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By JULIE TROCCHIO

BOSTON — Three Catholic systems — Trinity Health, Ascension and Providence St. Joseph Health — are among five health care systems testing a prototype for creating a more age-friendly health system.

The Creating Age-Friendly Health Systems initiative is sponsored by the Institute for Healthcare Improvement and the John A. Hartford Foundation, which invests in research and practice innovations to improve the care of older adults. According to IHI, the goal of the initiative is to develop an age-friendly health systems model of care that can be in use in 20 percent of the nation's hospitals and across the continuum of care in health systems by 2020.

The other systems participating in the first phase of the initiative are Anne Arundel Medical Center and Kaiser Permanente. Representatives from all five systems participated in a June 6-7 workshop here that brought together researchers, physicians, nurses and other health care professionals from academia and acute, long-term and primary care.

"Our goal is to close the gap between what we know and what we do when it comes to our older patients," said Ann Hendrich, senior vice president and chief quality/safety and nursing officer for St. Louis-based Ascension, a workshop faculty member. "We want to do the right thing for each patient, each time and we need to quantify this."

Central to the age-friendly prototype is attention to four "Ms":

• mobility
• medication
• mentation (mental activity, in this case related to depression, delirium and dementia)
• what matters most to older patients

The workshop covered strategies for addressing each "M" and methods for measuring results.

For mobility, participating programs are looking at such measures as the percentage of patients screened for fall risk and the percentage who improved in mobility during inpatient stays. Strategies included assigning staff to walk with patients several times a day and asking patients to track the number of steps they take.

"Some patients are not interested in walking while they are in the hospital and not feeling well," said Gwen McBride, manager at the observation unit at St. Mary Mercy Livonia hospital in Livonia, Mich., a Trinity Health facility, who was attending to learn more about the program. 

"When I round on patients, I explain to them the importance of keeping their strength up so that they can be safe at home. For instance, I will tell them: 'I see that you came in with shortness of breath. When you go home you need to be able to use the bathroom, get to the refrigerator and get out of the house if it's on fire. If that happens again with the shortness of breath when you are mobile, we want it to happen here in the hospital so we can take care of you before you go home and find yourself in a bad spot.'"

"We look at mobility instead of falls," said conference speaker Dr. Mary Tinetti, chief of geriatrics at Yale School of Medicine and a national expert on falls in the elderly.

"Too often, the prescription for fall risk is bed rest; that is not good for seniors. We want them to mobilize safely. The best exercise is whatever the person likes doing."

What matters
To focus on "what matters most to patients" the participating programs are tracking the percentage of patients who report they were asked about their health care goals. For patients with serious illness, participants are tracking whether those patients feel their current medical care is supporting them in reaching personal goals. This could be such things as going to a family wedding or being able to play bridge.

"Patients sometimes ask why we want to know what their goals are" said St. Mary Mercy's McBride. "We want to know what matters to them and motivates them to get out of bed to be sure we are serving their needs."

Participants also are measuring the percentage of elderly patients who have a valid health care power of attorney. This document designates an individual who can make medical decisions for a patient if the patient is not conscious or competent to make decisions.

"Having a health care proxy is more than a piece of paper," said workshop faculty member Richard Scoville, improvement advisor at IHI. "It needs to be a three-step process: educating the patient, the patient having a conversation with the designated proxy and making sure the proxy document is accessible in the record."

Managing multiple medications
Attention to medications involves screening for medications that are considered high risk for use in patients over the age of 65 and asking patients if they were given explanations for why drugs were added or discontinued by a prescriber.

There was agreement among workshop participants that drug review and reconciliation is especially important at times of transition, such as when a patient moves from the hospital to a nursing home, rehabilitation facility or home.

Medication is an area where hospitals can make a business case for following age-friendly protocols, said Ascension's Hendrich. "We should take the opportunity now that cost is king to look at how adding a pharmacist to do reviews can save the system money" by getting rid of unnecessary medications.

During a small group discussion Kim Thompson, vice president of operations for Trinity's Glacier Hills Senior Living Community in Ann Arbor, Mich., added that pharmacy reviews can decrease drug–related hospitalizations and ER visits.

Depression, dementia and delirium
Mentation measurements involve counting the number of patients screened for depression, dementia and delirium and checking whether there is a behavior management plan for those who screen positive. "A diagnosis of altered mental status is not acceptable," said Yale's Tinetti. "We need to identify the problem and get a plan started" to address it.

Medications can impact mental status and that in turn can impact mobility as well as the ability to voice what matters.

While age-friendly strategies are being tested in the five prototype systems or hospitals, other health care organizations can be involved by following updates on the IHI's website, ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems. Organizations can use a tool on the website to assess how age-friendly their health system is.

To receive notice when the initiative is expanded, or to join a quarterly call to review progress of the Age-Friendly Health Systems initiative and receive tips on getting ready, contact [email protected].