Age-Friendly Health Systems: What Matters Most
This approach to health care puts what matters for older adults at the center of patient care.
The night before the father of Marie Cleary-Fishman, BSN, MS, MBA, CPHQ, CPPS, CHCQM, had bypass surgery, he told her that he wanted two things: to see his wife—for whom he had been caring—again, and to spend one more summer using his riding mower. When his recovery hit a bump in the hospital, Cleary-Fishman reminded her father of those goals, and after he had returned home, his physical therapist was able to tailor her father’s care toward getting back on that mower.
“Nothing could have made my father more committed to working at his therapy,” says Cleary-Fishman, who is vice president of clinical quality for the American Hospital Association (AHA).
She didn’t realize it at the time, but by prioritizing what mattered to her father, Cleary-Fishman was employing age-friendly care—a framework aimed at helping adults aged 65 and older obtain the care that best suits who they are as individuals, rather than diagnoses.
“The great success story of the 20th century is longevity,” says Jane Carmody, DNP, MBA, RN, program officer at The John A. Hartford Foundation. “All of us want these extra years to be as joyful and as healthy as possible, and yet as we age, we will encounter more health challenges. The health system needs to be prepared and the best way to do this is to be age friendly.
“Older adults really are at greater risk for harm,” she continues. “Two out of three have multiple conditions with five or more medications and if the care they receive is not coordinated, not suited for older people, and not aligned with goals and preferences, more harm than good will result.”
When patients are receiving care across multiple providers that are not coordinated, they become more vulnerable. They may, for example, be prescribed a medication that worsens their health and/or well-being rather than improving it due to factors not known by the prescriber.
What’s more, they may end up receiving care that does not align with their personal goals and wishes. That’s where age-friendly care comes in. Age-friendly care focuses on the person and their family through the “4Ms”—what matters, medication, mentation, and mobility. According to The John A. Hartford Foundation and its partners in age-friendly care, the 4Ms are elucidated as follows:
• “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 care, and across settings of care.
• “Medication. If medication is 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.
• “Mobility. Ensure that older adults move safely every day in order to maintain function and do what matters.”
What matters—the first of the 4Ms—is, according to Leslie Pelton, MPA, senior director at the Institute for Healthcare Improvement (IHI), paramount. According to Pelton, “The innovation [of age-friendly care] is the 4Ms as a set and ensuring that they are reliably used to organize the care of older adults,” she says. “What matters is the key to the kingdom of that set. We can’t effectively make choices unless we know what matters to [the older adult].”
By way of example, Pelton describes a patient who loved gardening. The older adult preferred to garden in the morning, when the garden itself was in the shade and she could work without getting too hot. However, she took a medication that made her too tired to do so, and she told her provider this. “Because she was able to have that conversation,” Pelton says, “she could shift the timing of the medication.”
“There is a very large health system that we are working with on the West Coast where the chaplains and the volunteers who work with the chaplains have conversations with the older adults about what matters and actually scan the information they collect into the records using a barcode scanner,” Pelton notes. She adds that these individuals do not have access to the medical records themselves.
And in other settings, it’s the social worker. This is the case at Kaiser Permanente in Hawaii, where “Social workers have been designated as the fire starters to start this movement where the focus is on identifying what matters most (WMM) to the frailest of our frail elder members and learning about their preferences for care,” says Susan Michihara, MSW, a medical social worker at Kaiser Permanente.
“Armed with information gleaned from a preference-based assessment with a member, the social worker facilitates an interdisciplinary team discussion where the [primary care physician], pharmacist, nurse, and other providers come together to align our care with WMM to the member.” Kaiser Permanente refers to their Age-Friendly care model as SWITCH (Social Wellbeing’s Impact to Care and Health).
Outside of What Matters, team members must take into account the remaining Ms, which they may not have done previously. Again, these factors may fall to different team members in different settings. In some, for example, social workers may be screening for depression, dementia, and delirium. In other settings, that may fall to the nurse or physician.
Overall, it is up to the whole team to take all 4Ms into account when providing care to a patient. “We find that mature teams really start to all kind of blend. The social worker may ask pharmacy questions; the pharmacist may ask about appropriateness for hospice. We cross boundaries and start to mesh and blend and challenge each other,” Michihara says.
For the patients, there is the feeling that they are getting care that is about them. “[There is] member satisfaction knowing that there is a social worker and a SWITCH team who will be supporting this member until death. Members also find satisfaction in knowing that they are viewed and treated as more than a sum of their illnesses,” Michihara says.
There is also a sense of empowerment, Pelton says. “My 81-year-old mother is fiercely independent,” she notes. “I do not manage her care for her. It is with her. It helps me to encourage her and empower her at every visit to have her provider stop and let her say what matters to her about this interaction and to question, [for example], whether she should be on a medication anymore. It’s about engaging her around the 4Ms and encouraging her to be empowered.”
For the providers, the benefits come on multiple levels. For the individual team member, Michihara says, they get the satisfaction of knowing they are doing good work. “Practicing in a ‘know me first, treat me second’ mode is the right thing to do,” she affirms.
For the team as a whole, the 4Ms are an onramp to evidence-based practices and a rethinking of care that is already in place, Carmody says. Ultimately, it allows the team to think more upstream. Thinking upstream means taking action to ensure better outcomes rather than simply responding to crises and other issues.
Carmody offers mobility by way of example. “In efforts to reduce falls, older people were immobilized in beds and chairs and overall activity reduced,” she says. “Not only were falls not prevented, [but] harms of immobility resulted. The evidence shows that to truly prevent falls, promoting safe mobility is key and produces better long-term health outcomes.”
Michihara adds that thinking upstream often allows for a patient to spend their last days and hours where they most want to be: home. “What most members want is rarely to have their last days spent in the ICU or recovering from a major surgery,” she says.
And from the health systems perspective, using the 4Ms creates a system of more efficiency and less risk. Talking about all four areas and ensuring coordinated care means that the older adult will be less vulnerable. There will still be crises and additional concerns that arise; however, the older adult may be able to avoid a longer stay at the hospital or a more invasive procedure.
“If older adults experience a complication, their length of stay in the hospital will likely increase. Oftentimes a health system will bear that cost. If we can prevent delirium [for example], we are mitigating a problem that increases risk, and we can keep the cost and complexity of care more closely in line with how we are reimbursed,” Cleary-Fishman says.
IHI offers information and tools on the “business case” for employing age-friendly care.
However, Cleary-Fishman, Carmody, and Pelton are quick to note that many provider teams already do some if not all of the 4Ms. Rather than view age-friendly care as something brand new, they should view it as an extension of their current efforts.
“We think it’s really important to say that this work is about building on the assets that already exist in a hospital or practice,” Pelton says. “The first step is to recognize where the 4Ms are in practice and who some of the local champions are in that.”
Cleary-Fishman also advises approaching Age-Friendly care from a manageable place. An entire health system does not need to change overnight. Rather, “you can start really small—one nursing unit,” she says, and go from there. “There is a lot of flexibility in how this is done. The thing that is not flexible is that you must use the 4Ms. The ‘what’ is tight; the ‘how’ is loose,” she explains.
Beyond a willingness, there must also exist a change in mindset—for the providers and the patients. In many instances, both have become accustomed to seeing conditions first and individuals second. In fact, Michihara shared a colleague’s story in which the social worker had called a member to ask how he was and learn more about him. His immediate response was a list of his current illnesses.
“She was quick to say, ‘No. I can read that about you. I want to know about you.’ He went on for another 40 minutes, [asking] ‘Wow! You really want to know about me?’” Michihara says. “He was very moved.”
“We take care whenever possible not to call it an initiative. Most of us are overwhelmed by projects and priorities and initiatives,” she says. “What we don’t want to do is layer a way of caring right on top of what we’re already doing. We want change, and that is why this a movement.”
The goal of the movement is to have 20% of U.S. hospitals and health systems recognized as age-friendly health systems by 2020. And they are well on their way.
As a part of the movement, in 2017, five pioneer health systems including Kaiser Permanente signed on to test the age-friendly framework. Since then, IHI and now AHA have launched action communities to include and educate additional health systems. A seven-month program, the action communities offer virtual learning with one in-person meeting per cohort. To date, more than 125 health systems and 300-plus sites of care in almost every state have joined an action community.
With the increasing number of health systems signing on, the organizations are now also looking to better include the patient’s voice. “We have worked to engage patients and families in health care for several years now,” Cleary-Fishman says. “But the way we’ve gone about it is to put people on advisory committees. It’s time to move to the next phase of that, which is to engage people where they are—at the bedside.”
In doing so, the movement will ensure that the most important players in age-friendly care—the older adults—are involved in the development of their care. After all, Michihara says, “They are the member of the team. The team exists for this person.”
— Sue Coyle, MSW, is a freelance writer and social worker in the Philadelphia suburbs.
• The John A. Hartford Foundation: www.johnahartford.org/age-friendly-health-systems-initiative
• Institute for Healthcare Improvement: ihi.org/AgeFriendly
• American Hospital Association: www.aha.org/center/new-payment-and-delivery-models/age-friendly-health-systems