining a better perspective on an important segment of the patients they serve. Their learning is one facet of the work that Providence St. Joseph Health is undertaking as a leader in the Age-Friendly Health Systems initiative.

Age-Friendly Health Systems is a movement — a plan to systematically spread best practices in the care of older adults across the country — developed through a partnership of the Health Research & Educational Trust, an affiliate of the American Hospital Association; the Catholic Health Association; the Institute for Healthcare Improvement; and The John A. Hartford Foundation.

“We’re calling this a movement because there’s a lot of energy and a groundswell of excitement that’s building up about this effort,” says HRET President Jay Bhatt, D.O., senior vice president and chief medical officer of the AHA. “And we know how important it is given the issues of affordability and poor outcomes among older adults.”

The philanthropic John A. Hartford Foundation has worked on behalf of older adults for more than 35 years, supporting the development of many proven care models. But none has spread universally throughout the continuum of care, says Terry Fulmer, Ph.D., R.N., the foundation’s president, speaking on why we need age-friendly health systems.

America’s changing demographics are forcing new attention on the need. More than 46 million Americans are 65 or older today, and that number will double by 2060. Currently, 77 percent of U.S. seniors have chronic diseases. Many seniors live well past age 80, and the majority of them will require some type of long-term care.

The foundation provided grant funding to help five systems — Providence St. Joseph; Anne Arundel Health System, Annapolis, Md.; Ascension, St. Louis; Kaiser Permanente, Woodland Hills, Calif.; and Trinity Health, Livonia, Mich. — develop and test new care processes for older adults. The goal is to make life easier and better for health care providers and older adults alike.

“We want to be effective, add value and be measurably impactful so that every CEO in this country says, ‘I want my system to be age friendly,’” says Fulmer. “We are creating a social movement where our further goal is for every person to say, ‘I demand age-friendly health care for me and my family.’”

What “Age-friendly” Looks Like

As they age, many seniors experience decreased mobility, social isolation, loss of independence and changes in their self-identity that make everyday life harder. On top of this, the challenges inherent in America’s fragmented health care system are magnified when viewed through the lens of their complex needs.

“That includes transitions between care settings, potential side effects or problems with adverse drug interactions, the lack of care planning and poor coordination between caregivers,” says Marie Cleary-Fishman, HRET vice president of clinical quality.

The best response from health care providers, Bhatt says, is the age-friendly “4M” model, which takes its name from four broad priorities:

• What Matters: Knowing and adhering to each older adult’s personal health goals and care preferences.
• Medications: Limiting medications to those that, as much as possible, do not interfere with the patient’s mental functioning, mobility or personal preferences.
• Mentation: Recognizing and managing depression, dementia and delirium across care settings.
• Mobility: Ensuring that older adults move safely every day, at home or in any care setting, so they maintain function and can do what matters to them.

The four M’s line up with the goals of hospitals and health systems that seek to use evidence-based practices to improve the quality, efficiency and patient/family experience of the care they deliver, Fulmer says.

For example, preventing a serious, fall-related injury during a hospital stay can decrease a patient’s length of stay by an average of 6.3 days, according to a review of 57 hospital inpatients discharged between Jan. 1, 2004, and Oct.16, 2006. (See “The Cost of Serious Fall-related Injuries at Three Midwestern Hospitals,” by C. A. Wong et al., Jt Comm J Qual Patient Saf. 2011 Feb; 37[2]: 81-87.)

And delirium detection and treatment programs save $16 for every $1 investment, according to a review of the 2008 performance of an inpatient delirium-prevention program. (See “Sustainability and Scalability of the Hospital Elder Life Program at a Community Hospital,” by Fred H. Rubin et al., J Am Geriatr Soc. 2011 Feb; 59[2]: 359–365.)

Birthing a Movement

The 4M model was born out of an extensive process to determine the most important elements of good care for older adults. Staff at the Institute for Healthcare Improvement (IHI) examined 22 evidence-based care models developed in recent years to identify 13 core features, says Kedar Mate, M.D., IHI’s chief innovation and education officer. Staff members then assembled a group of geriatricians, health system executives and other stakeholders to prioritize the most important ones.

“Distilling our work to the four M’s — what matters, medications, mentation, mobility — looks simplistic, but it was very hard to do,” Fulmer says. “Thanks to IHI and our clinical partners, we’ve got a parsimonious, elegant model, which we think of as the gateway into excellent geriatric care.”

By design, each of the four elements reinforces the others. For example, making sure that medications are properly managed increases an older adult’s ability to move safely and think clearly. Likewise, managing dementia and delirium increases the likelihood that medications will be taken properly and patients can express their “what matters to me.”

Also by design, the 4M priorities cross the continuum of care, Mate says. Mobility — staying as active as possible without falling — is as important on a hospital unit as it is in a patient’s home, doctor’s office or skilled nursing facility. So leaders at all settings of care can share that priority when thinking about how they care for patients.

Another intention was to create a care model that could be adopted widely. The five health systems are currently prototyping and testing ways to operationalize the four M’s. They are starting with small-scale tests, then spreading that knowledge within their organizations.

“They will teach us what it would take for those systems to reliably implement those four M’s for every patient who crosses their thresholds,” Mate says.

That learning will be used for an Age-Friendly Health Systems campaign next year with the goal of having 1,000 care sites — including ambulatory, inpatient, and post-acute — committed to age-friendly care by 2020.

That does not suggest that all systems will be using identical protocols; rather, they will all be embedding the tenets of the 4M care model as it makes sense for their own organizations. And because of their focus on best care for older adults, they will be learning from experience and from each other.

“I fully expect that we will continue to improve the content of what it means to be ‘age-friendly’ so that we will be constantly pushing the field forward towards improving care for older adults over time,” Mate says.

Age-friendly Care in Action

The pilot sites, each of which has its own goals, are experimenting with different practices in different settings.

For example, Kaiser Permanente’s (KP) goal is to reach nearly 3,500 older adults served in Acute Care of the Elderly (ACE) units, a nursing and rehab center and palliative care clinic at the Woodland Hills Medical Center. Initial steps included developing patient-facing medication lists and a patient survey to determine “what matters.” Looking ahead, KP will work with physical therapists to develop “My Daily Exercise” sheets to keep patients and clinicians focused on improving mobility.

Anne Arundel Health System, meanwhile, is trying to reach nearly 20,000 older adults in nine acute-care units, the emergency department and 25 assisted-living homes. The system started by incorporating “what matters” responses into patients’ electronic health records, improving patient and family education and working to reduce inpatient average lengths of stay for older adults.

HRET staff will help evaluate the results of the prototype sites and identify the best metrics to track going forward.

Age-friendly Care in Oregon

While other health systems are testing age-friendly practices in acute-care settings, Providence St. Joseph is focusing its work in the outpatient arena.

“It would be a slow pace for us if we tried to create all the best practices for both inpatient and outpatient,” Johanson says. “Being part of the Age-Friendly Health Systems network allows us to learn inpatient practices from others and to share our outpatient findings with them as we get further down the road.”

To focus on mobility, Providence St. Joseph recruited a nurse practitioner with geriatrics expertise to develop a comprehensive fall-prevention program to serve patients in their homes, when they visit medical clinics, and in the community.

While some of the health system’s primary-care clinics have routinely conducted fall risk assessments in the past, Johanson says, there has not been a standard process for referring at-risk patients for physical therapy, a medication assessment, or a home-safety evaluation.

“We are working to make that a really efficient loop so that providers are equipped to make that happen very easily,” she says.

The health system is working to optimize the use of the STEADI — Stopping Elderly Accidents, Deaths & Injuries — toolkit developed by the Centers for Disease Control and Prevention. That includes educating patients and their family members on how to reduce the chance of falling at home; developing a Tai Chi training program that makes people steadier on their feet; and coaching providers on how to incorporate a fall risk assessment into a patient visit.

For the medication “M,” Providence St. Joseph is encouraging providers to limit the use of “Z drugs” — insomnia treatments that are associated with falls and injuries among seniors. To address mentation, the system plans to develop a dementia-care pathway.

And for “what matters,” Providence St. Joseph is creating a conversation guide that will help staff members learn about an older patient’s priorities and preferences and share the information.

“Whether it’s a front-desk person or a nurse or a medical assistant or a physician, we need to be able to ask those questions in a way that is natural and respectful,” Johanson says. “And we need to be able to document the information in a consistent way so that any of our caregivers who come into contact with that individual will know what matters to that person.”

Joining the Movement

The age-friendly movement doesn’t ask health systems to add work but rather to redeploy existing hospital resources in a way that intentionally addresses the needs and preferences of their ever-growing population of older patients, Bhatt says. Age-friendly practices line up with the mission, vision, and values of American health care providers.

“This puts hospitals ahead of the curve in preparing for this continued demographic change,” he says. “It reduces the costs associated with inappropriate utilization and variation in care delivery. And it honors the wishes and preferences of patients and their families.”

Fulmer says that’s why more than 200 individuals and groups are participating in “Friends of Age-Friendly” quarterly conference calls so they can start learning from the test sites and embedding the best practices in their own institutions. (Send an email to AFHS@aha.org or AFHS@ihi.org to be notified of future calls.)

The Age-Friendly Health Systems initiative is inviting up to 100 teams from health care settings across the nation to join the Age-Friendly Health Systems Action Community. Teams will work together to rapidly scale up the 4M model over seven months, starting in September, Mate says. (For more information, visit http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems.) “People are ready, they understand this needs to happen, and they want to leapfrog what has gone relatively slowly over the past decade and accelerate the change,” she says.

Roughly 10,000 Americans are turning age 65 every day. By 2050 — just 32 years from now — 4.5 percent of the U.S. population will be 85 or older.

“We have known since baby boomers were born that they would get older, and here they are,” Fulmer says. “We have to get ready to care for them with the quality and reliability we would want for ourselves and for our families.”

Lola Butcher is a contributing writer to Trustee Insights.