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Rolling Out the 4Ms for Age-Friendly Care Across the Care Continuum

3 minute read

Kaiser Permanente Woodland Hills is testing creative strategies to improving senior care in acute, post-acute, and ambulatory settings

The Issue

When determining how to pilot new approaches for enhancing health outcomes for older patients, Kaiser Permanente leaders decided to focus initial efforts at Woodland Hills Medical Center in Woodland Hills, Calif. Twenty-two percent of Kaiser Permanente members who visit Woodland Hills are age 65 or older, which is the highest density of older people in the health system’s Southern California service area. Our goal is to test strategies that can be adapted and scaled across the care continuum.

What We Tried

Kaiser Permanente is among the first five pilot hospitals and health systems to join the Age-Friendly Health Systems initiative, which follows the 4M model to guide senior care:

  • 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 roll out the “4Ms” across different care settings, we put together a team at Woodland Hills Medical Center that included Kaiser Permanente staff from three areas:

  • Our acute care for elder (ACE) inpatient unit
  • Our on-campus palliative care geriatric clinic
  • Canyon Oaks Nursing & Rehabilitation Center, a contracted skilled nursing facility (SNF), where Kaiser Permanente physicians and case managers oversee the care of Woodland Hills patients

Here are examples of strategies we have successfully employed since 2017 in these settings:

Mobility: Range-of-motion exercise sheets. At the Canyon Oaks skilled nursing facility, one of our physicians worked with physical therapists to develop a worksheet that illustrates simple range-of-motion exercises that patients can safely do by themselves while lying in bed or sitting in a chair.  The exercises are intended to help patients move their legs, arms, hands, feet and other body parts throughout the day so they can be stronger and more limber for their scheduled physical therapy sessions and get discharged home sooner.

Medical conditions are taken into account when selecting specific exercises for patients to perform on their own. For instance, patients recovering from hip replacement surgery would only be assigned upper body exercises and told to wait for physical therapy to work on their lower body.

When piloting the exercise sheet, we first had our case managers give patients the sheets and encourage them to do their exercises. But not many patients followed through on their assignments.

We revised the workflow and asked our physicians to “prescribe” a few range-of-motion exercises to each patient during their daily rounds. Physicians tell our members something like, “In addition to going to physical therapy, I would like you to perform Exercises 1 and 3 on this exercise sheet three times before I return to see you tomorrow.” Our members at Canyon Oaks have been much more likely to comply with their exercise routines when prompted by their physicians.

After hearing about Canyon Oak’s success with the exercise sheet, our inpatient ACE unit at Woodland Hills Medical Center borrowed the idea. ACE unit staff worked with physical therapists to adapt the exercise sheet for an inpatient geriatric population that has more acute needs than older adults in skilled nursing.

What matters: Getting to know you questionnaires. Prior to Kaiser joining the Age Friendly Health System initiative, our ACE inpatient unit had given patients a “Getting to Know You” questionnaire that asked patients about their family, hobbies, work life (current and past), favorite foods etc. As we thought about how we could better identify what matters to patients, we decided to expand the “Getting to Know You” form to solicit additional information on patients’ health priorities, preferences, and concerns. Our clinicians on the ACE unit refer to the completed questionnaires during patient rounds and discuss how to address, for example, a patient’s fear of needles.

Medications: User-friendly medication summary sheets and dedicated pharmacists.  Our physician in charge of our geriatric palliative care clinic was struggling with ensuring that members were taking the right medications at the right time. The medication information sheet that was given to patients was difficult to follow.

Our team helped the palliative care clinic develop a medication summary sheet that is more user-friendly. It uses graphics to help patients understand what time of day to take each medication. For instance, a bed icon indicates that patients should take a medication at bedtime while a sun icon means to take it in the morning.

Case managers for the clinic fill out the medication sheet while talking to the patient about each medicine and when to take it. Then the patient goes home with the filled out, easy-to-follow list.

Our ACE inpatient unit is also working on developing a more user-friendly medication list in our electronic health record that can be given to patients and families at discharge. In addition, a hospital pharmacist is assigned to the ACE unit a few hours a day. Part of the pharmacist’s role is to work with physicians on medication reconciliation (e.g., identifying medication interactions, cutting out unneeded drugs). The pharmacist also participates in patient rounds and provides pre-discharge education to patients and their families about medication compliance.

Mentation: Games and puzzles. Our ACE inpatient unit has engaged hospital volunteers during the day to spend time with our older patients putting together puzzles or playing Sudoku or other games. The goal is to help patients stay awake, interact with others, and use their mental faculties. This helps ensure they can sleep better at night and are more rested during the day.  We are also planning to start giving patients placemats on their food trays that include puzzles and other mentation games.

Impact

Most of the results we’ve been able to document to date have been qualitative based on reports from patients and staff.  For instance, our palliative care physician told us about one of her patients who was severely mismanaging his medications, causing numerous emergency department visits and hospitalizations. In early 2017, he was given the new user-friendly medication summary sheet. Since that time, he has become adherent to his medications and avoided any further hospital admissions.

In addition, nurses on our ACE unit shared stories about patients being more interactive and willing to get out of bed and move around after hospital volunteers worked with patients on mentation games.

We have also gathered the following quantitative results on our mobility interventions on our ACE unit:

ACE Unit Mobility Scores Based on Comparison from Admission to Discharge

ACE Unit: Whether Unit Mobilized Members per Policy Requirements

ACE Unit: Whether Unit Mobilized Members per Policy Requirements

Tips

 

  • Frequent and regular team communication has been vital to our success to date. In the first year of the initiative, our team met once every two weeks to exchange ideas on what was working — as well as what was not working — as we tried different 4M strategies in acute, outpatient, and post-acute settings. Our multidisciplinary team included physicians, administrators, case managers, nurses, pharmacists, and others from the three different settings.
  • Piloting 4M strategies on a small scale has helped us learn whether an approach will work in a given setting and situation. For instance, one program we tried on the ACE inpatient unit turned out to be impractical for that setting. The program, which we called “Just Like Home,” encouraged members to bring a favorite pillow, blanket, or other comforting item from their home to the hospital. But many patients did not want to do that because they were concerned they’d lose or misplace the item (e.g., during a transfer to another unit). Now we are considering how we might modify the program to make if more successful.

Age-Friendly Health Systems is an initiative of The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI) in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA).

 

 

Karineh Moradian

Profession: Assistant Hospital Administrator

Organization Background

Kaiser Permanente Woodland Hills and West Ventura Areas

Organization Name: Kaiser Permanente Woodland Hills and West Ventura Areas

Location: 5601 De Soto Ave. Woodland Hills, CA 91367

Organization Type: Hospital

Organization Model:

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