Trinity’s Saint Alphonsus Health System is improving health care processes that affect older patients in the domains of What Matters, Medication, Mentation and Mobility (the 4Ms).
Saint Alphonsus Health System has been making changes to be more age friendly for many years. The emergency room (ER) adopted the Senior Emergency Department (ED) initiative, making physical changes to the ER, such as softer beds, bigger clocks, a quieter environment, steps available to get in and out of the bed, closer restrooms, as well as learning how to change the providers’ approach to meet the unique needs of the older patients in a crisis setting. A case manager for the ER, Becky Beaver, concentrated on the older patients and their discharge needs. In many cases, older patients returned to the ER in a deconditioned state, confused about their medications or non-adherent to their prescribed medications.
Dr. Chad Boult, a geriatrician for Enhancing Care Initiative at Saint Alphonsus, opened three specialized clinics to address the complex care of the older population in this community. Yet, there still remains a need for improved care for older people at all levels of health care, including the community resources. Dr. Boult reminds others that “older people are the fastest-growing segment of the U.S. population – and their growth in numbers will accelerate throughout the coming decade. It’s time, past time, actually, for our health care systems to start focusing on meeting the special needs of these older patients.”
What We Tried
Trinity Health is one of five U.S. health care systems participating in this initiative, and Saint Alphonsus in Boise, ID, is Trinity Health’s pilot site for creating and testing the interventions.
Saint Alphonsus chose seven clinical sites of care to launch this initiative:
- 2 home health agencies
- 2 hospice agencies
- 1 house call program
- 1 geriatrics clinic
- 1 inpatient palliative care service
in four domains, also known as “the four Ms.”
- What Matters: asking patients what matters to them, identifying their goals and wishes, tailoring their plans of care to meet their goals, and transferring Advance Directives from the hospital to the sites where patients receive their post-acute care
- Medications: reconciling medications, identifying high-risk medications, and “de-prescribing” high-risk medications
- Mentation: recognizing, addressing and treating dementia, delirium and depression
- Mobility: identifying and treating patients who are at high risk for falling and being injured
Because of the diversity of care sites, tools used vary, but all are evidence-based. Examples of these tools and approaches include:
The success of these tools and the AFHS program is dependent on the whole process, not just one part. The team must review their current process for gaps in care, select appropriate tools to support any needs, educate staff of the changes and run PDSA cycles for process improvement. The quality improvement process addresses everything from the assessment and screening through the referral for all patients identified as needing further testing or therapy or alerting the PCP for continued care. We need to ensure that all steps are followed with each patient every time to give the best patient care with the best outcomes possible.
Our goal is to provide age-friendly care to at least 4,500 patients in 2018. Data is currently being collected on the number of patients touched by the age-friendly teams and outcomes.
Being part of the age-friendly care improvement initiative has been an eye-opening experience for many participating staff members. They came to recognize that there were deficiencies in how they were providing care for their older patients, that their care was not in fact always age friendly. For instance, sometimes the things that improve the quality of care are not clinical at all, and this is often forgotten. When one hospice patient was asked, “What matters most to you today?” it was discovered that all she wanted was an ice cream cone. Staff realized they had a duty to make necessary changes in order to give the best care and achieve the best outcomes for their patients.
One of the hospice teams reported that their patients who had participated in a “Serious Illness Conversation” had no hospitalizations from May 2017 to February 2018. Another noted an increase in the hospice nurses’ confidence in leading patients through sensitive conversations about planning for their health care in the future. “What I am seeing is that nurses are identifying patients’ needs, recognizing that they (the nurses) are end-of-life experts, and then using the Serious Illness Conversation Guide to meet their patient’s needs. This tool has given them a way to use their nursing knowledge to attain better outcomes for their patients.”
Becoming age-friendly is not without challenges. Most of our clinical sites are in community settings, and many of the 4Ms interventions are carried out during the first visit with a patient, which is already a very busy encounter. The results, however, have demonstrated to staff members that their efforts are worthwhile, as they incorporate new age-friendly interventions into their plans of care. As a result, some of the staff proposed hanging out a banner that boasts, “We’re Age-Friendly!”
The inpatient palliative care team has caught the attention of other departments with their work on medication reconciliation and management. They are working with a pharmacist who reviews the patient’s chart for any relationship between symptoms and current medications – and considers whether some medications could be eliminated or replaced and whether any medications are causing adverse reactions.
It did not take long for the word to spread regarding the great work that is occurring in the AFHS initiative. The results have sparked interest in other departments that now want to learn more and to join the AFHS team!
The “Age-Friendly Health System” (AFHS) initiative is one of the investments Saint Alphonsus is making to provide appropriate care to the aging population. This initiative is funded by The John A. Hartford Foundation and led by the Institute for Healthcare Improvement, in partnership with the American Hospital Association (AHA) and Catholic Health Association (CHA).