What We Tried

Trinity Health is one of five U.S. health care systems participating in the Age Friendly Health Systems 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 elements, also known as the “4Ms.”

• 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.

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 age-friendly initiative 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.