Hospitals are reporting positive results from a program sponsored by The John A. Hartford Foundation (JAHF), a nonprofit, nonpartisan organization in New York City that works to improve conditions for the care of older adults in the healthcare system.
The Age-Friendly Health System initiative seeks to improve care transitions and the way episodes of care are addressed for an aging population, says JAHF President Terry Fulmer, PhD, RN, FAAN.
Five health systems providing care in 40 states have adopted the program, which focuses on four key elements that can be applied to any hospital or health system. JAHF calls them the four M’s:
• what matters to the patient;
• mentation, or mental activity. This includes confusion, delirium, and mood.
JAHF also urges an age-friendly healthcare system to employ leadership committed to addressing ageism, a geriatric care prototype specific to older adults, clinical staff who are specifically trained and expert in the care of older adults, care teams that are high-performing and can show measurable results for care of older adults, a systematic approach for coordinating care with organizations beyond their walls, and a strategy to identify, coordinate with, and support family caregivers.
The organization also should elicit patient goals and preferences so as to define a plan of concordant care, reduce polypharmacy, address common geriatric syndromes, manage pain and symptoms, and support the needs of family and caregivers.
The age-friendly initiative is an opportunity to explore population health and person-centric care models, says Ann Hendrich, PhD, RN, FAAN, senior vice president and chief quality/safety and nursing officer with Ascension Health in St. Louis. Ascension is adopting and testing many of the age-friendly prototype models not only in its population health management systems, but also on the acute care side, working directly with providers.
“In the area of pharmacy, there are a lot of medications that should be minimized or not used at all in the older adult. Often, they’re unnecessary,” Hendrich says. “We’ve worked with our pharmacists at a national health level to identify medications that can be minimized and avoided. We want to understand why the medication is needed before we provide it, especially if it might have an effect on mobility.”
Ascension also is addressing ways to explore what is most important to older adults, including end-of-life care decisions.
“In our clinic and ambulatory areas, our providers are changing the way they do assessments and taking histories, trying to understand what matters most to these patients. We are trying to have meaningful discussions about what they want and having that guide decisions in their care process,” Hendrich says.
The four M’s of the JAHF Age-Friendly Health System initiative provide a structure for any organization to address the concerns of older Americans, Hendrich says.
“Those four M’s apply to any healthcare system regardless of size, and in the ambulatory system as well,” Hendrich says. “Ascension has set a goal of reaching 20,000 adults this year with age-friendly care, and I think every system could set a goal like that to see how many older adults they reach.”
The age-friendly initiative should fit into any integrated model of care, she says.
“Don’t consider it an add-on. Look at it as an integral part of your healthcare system’s efforts to improve quality of care,” Hendrich says. “Once you get your providers involved, these changes are not hard to implement with small numbers and then you grow from there. The impact on older adults can be tremendous. Our challenge is to scale these programs up quickly.”
There are existing geriatric models of care, but they reach only about 10% of the older adults who need that kind of care, says Amy Berman, RN, LHD, FAAN, senior program officer with JAHF.
“We brought together the people who developed these models and looked at 17 that had the greatest spread and the highest degree of evidence, asking these innovators to deconstruct their models to find the key elements. We found there were 90 key elements and a lot of overlap, with about 24 common themes,” Berman says. “Then, we asked the people who developed this evidence, leaders from health systems, and older adults to pick the things that would have the greatest impact on cost and quality. We wanted to find the things that would be the most influential in helping this group of patients have a better life, and that became the four M’s.”
The four M’s are implemented in various ways, including some small interventions. For instance, an older adult with cognitive impairment typically has a hospital length of stay 3.5 times longer than average, Berman notes. If that impairment is not recognized and addressed, nurses may take little notice of the fact that the patient did not eat a meal.
Under an age-friendly model, the clinician would be more attuned to that and perhaps suggest that family members stay with the patient during meal times, Berman says.
“One participating hospital is focusing on hydration. The typical bedside pitchers were not being used much, so they changed to the big cups with straws like people carry around in the park every day,” Berman says. “They’re finding that older adults are more comfortable with them and using them more, so hydration is improved. Something as simple as a cup and straw can have a huge impact because people who are dehydrated are at more risk of falls and delirium.”
Mobility is another major concern. Clinicians can be so concerned about the risk of falls that they keep older patients immobile, which leads to an overall deterioration of health, Berman notes.
“Some facilities are implementing mobility programs that actively seek to keep older patients mobile and not let them decline to a state of immobility just because they are hospitalized,” she says. “Some are making it a goal to improve the patient’s mobility while an inpatient, even if that is unrelated to the primary reason for the hospitalization. This is a new way of looking at the care of older adults, but we’re seeing organizations take these steps in the right direction.”