Photo by Alessandra Caretto | Unsplash
When care providers at Maine Medical Center (Portland, Maine) started asking every older adult patient what mattered most to them, patients would often say similar things like, “I want to get out of here. I want to go home. I want to stay out of the hospital.” To get more specific answers, the staff would press them: “What is it that you’re doing at home that makes you want to stay out of the hospital?” The patients then had their own unique responses. One woman was a caretaker for her husband. Another patient mentioned beloved pets. Another gentleman said he went ballroom dancing with his wife every week.
The population of the state of Maine is one of the oldest in the nation, with a significant segment aged 65 and older. At Maine Medical Center, the geriatrics department was already focused on providing optimal care for older adults when they heard about the Age-Friendly Health Systems initiative launched by IHI and the John A. Hartford Foundation. They immediately wanted to get involved.
“We started small,” said Molly Anderson, manager of the geriatrics program at Maine Medical Center. They began about a year ago with their Hospital Elder Life Program (HELP). They knew that they were already using elements of the Age-Friendly Health Systems 4Ms Framework for Age-Friendly Care (see Figure 1 below). “I think in geriatrics we hear about the 4Ms and it makes a lot of sense to us,” said Anderson. “It’s a great framework to describe [good geriatric care] to other people.”
Figure 1 — Age-Friendly Health Systems 4Ms Framework for Age-Friendly Care
Although they were already essentially working on the 4Ms, they wanted to be more deliberate and explicit about it, especially asking patients what matters. “We felt like at some point someone asked this person [what mattered most to them],” said Anderson, “but it was often different depending on the discipline and it wasn’t necessarily documented. It wasn’t always accessible.”
They built a prompt into their electronic health record (EHR) to support providers asking what matters. “We started asking the patient, ‘What matters most to you here in the hospital?’” said Anderson. They then ask about what will matter most when the patient is discharged. The answers are documented in the EHR. Patients were used to being asked about goals of care and their social history. “People were not used to having this question asked of them explicitly,” Anderson said. Some retraining of staff was needed to ensure these questions were asked consistently.
The geriatrics program is currently scaling the 4Ms to a cardiology floor, a trauma floor, and the ED. “They all have different gaps and different priorities, and different cultures,” said Anderson. For instance, in cardiology, they were great at getting patients up and moving. However, being age-friendly with their use of medications was one of their challenges, often prescribing sleep aids, for example. The geriatrics team introduced non-pharmacological interventions for sleep, such as guided relaxation, white noise machines, headphones, and earplugs. They also encourage physical activity and discourage naps during the day. At the same time, it’s important to respect the circadian rhythms of individuals. “If somebody is a night owl, we let them be night owls,” said Anderson.
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The trauma floor was already doing very well with age-friendly medications. Their challenge was with mobility. Since their patients were injured, they had less of a culture of encouraging mobility. The geriatrics team decided to start small. “If they can’t walk, let’s make sure they’re up to the chair,” said Anderson. “We meet people where they’re at.”
From this work, Anderson and her colleagues have learned some important lessons. One is the importance of presenting the 4Ms as a useful framework through which to see and adjust existing work. “This isn’t something new that we want people to do,” said Anderson. “[It’s] an adjustment to what people are already doing to provide better care for older adults.”
Another practical tip: Don’t let lack of hard data be an impediment to getting started. “You probably have a good feeling for where your gaps are,” said Anderson. “Don’t let data be a barrier to getting started.”
Other advice for getting started: Find a champion, or multiple champions. “We knew people who were interested in geriatrics. We engaged those people to be our champions so they could disseminate the excitement among their peers and colleagues.”
As for the what matters question, 100 percent of patients in HELP now have that question asked of them. For the man who mentioned ballroom dancing with his wife, the geriatrics program let his care team know. “That’s when it spilled over to the other Ms,” said Anderson. The care team looked at his medications and how they were affecting mobility. They put him in physical therapy and got him involved in A Matter of Balance, an eight-week structured group that emphasizes practical strategies to reduce fear of falling and increase activity levels. After he left, they set him up with a home health physical therapist.
Although these were all measures the team probably would have taken anyway, it made a difference to the patient to express his values explicitly. “He was very appreciative of being asked [what mattered to him],” said Anderson. “He saw that the things we were putting into place for him connected to what he had told us.”
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