St. Vincent Health is creating longitudinal care plans for older adults focused on what matters to patients.
As part of the mission and strategic plan, Indiana-based St. Vincent is working to improve the health, quality of care and functional status of adults age 65 and older. Indiana ranks last among 51 states on a national scorecard that evaluates long-term services and support for older adults, people with disabilities and family caregivers. With the number of elderly patients increasing, St. Vincent is working to change this scenario.
What We Tried
St. Vincent is part of Ascension, which is one of the first five hospitals and health systems to join the Creating Age-Friendly Health Systems initiative, using the 4M model to guide older adult 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.
Across Ascension, the age-friendly work began by identifying and encouraging areas of the health system that are already working to improve care for older adults — including St. Vincent — to expand and share elder care initiatives with other Ascension entities. St. Vincent is currently rolling out the “4Ms” in two main ways in the ambulatory setting:
Geriatric consultations: Clinicians at St. Vincent’s Center for Healthy Aging (the Center), which is an outpatient geriatric specialty clinic, have been addressing the 4Ms as part of standard care for decades. Using the 4M framework within the Center’s geriatric consultation process provides structure and the opportunity to document the care plan as addressed by the 4Ms.
Geriatric consultations generally consist of two elements:
- A comprehensive physical exam and review of medical, psycho-social and functional history
- A patient/family conference with the geriatrician, registered nurse case manager or licensed clinical social worker to discuss findings, provide education and align recommendations to what matters to the patient
Geriatricians developed a simple template in the Center’s electronic health record (EHR) to guide their assessment. The template has a section for each of the 4Ms along with a few suggested prompts to consider while evaluating the patient. The case manager uses the same template to talk with the patient about the physician’s recommendations, essentially creating a care plan.
The traditional exam approach had been more problem focused and involved assessing the various biological systems (e.g., gastrointestinal, neurological). In comparison, the 4M template is centered around the goals (i.e., the patient’s own priorities, mentation, mobility, medication management), with the physicians and case managers determining what medical, functional and psychosocial problems may be interfering with the patient’s ability to achieve these goals.
Information is also collected from patient and families/caregivers before the geriatric consultations, which is particularly helpful in preparing for visits with patients who have dementia and related conditions. A form is mailed to the patient’s home, which asks what matters to the patient as well as specific questions related to the other 3Ms. For example, the form asks whether a lack of mobility is interfering with the patient’s goals.
Medicare wellness exams: The Center only sees a small percentage of the older adults served by the St. Vincent system. To impact more patients, the health system is structuring annual Medicare wellness exams — which Medicare covers and encourages beneficiaries to get — around the 4Ms. The St. Vincent nursing group that is dedicated to conducting these exams enthusiastically agreed to pilot a 4M approach.
A multidisciplinary team, which included nurses, geriatricians, quality improvement staff and others, redesigned the EHR documentation template for Medicare wellness exams around the 4Ms. With this approach, a longitudinal plan of care for older patients based on the 4Ms, can be continually addressed and updated when patients return each year.
One of our clinicians, Dr. Pat Healey from the CHA, and a patient and their family member were featured on a local TV segment about the benefits of a medication audit.
Between January 1, 2018 and March 5, 2018, St. Vincent Medicare wellness nurses and geriatricians at the Center for Healthy Aging have used the 4M template to guide the care of more than 2,100 patients, which far exceeds the goal of reaching 500 patients during that time frame.
In addition, the 4M approach has helped to streamline geriatric consultations at the Center for Healthy Aging. One of the geriatricians said the template is making her more productive: “Okay, we’ve hit on something here,” she said.
- A lack of time can be a challenge. A pilot of the 4M assessment approach in primary care demonstrated that a typical primary care visit of 15 to 20 minutes was not enough time to address all 4Ms as well as address the reason the patient came for the visit. In the pilot, the physician decided to prioritize medications and mobility during each visit. She reviews the patient’s medications, particularly if the patient is on 10 or more, and her medical assistants assess mobility issues when they walk the patient back to the exam room, weigh the patient on a scale, etc.
- It has been helpful to have groups dedicated to elder care, like the Center for Healthy Aging and Medicare wellness nurses, in rolling out the 4Ms. But it is not necessary. Health systems need to engage passionate staff to push these age-friendly initiatives forward.
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).
About St. Vincent: In Indiana, Ascension’s St. Vincent operates 19 hospitals in addition to a comprehensive network of affiliated joint ventures, medical practices and clinics that cover Central and Southern Indiana and employ more than 15,000 associates. Across the state, St. Vincent provided more than $268 million in community benefit and care of persons living in poverty in fiscal year 2017. Serving Indiana for 145 years, Ascension is a faith-based healthcare organization committed to delivering compassionate, personalized care to all, with special attention to persons living in poverty and those most vulnerable. Ascension is the largest non-profit health system in the U.S. and the world’s largest Catholic health system, operating 2,500 sites of care – including 141 hospitals and more than 30 senior living facilities – in 22 states and the District of Columbia. Visit www.stvincent.org.
Melanie Holt Fauth, RN, BSN
System Executive, Post-Acute, Care Transitions & Senior Services
St. Vincent Health
Jennifer Allbright, RN, BSN
Manager, Senior Services
St. Vincent Center for Healthy Aging
Ascension Health System
Director, Care Excellence
Director of Regional Operations
St. Vincent Medical Group