By Jeanie Davis
Case managers see it all the time: an older adult who has difficulty navigating the healthcare system. And, too often, this difficulty can lead to 30-day readmissions because the patient did not receive optimal care.
Vision and hearing problems, confusion, emotional disorders, and other difficulties interfere — and the patient’s care suffers, despite everyone’s good intentions.
Solving that problem is the crux of the Age-Friendly Health Initiative, developed to improve the experience and outcomes of care for older adults and their families. In 2017, five health systems adopted the model, and more than 100,000 patients received age-friendly care at 26 sites.
In less than two years, the Age-Friendly initiative has gone global, adopted at 350 sites in 126 systems in 37 states, as well as sites in Australia, Brazil, Nigeria, and Canada. “Those are just the ones we know about,” says Terry Fulmer, PhD, RN, FAAN, president of The John A. Hartford Foundation (JAHF). “It’s just wonderful; I couldn’t be happier.”
The health systems are collecting data on improvements in patient outcomes, which are already evident, reports Fulmer. More than 70 articles on the initiative have appeared in peer-reviewed journals and industry publications.
The core of the program is the 4Ms, based on a careful analysis performed by the Institute for Healthcare Improvement (IHI). This expert team studied the best practices and care models in the literature, then distilled the best concepts into these points:
• What Matters: Understanding and aligning care with what is most important to each patient;
• Medication: Using appropriate prescriptions that do not interfere with What Matters, stopping medications where needed;
• Mentation: Preventing, identifying, treating, and managing delirium, dementia, and depression;
• Mobility: Promoting safe and regular movement to preserve function, and implementing falls prevention strategies.
Case managers are prime “champions” for ushering this program into their hospitals, Fulmer emphasizes. “They’re the critical link to the transition of care from hospital to home. If they look at the discharge sheet, they will see the 4Ms in it.”
Case managers will be thrilled to see what the program can achieve, she adds. “The 4Ms empower the case manager to do their job effectively.”
Are you ready to carry the torch in your institution? In the following case studies, two hospitals describe their processes for implementing the program. If your hospital already is involved in NICHE (Nurses Improving Care for Healthsystem Elders), you are making progress — and are ready to take those concepts hospitalwide.
If you are in the early stages of gaining buy-in from hospital leadership and staff, it is important to make your message personal. By telling patients’ stories, you touch the hearts of everyone with an elderly family member or friend — and that sells the 4Ms initiative, Fulmer says.
Christiana Care System Launches 4Ms
Early last year, when Fulmer was looking for the first 100 sites to sign on, one hospital signed up immediately. “With it being evidence-based care, we knew it was the right thing to do,” says Denise L. Lyons, DNP, APRN, AGCNS-BC, a clinical nurse specialist at Christiana Care Health System, based in Wilmington, DE.
Lyons also is manager of the hospital’s NICHE program, a nursing program designed to improve geriatric care in healthcare organizations. Her team had already set up the Acute Care of Elderly (ACE) Unit at Christiana Care’s Christiana Hospital.
“The Age-Friendly initiative challenged us to take the 4M concepts to both Christiana Hospital and Wilmington Hospital and our primary care centers,” says Lyons.
Working directly with the section chief of geriatrics, they piloted the Age-Friendly 4Ms program within the ACE Unit and one primary care office. A whiteboard at the foot of each patient’s bed became the primary tool. The patient’s 4Ms were prominently listed on the board and updated daily based on the patient’s evolving goals and medical status.
“We wanted to embed the 4Ms in the electronic health records system, and started working with our colleagues in information technology,” says Lyons. “The whiteboard allowed us to move forward with the program in the interim.”
When that pilot program proved successful, Lyons’ team approached the Professional Nursing Practice Council to implement the 4Ms on a larger scale throughout the hospital. The council would determine how the 4Ms program and bedside shift reports would be integrated into daily workflow.
The senior nursing leaders were in “full support of the 4Ms,” Lyons says. The team currently is testing the program on a second nursing unit, then will roll it out to the other service lines. The nursing informatics team is working to embed these elements into the electronic health records.
Wellness nurses in the primary care clinics reported that the program is well-received by patients. “It’s all very positive,” says Lyons. “And there’s really not one extra thing for nurses to do. Really, it’s the focus on what matters most — that’s the big M that matters most to our patients.”
Anne Arundel Medical Center Rolls Out 4Ms
Anne Arundel Medical Center (AAMC) was also in the first wave to launch the Age-Friendly initiative. The hospital’s chief operating officer was on board from the start, as the hospital was already participating in the NICHE program.
Barbara Jacobs, RN, AAMC’s chief nursing officer, and Lil Banchero, MSN, RN, senior director of AAMC’s Institute for Healthy Aging, championed the 4Ms launch throughout the medical center.
The ACE Unit served as their pilot program and the organizing team made good use of all available training modules, podcasts, and webinars from JAHF and IHI websites, says Jacobs.
This core group of nursing supervisors led the program initially, then the ACE Unit nurses spread the message to the other service lines to “educate the educators on the units,” Jacobs explains. “These became the ‘superusers’ — each leading their own teams in the training and conducting full-day seminars.”
Physicians also received training in the 4Ms and other Age-Friendly concepts, as did social workers, physical therapists, occupational therapists, and other team members who work with the elderly.
Jacobs and Banchero have advice to get staff and the C-suite on board: “If you can tell the stories of these older patients, you can win them over,” says Jacobs.
“Everyone has an older person in their family, in their life,” she explains. “That will resonate to get others involved. We were very good about telling patient stories in every presentation. You need to touch their hearts.”
One patient story proved to be especially powerful. The team decided a patient needed to go to rehab. But the patient kept declining to go.
“We finally learned that for him, getting home to his dogs was much more important,” Banchero explains. “He didn’t want to spend that precious time in a rehab center. So we had to rethink the plan so he could go home and live there safely.”
This happens frequently, she says. “We assume the patient should go to rehab, but we don’t think to ask if that’s what the patient wants. The 4Ms show it’s not about us, the providers — it’s about the patients and what they want.”
The first M — “What Matters” — is the guiding force, Jacobs and Banchero say. “If we don’t get to the heart of what our patient wants, we won’t serve that patient well,” says Jacobs.
They also suggest tapping the hospital’s patient/family advisory group. These are current or former patients or family members who can become advocates for the 4Ms program.
The patient’s motivation will affect end-of-life discussions, adds Jacobs. “A patient might need dialysis, but if you ask that patient — such as a 96-year-old who is relatively disabled — they might decline. They don’t want their last months spent in dialysis. They want to go home. They want to go to a grandson’s graduation. They just want a bag of popcorn. Whatever they want, that’s the driver for their care.”
“Just imagine how powerful the 4Ms can be,” she adds. “Especially if they are documented so everyone can see what they are. These are the things most important to me, the patient — my three grandchildren. We will make sure you get home to see them.”
There is power in viewing the patient “as a person outside this illness,” says Banchero. “It’s extremely powerful to see that patient as a human. This sickness is just a little piece of them. Whatever it is they love, that becomes the focus we take.”
The AAMC team has hundreds of stories to tell, says Jacobs. “Right now, every single patient in the hospital is asked what matters most to them. The goal is that every patient, every day, will be touched by the 4Ms. The goal is that every day, we will look at what matters to them: the right meds, mobility, mentation. We’re doing dementia and depression screenings in our ambulatory care clinics today, for the first time.”
Enhancing care of the elderly is a movement, says Banchero. “We will provide safe care, the right care, so patients feel what matters to them is part of their care. This improves outcomes — reduces falls and infections. Patients are getting up and moving earlier, so they are less likely to fall and break a hip. They’re better hydrated, so there’s less likelihood of infections.”
Implementing the Age-Friendly 4Ms was “relatively easy,” says Jacobs. “We didn’t have to bring in extra resources. We’ve just redesigned some of our workflow. Any organization can do this.”
The initiative dovetails perfectly with AAMC’s mission “to enhance the health of people we serve,” she adds. “This program is a perfect example of that. We’re touching hundreds and hundreds of people. Not just patients; family feels it, too. The positives are great. It strikes a very powerful note with everyone.”