What We Tried

As one of five pilot organizations in the Age-Friendly Health Systems initiative, Providence St. Joseph Health is committed to improving health care for seniors and their families focused on the 4M model:

• What Matters – Know and align care with each older adult’s specific health outcome goals and care preferences including, but not limited to end-of-life, and across settings of care.
• Medication – If medications are necessary, use Age-Friendly medications that do not interfere with What Matters to the older adult, Mobility, or Mentation across settings of care.
• Mentation – Prevent, identify, treat, and manage dementia, depression, and delirium across care settings of care.
• Mobility – Ensure that older adults move safely every day in order to maintain function and do What Matters.

To address “what matters” to patients, we formed a multidisciplinary team that includes a physician, physician assistant, nurse, social worker, and chaplain. As team members thought about how to better understand and address older patients’ goals and preferences, we found inspiration in a tool called “The Serious Illness Conversation Guide,” which helps clinicians talk with patients about end-of-life care. The guide gives providers language to use or adapt, including a series of questions that can help uncover a patient’s goals, worries, and wishes.

We decided to use the “Serious Illness Conversation Guide” as a template for developing a “What Matters Conversation Guide” that providers can use for our general patient population ages 65 and older who are not near the end of life. We are designing the guide as a template that can be used and adapted by staff across different care sites at Providence St. Joseph Health, including acute, ambulatory, and home care.

First, we identified six key steps to follow before, during, and after these conversations with patients:

1. Set up: Invite the appropriate people to the conversation and check the electronic health record (EHR) for notes from previous discussions with the patient.
2. Invite the patient to the conversation: Explain the reason for the discussion and request permission to ask the patient a few questions.
3. Ask the questions: Learn what matters to the patient by posing a few questions
4. Summarize and action planning: Confirm what the patient said and invite the patient to help determine how to best fulfill his or her goals and preferences.
5. Next steps: Acknowledge that this will be an ongoing process.
6. Document: Add or update the patient-stated goals in the longitudinal plan of care in EHR.

Identifying the right questions to ask patients has been an ongoing process. We have been testing different questions and phrasing in our outpatient clinic and through our Elder at Home program, which provides multidisciplinary support to fragile seniors in their homes. Using the Plan-Do-Study-Act process improvement model, we test the questions on at least five patients and log the interaction. One of the things we’re looking at is whether the patient appears comfortable answering the question.