Photo by Dewald Van Rensburg | Pixabay
Emerging data from the COVID-19 crisis in the US indicates that the pandemic is having an outsized impact on communities of color, especially African Americans. While addressing systemic inequities that contribute to these outcomes will require a range of remedies, one approach to improving health care for older adults may prove helpful.
Since the Age-Friendly Health Systems 4Ms Framework for Age-Friendly Care (see Figure 1) — What Matters, Medication, Mentation, and Mobility — helps ensure the reliable practice of evidence-based care, one proponent of the 4Ms has found that it has the potential to address health inequities related to race or income.
Figure 1 The Age-Friendly 4Ms Framework
Washington University School of Medicine Associate Professor Lenise Cummings-Vaughn, MD, is an internist and geriatrician. She had incorporated the Age-Friendly 4Ms Framework initiative into her work before the coronavirus crisis hit. Based at Barnes-Jewish Hospital in St. Louis where she serves as medical director for the hospital’s readmissions prevention program, she also sees patients at an outpatient geriatric consultation clinic and is the associate medical director at a private nursing home. “I see quite an array in demographics and the differences that are present,” Cummings-Vaughn says.
While working in this range of settings during the coronavirus crisis, says Cummings-Vaughn, “Everything’s changed. There’s not a thing that’s the same.”
Some of the changes that have occurred as a result of the current crisis have been positive, including the shift toward telehealth. Most of her outpatient visits are currently being conducted by telephone visits or virtual visits. “I think there’s lots of good things about it,” says Cummings-Vaughn. “For those patients who would be reluctant or they live too far away,” she says, telehealth “will allow us to touch more people post-hospital.”
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At the same time, telehealth presents some new challenges. “Seeing a person in person allows me to see a lot of things without them saying anything,” says Cummings-Vaughn. That said, she can mostly compensate by asking more and different questions than she would in person.
More problematic, she has observed stark disparities in terms of access to the technology that facilitates these remote visits. Some patients do not have smartphones or internet service, so they must settle for telephone visits, which are more limiting. Although Cummings-Vaughn acknowledges that perhaps some older adults “wouldn’t be able to operate this stuff because it’s not in your wheelhouse,” others simply lack access to the technology because of their socioeconomic position.
There are disparities among facilities too, although even the most well-off — such as the private nursing home where Cummings-Vaughn works — are grappling with extraordinary challenges, including getting needed equipment. As Cummings-Vaughn puts it, “They have resources to potentially acquire more personal protective equipment and swabs to do tests, and it’s incredibly difficult for them. I can only imagine how difficult it is for nursing homes that have Medicaid beds.”
Cummings-Vaughn says that the 4Ms can not only help improve care for older adults generally; they can help mitigate bias on the part of care providers toward different subsets of older adults. The 4Ms can reduce subjectivity in answering the question of whether something needs to be done — such as explicitly asking What Matters — and make it automatic. “I think a lot of times we don’t know what matters to people,” says Cummings-Vaughn. “We might believe we know what matters and treat them a certain way.” She says the 4Ms may be “a great leveler.”
For example, Cummings-Vaughn recently had a telephone visit with a new patient. From his chart, she learned that he had a substance abuse issue and had missed some appointments. Some providers might have dismissed him as “noncompliant.” Says Cummings-Vaughn, “I could have let [his history] affect my perception of him, but I was more concentrated on his medical problems and how aging might have affected his ability to deal with these things.”
For this patient, addressing medications and mobility — two of the 4Ms — became particularly important to understanding his situation. The patient had a history of cardiomyopathy and was prescribed a diuretic. He had not been attending physical therapy as had been recommended. Cummings-Vaughn knew he would be needing to go to the bathroom frequently as a result of his medication, and she wondered if he was having mobility issues. She started asking questions. “It opened up a Pandora’s box about his situation,” she recalls.
Cummings-Vaughn learned that the bathroom in the patient’s home was on the second floor, which presented difficulties for him. By paying attention to mobility, she realized that he might have reasons for not wanting to take a diuretic.
Cummings-Vaughn points out the importance of a nuanced approach to differences and similarities among patients. On the one hand, there are some evidence-based, broad differences among certain demographics. There are some vulnerabilities that are elevated for older adults and to which providers should be sensitive, including those related to reactions to pain medications or risk of dehydration, for example.
On the other hand, it’s also essential to have “care that addresses the particular person in all of their facets, especially when it comes to older adults.” The challenge is striking the right balance: recognizing commonalities within certain groups without making unwarranted and biased assumptions. “Being aware of similarities as well as differences helps us to provide good care,” says Cummings-Vaughn.
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