Mak­ing Your Health Sys­tem Age-Friendly

How providers are in­no­vat­ing to ad­dress the unique needs of older adults

Modern Healthcare - - News -

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

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