Making Your Health System Age-Friendly
How providers are innovating to address the unique needs of older adults
Health systems must adopt evidence-based models and practices in delivering care that meets the needs of our aging population across the continuum. Older adults want care that is effective and affordable, and they increasingly expect that the healthcare they receive will align with their own goals and preferences. They don’t want to break their bank—or the nation’s—to get the care they expect.
Terry Fulmer, president of The John A. Hartford Foundation, sat down with four healthcare leaders at Modern Healthcare’s 2019 Leadership Symposium to discuss how health systems are finding new ways to care for older adults, exploring best practices, innovations and challenges.
TERRY FULMER: How big of an impact is the aging population having on your institutional planning? What are your challenges? Given that this population will continue to grow, what changes are you currently making in order to continue delivering high-quality care?
BRIAN PETERS: For us, we view the opportunity to improve care for the aging population as perhaps our greatest opportunity. In Michigan, two out of every 10 folks in our state is over the age of 65. That is a number that is rapidly increasing. Several years ago, we looked at the demographic reality in our state and understood that the traditional model of care delivery wasn’t serving that population very well.
One of the things we did was join AARP, AHA and others in being a founding member of the Root Cause Coalition — which recognizes that the social determinants of health that affect a broad swath of our population in Michigan impact the elderly population much more significantly, especially in their ability to follow up on their care.
Our hospitals have also tried to get away from using the term “discharge,” because it implies that our job is done when patients leave the hospital. Instead, we’re using the term “handoff,” because we want to hand off that care to navigators and organizations that can help.
“We’re not just thinking of the patient; we’ve also come to realize the role of family caregivers, especially those who have challenging situations at home… we as a healthcare system — and maybe even nationally — have been dropping the ball on this silent, secondary population.”
Natalya Faynboym, MD, CPE | Executive Director for Innovation – Affordability and Medicare Advantage, Banner Health
NATALYA FAYNBOYM : We have created independent innovation hubs to look specifically at older adults’ care in Medicare Advantage as well as in our ACO. We’re looking at care transitions from a care management perspective. Our healthcare navigators make house visits, but we also look at behavioral health and what mental health may mean for older adults.
For example, our older patients usually put their best clothes on when they go to the physician and they usually don’t tell their primary care doctor what’s going on in their heads. And if they do, they’re not ‘depressed,’ they’re blue. So, we’ve enabled our providers to have a more transparent conversation by allowing patients to connect with a health coach, a psychologist or even a psychiatrist as needed during their primary care appointment. For a lot of our older patients, it has helped to take the stigma away from mental and behavioral health issues.
And we’re not just thinking of the patient; we’ve also come to realize the role of family caregivers, especially those who have challenging situations at home. Maybe it’s Alzheimer’s, maybe it’s another kind of decline. We as a healthcare system — and maybe even nationally — have been dropping the ball on this silent, secondary population. So, we’re also looking at how we can provide care for the caregiver, as well.
GARY BAKER: We’re able to use focus groups of seniors to understand their needs, and we’ve found that what they need most is patient navigation. They need help navigating this complex medical system and their day-today challenges. So, we have health coaches that are very proactive and reach out with home visits. They conduct home evaluations and check for a safe environment and really help educate people about things, such as explaining that if you fall, you may not return to normal activity. So, let’s do everything we can in your home.
Our model is a clinically integrated network. That has allowed us to come together and develop care protocols with independent practices for the best care of certain disease states and populations. We integrate that into our ACO strategy in terms of providing value to the insurance market as well as providing opportunities for stickiness within our patient population.
We’re also doing some work in the end-of-life space — both inpatient and outpatient coordinated palliative care services — and meeting patients’ unmet social needs.
KEDAR MATE: At IHI, we’re increasingly seeing interest in the quality of care for older adults amongst the systems we work with. And, what’s interesting about this work is that I’ve yet to encounter someone who hasn’t had a family member, a friend, a close colleague — who’s over the age of 65 that’s had a challenging experience with the health system. Some form of discoordination has occurred, and that’s led them back to the hospital or to some unfortunate outcome. I think we all recognize that we can do better.
The good news is that there’s good evidence around how to improve care for older adults. But the translation of that knowledge into practice to reach every older adult reliably every time is a persistent, common challenge. We have pockets of excellent programs that impact some older adults, maybe a couple hundred thousand people. But there are 46 million older adults in the country and many are not getting that same level of attentive care.
So, together with The John A. Hartford Foundation, we’ve been studying how to deliver better care for older adults. We began by working with experts in geriatric care and five major health systems. That effort resulted in the creation of the Age-Friendly Health Systems initiative which is guided by four primary principles: understanding what matters to older adults and their families — that has everything to do with navigation, goals of care, family caregiving and many of the themes that you all raised —
emphasizing mobility, focusing on medications, and paying attention to mentation, including depression, dementia and delirium.
For these four things, we’ve identified the practices that would be really useful, and we’ve started to scale that around the country to more than 100 systems.
TF: At The John A. Hartford Foundation, we look to improve care for older adults by creating age-friendly health systems, improving serious illness and end-of-life care, and supporting family caregivers — things that you’ve all touched on so far. For 30 years, we’ve curated experts and models of care, but we also struggle with the issue of reliability and appropriate dissemination of those evidencebased models. Do our panelists have any thoughts on how this can be better approached? In what areas do you seek partners to help put evidence into practice?
GB: I think there’s great opportunity for partnership in the space of medication management and raising awareness in the general population of polypharmacy — the benefits as well as potential risks of simultaneous use of multiple drugs to treat a single ailment or condition. We see that as an intervention we’ve been able to make.
NF: Proper medications and medication reconciliation are incredibly important. For example, in care transitions, medications may change from acute setting to post-acute setting to home. Unless you know with 100% certainty what they have at home, sometimes there may be duplications or other challenges. We know that more often than not readmissions happen around seven to 10 days post-discharge because of medication errors. That makes patient education and coordination crucial, as older adults are also seeing multiple outpatient providers that need an accurate medication list.
KM: These things build on each other. Medications can inhibit mobility and precipitate falls or lead to problems with mentation, like with delirium. One thing we’ve thought a lot about is simplification — getting these evidence-based models down to simpler principles that are easier to follow.
BP: One challenge for an organization like ours is the ability to get the word out about successful interventions and scaling them for systems of different sizes. Another challenge is that often providers don’t have the full picture of the patient. Our members know what happens inside the four walls of their institutions, but they may not have the complete picture of what happens to that individual out in the rest of the care continuum.
TF: We like to say that an age-friendly health system starts and ends at your kitchen table as you transition through primary care, the emergency department, the rehabilitation facility, or a nursing home. We know we have tremendous challenges in continuity of care across settings. Do you see broader shifts happening that can help spread better care and better practice to our older adults?
GB: Payment reform is going to drive more innovation. We’ve seen it time and again. Investments in IT that offer caregivers relevant information can also help disseminate best practices.
NF: When you take full risk with a Medicare Advantage or similar plan, it really allows you to concentrate more on prevention and social determinants of health and allows for better care coordination to happen.
“Payment reform is going to drive more innovation. We’ve seen it time and again.”
Gary Baker | Regional Hospital Senior VP/CEO, HonorHealth
BP: I think it’s critically important to keep in mind the public policy domain as well. Medicare and Medicaid policy will have so much to do with how successful we can be going forward.
TF: Do you think there is a business case that could be made for delivering more effective, higher quality services to older adults, even within the four walls of an institution?
GB: Well, it’s certainly a focus and a goal currently. I influence more within my four walls than I do with what’s happening in the community and patients’ homes. We actually look to partner with practices that will help us through the continuum, even to the point where groups have now incorporated home visits into their model, which is a throwback to the house calls of the past. We justify it with the need to keep the patient safe and healthy, while preventing avoidable readmissions. I’m encouraged by the entrepreneurial spirit, and that typically is generated by alignment with health plans willing to recognize and value that kind of model for the practices.
KM: We all recognize that if we get to continuum-based care, that would be terrific. The cost of coordination is enormous, so the benefit has to overcome that cost. But the hypothesis we have is that there’s probably sufficient value that you can obtain even from a fairly narrowly defined perspective around an institution getting better value out of the services that they offer to older adults.
BP: We operate a federally certified patient safety organization (PSO), so we’ve been in the business of collecting adverse event data for the last eight, nine years. Since the inception of our PSO, the number one most frequently reported adverse event is patient falls, and the overwhelming number of those patient falls affect the elderly population. There’s a great opportunity for improvement in that space, and there’s certainly a business case, as falls have a significant impact on providers from both a quality and financial perspective.
NF: From a hospital perspective, we’re putting resources toward prevention of delirium. We’re also putting in resources to encourage early mobility on general medicine and telemetry floors — not just in the ICU — because it has the potential to help you run a much more efficient admission. That prevents readmissions and potentially prevents the need for a post-acute stay and additional complications, and that can potentially shorten length of stay for that patient. Overall, that creates a better experience for the patient as well as, I suspect, the hospital.
KM: It’s hard to imagine that we won’t also be somewhat motivated intrinsically. Even if there are external motivators like incentive payments, or disincentives, or certifications, I think we’ll always have some form of inner motivation, because we can think about our parent, our spouse, or ourselves who need age-friendly care.
TF: Thank you everyone for your perspectives on how to drive improvement in care for older adults.
“Our members know what happens inside the four walls of their institutions, but they may not have the complete picture of what happens to that individual out in the rest of the care continuum.”
Brian Peters | Chief Executive Officer, Michigan Health & Hospital Association