Care Process Redesign

New Program Seeks to Enhance Care of Elderly Patients

March 19, 2018 5:06 pm

Two national organizations seek to spread the “Age-Friendly Health Systems” movement to 20 percent of all health systems by 2020.

Nurses know that older patients need to be active—and that many resist. So nurse leaders in Anne Arundel Medical Center’s geriatric unit decided to push the matter a bit.

“We tapped one of our techs on the shoulder and said, ‘Today, on your whole shift, all I want you to do is walk everybody you can,’” says Lillian Banchero (pictured at right), MSN, RN, senior nursing director at the Annapolis, Md., hospital.

On that day, 15 patients on the 30-bed unit walked—triple the number from the day before. The next day, many of those patients were able to double their distance.

“It’s pretty dramatic,” Banchero says. “And the outcomes of mobility are just so well-documented. The more you move, the better you are, period. Your brain is better, you eat better, you sleep better. So, mobility is just part of what we do now.”

Anne Arundel is one of five health systems working through the Age-Friendly Health Systems initiative to create a sea change in the way that U.S. healthcare providers care for older patients.  Spearheaded by The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI), the effort seeks to create an industrywide movement that demands that older adults get the best possible care in hospitals, outpatient settings, nursing facilities, and the home.

“We want to have older adults satisfied with their care, and have value optimized for patients, for the payer, and for the system itself,” says Amy Berman, BSN, the Foundation’s senior program officer.

Preparing for Now

By 2020, 17 percent of the U.S. population will be 65 years or older, and that share grows to 20 percent by 2030. Already, nearly 6 million Americans are 85 or older—and that age group is one of the fastest-growing.

But you don’t need to look to the future to see the graying of America.

“If we look at the number of days in hospitals or home care—regardless of what the healthcare setting is—you’ll find that the majority of people being cared for are older adults,” Berman says.

The Foundation, which has been working to improve the health of older adults since 1982, identifies several widespread problems that place an unnecessary burden on older patients—and on the U.S. healthcare industry. Older adults often:

  • Receive unwanted care and treatment
  • Are harmed by inappropriate medications
  • Decline functionally because they are inactive
  • Experience delirium and cognitive decline that could be effectively addressed
  • Are subject to avoidable harms and death

While the Foundation has supported the development of many care models that have proven successful—for example, discharge-planning protocols and home visits—adoption has been slow. For that reason, the Foundation partnered with IHI to help spread the age-friendly movement across the industry.

Unlike the traditional pilot-program approach, the Age-Friendly Health System initiative is seeking rapid adoption of evidence-based practices that have proven their worth, says Kedar Mate, MD, IHI’s chief innovation and education officer. In the first phase of the program, in 2017, IHI and the Foundation began partnering with Anne Arundel, a stand-alone hospital, and with four giants—Ascension, Trinity Health, Providence Health & Services, and Kaiser Permanente. The providers are serving as prototypes for embedding age-friendly principles throughout an organization.

“They will teach us what it takes for those systems to reliably implement the principles for every patient who crosses their threshold, including for post-acute and ambulatory care and, in some cases, for home care,” Mate says. 

Because those systems are so large, their efforts will extend the age-friendly practices to 450 hospitals and more than 600 other healthcare settings in 40 states over the next two years. But that’s just the beginning. “The goal is to get 20 percent of U.S. health systems and all their locations to be age-friendly by 2020,” Mate says.

What Age-Friendly Looks Like

IHI and the Foundation convened a group of geriatricians and other stakeholders to review 22 evidence-based care models to identify the essential elements of age-friendly care. “We didn’t just ask them what would create better outcomes; we also asked what would create better value for the health system,” Mate says.

The result is what is being referred to as the “4 M’s:” what matters to patients, mentation, mobility, and medication. While many strategies and tactics can be applied to each of the components, an age-friendly health system will be working on all four priorities.

What matters. This component goes beyond advanced-care directives and end-of-life planning, Berman says, and requires providers to learn about and provide the care that a patient wants now: “How do you avoid things that a person does not want within their care, and how do you focus the care on achieving what the person is trying to achieve?”

Mentation. Age-friendly provider organizations will proactively diagnose, treat, and manage dementia and delirium in older patients. Failure to do so hastens physical deterioration, sometimes resulting in a nursing home stay for a patient who could stay at home with proper care.

Mobility. Making sure that older patients stay active—but avoid injuries from falls—requires careful planning, regardless of the care setting. Older adults often do not realize they should be mobile, Berman says. “When there isn’t an expectation that they should be mobile, they lose function, and then we have to work doubly hard to help bring them back,” she says.

Medication. Many older patients are overmedicated or taking medications that affect their mobility and mentation. Age-friendly providers work to optimize the use of medications and reduce potential harm.

The Age-Friendly Business Case

In addition to improved patient outcomes and patient satisfaction, age-friendly health care offers financial value, Berman says.  

For health systems paid in the fee-for-service system, the basic concepts—decreased medication, improved mobility, and improved mental functioning—all translate into decreased length-of-stay. That either improves the margin associated with the patient’s DRG code or reduces the losses that come with long hospital stays for complex patients.

Providers paid through shared-savings or other value-based contracts may benefit even more from age-friendly care delivery. “If you focus on what matters to older adults and you improve decision-making regarding their care, patients tend not to want the most expensive things to be done to them as they get older,” Berman says.

Age-Friendly at Anne Arundel

When Anne Arundel added inpatient capacity several years ago, it created an Acute Care for the Elderly unit to serve the area’s growing elderly population. The average age of an ACE patient is 82, and the unit typically includes 20 inpatients who are 80 or older.

Many nurses on the unit are certified in geriatric nursing. Moreover, the hospital has earned the NICHE (Nurses Improving Care for Healthsystem Elders) designation, and all nurses and patient care technicians on the unit get continuing education through that program each year.

And yet, Banchero says participating in the Age-Friendly Health System initiative will improve patient care.

In particular, improving medication regimens for older patients poses a challenge for Anne Arundel and for most health systems, she says. Knowing that patients are taking too many medicines is one thing; working with several physicians, each of whom is treating the patient for a different condition, to limit the number of medications, dose properly, and avoid drug-drug interactions is another.

“It’s a pretty daunting task, but we’ll get there,” she says. “We are trying to figure out how to best measure the outcomes for that.”

On the other hand, Anne Arundel’s “ACErcise” program is an idea—popular with patients, family members, and staff—that other systems on the age-friendly journey may want to adopt. Five days a week, patients gather at the end a corridor for a group exercise class; the social interaction improves mentation while the movement improves mobility.

“We wheel people down, and they have to walk back to their rooms after they have done some arm and leg exercises,” Banchero says. “For those who participate, it is incredible: They can walk 30 feet one day and 100 feet the next day. And the next day they’re walking the whole unit.”

Lola Butcher writes about healthcare business and policy topics for several HFMA publications. 

Interviewed for this article:  Lillian Banchero, MSN, RN, senior nursing director, Anne Arundel Medical Center, Annapolis, Md.; Amy Berman, senior program officer, The John A. Hartford Foundation, New York City; Kedar Mate, MD, chief innovation and education officer, Institute for Healthcare Improvement, Cambridge, Mass.


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