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On the Ground with Age-Friendly Health Systems

Liz Seegert September 17, 2018
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There’s no one-size-fits-all approach to applying age-friendly health concepts in a practice environment, because each system is unique.

Age-friendly health systems have the potential to improve care, reduce length of stay, empower staff and improve the bottom line. While change can be challenging, clinicians and staff in the participating health systems have embraced the process.

In a just-concluded year-long pilot program, five participating health systems—Ascension, Anne Arundel Medical Center, Kaiser Permanente, Providence St. Joseph and Trinity Health—have each found a way to succeed within the age-friendly framework. Thanks to the framework’s flexible approach, at least one key element of the initiative has taken root within each partner’s system, whether in-patient, ambulatory or skilled nursing setting.

“Adoption was much easier than anticipated,” said Ann Hendrich, Chief Quality and Nursing Officer at Ascension. “Asking patients what matters most focuses care and is making a big difference in how they’re experiencing each day.” Ascension is the largest nonprofit health system in the U.S., with 153 hospitals and over 2,600 sites of care in 26 states and the District of Columbia.

Staff at Ascension’s Center for Healthy Aging in Indianapolis began asking clinic patients about their care goals. “What matters” is one of the four core elements, along with mobility, mentation and medications, that comprise the “4M Age-friendly” health system framework. Understanding individual priorities easily and efficiently helps define care management. The process proved so helpful that the Center far surpassed its initial assessment goal of 500 patients. To date, they have screened over 5,000, according to Hendrich.

Nationally, more than 50,000 older adults across 26 sites in seven states received age-friendly health care from the five participating health systems during the pilot phase, according to Terry Fulmer, President of the John A. Hartford Foundation. The organization worked with the Institute for Healthcare Improvement (IHI) to create this evidence-based, elder-focused model of care. “Every older person needs to get reliable care, every time, every place,” she said.

At Anne Arundel Medical Center, a 425-bed facility in Annapolis, Maryland, average length of stay for older patients decreased 26 hours, or roughly 24 percent, since the start of the age-friendly pilot program. They’ve also seen a reduction in falls and a surge in patient satisfaction rates. “Having a conversation about what matters is powerful,” said Chief Nursing Officer Barbara Jacobs. “That’s the soul of the patient and it allows us to tailor care to what is most important to them.”

Someone may want to attend a wedding, be well enough to care for a spouse, or in the case of one 97-year-old, avoid rehab so he could be home with his dogs. Rather than sending him to a skilled nursing facility, the hospital arranged for in-home support to meet his goal.

They also took time to better educate clinicians and staff about issues like differentiating between delirium and dementia, and the importance of getting people out of bed and walking as soon as possible after surgery. “If mobility doesn’t degrade, it can change the destination upon discharge,” Jacobs said.

One solution to aid movement is a program called ACEercise (Acute Care of the Elderly). Regular group exercise conducted by a physical therapist not only encourages mobility, but also promotes socialization and helps mentation, another age-friendly “M.”

Jacobs calls the success of the 4M framework a “wonderfully positive endeavor for the system.” In year two, the program will expand to Anne Arundel’s emergency department. “I hope this really gets embedded in the ambulatory environment, from basic assessment to understanding how monitoring medications can decrease confusion.”

Medication management is a high priority at Ascension. There’s a de-prescribing initiative underway at several sites, Hendrich said. “Overmedication in older adults is very prominent, so pharmacists and providers are working as a team to review the medication our patients are on and which ones can be removed.”

Modeling a System-Wide Approach
Lessons learned from early deployment of the 4M framework helps to build a strong business case on efficiency and cost of care. Hendrich hopes to spread adoption throughout the care continuum. “Our goal is to have this framework become a practice standard over time, and if we can do this, we’ll be a model for the nation, given our diversity.”

Kaiser Permanente, another pilot partner, has tracked continuous improvement within the KP Woodland ACE unit. They developed and now use patient-facing medication lists, including hydration instructions in the palliative care unit. At Providence St. Joseph Health, the team has increased falls risk assessment, dementia and depression screening.

These efforts all add up, according to Kedar Mate, IHI’s chief innovation and education officer. “While some efforts were incredibly successful and some less so, the idea of the 4Ms being feasible was confirmed.”

Some organizations, like the University of California, San Francisco, just picked up the idea and ran with it, he said. They weren’t part of the pilot program, but oriented some of their geriatric practice approaches to the age-friendly framework and made a business case for spreading it across their system. The effort received institutional support, and is expanding throughout UCSF’s geriatric enterprise.

“It comes down to minimizing obstructions in the care of older adults, like delirium or falls, which lowers length of stay or decreases rates of readmission. Ultimately, it benefits the health system overall under various payment arrangements,” Mate said.

Phase two of the initiative began in early September with the launch of an “action community.” This seven-month program allows more rapid adoption of the 4M model across 100 health systems. The goal is for 20 percent of the 5,000 health systems in the U.S. adopt an age-friendly framework by 2020.

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Liz Seegert

Liz Seegert is an independent health journalist based in New York City. She writes about aging, boomers, policy and related topics for online, print and broadcast media, and also co-produces the HealthCetera podcast.

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