Our health system, Baystate Health, recently had an opportunity to change the way we care for older adults. We already had multiple efforts underway. These included an interprofessional geriatrics and palliative care (Geri-Pal) team caring largely for homebound patients through our community health centers; geriatrics care pathways developed with an award from a Health Resources and Services Administration Geriatrics Workforce Enhancement Program; and a 35-bed Acute Care for Elders (ACE) program at Baystate Medical Center to improve outcomes for older adults. However, these processes were not always consistent, and progress sometimes felt slow.
When the call came in the summer of 2018 for volunteers to join the first wave of the Age-Friendly Health Systems initiative, the ACE and Geri-Pal teams enthusiastically enrolled. The evidence-based, core components of the initiative are the 4Ms (What Matters, Medication, Mentation, Mobility). At its core, this initiative of The John A. Hartford Foundation and IHI aims to democratize and spread core geriatrics principles. This is exactly what we were already attempting to do, so it was an easy decision. We hoped to improve care, secure quality improvement mentoring, plan for scaling, and learn from other participants.
Failing Forward and Learning from Networking
As part of the Age-Friendly Health Systems Action Community, colleagues across the nation gave advice and shared solutions to problems in emails and webinars. For example, the community helped us make decisions around trying a different tool to screen for delirium.
IHI’s Age-Friendly team helped us cope with the challenges of competing demands and limited resources. They encouraged us to make adjustments over time. For example, early on I made an error in recruiting members for our ACE planning group. Although we had broad interprofessional participation, including the nurse manager and nurse educator, we had not included any bedside nurses. Initially, the frontline nursing staff did not understand what we were doing or feel engaged in the process. They resented “being asked to do more” in terms of processes like screenings. We realized our mistake and invited bedside nurses to take part in the planning team and began celebrating patient successes, such as decreased use of restraints.
Too Good to Be True
At one point, our delirium rates were unbelievably low. All the clinicians looked at each other and said, “We can’t be that good.” We learned some new staff were not correctly and consistently using the screening criteria for delirium, the Confusion Assessment Method. Our nurse educator conducted quality checks. We retrained our staff and validated the nursing assessments.
Predictably, on paper, our delirium rate skyrocketed because we got better at reflecting the true prevalence. This made our numbers look worse at first, but we established an accurate baseline. We also generated a run chart of diagnostic codes for delirium for the same time period and discovered that physicians were not coding for delirium despite the documented screening results. This presents an opportunity to better capture the true complexity of the care and maximize reimbursement so that may be one of our upcoming targets for improvement through a Plan-Do-Study-Act cycle.
The team at first observed surprisingly low delirium rates. Following changes, an increase reflected the true prevalence.
Through this process, our teams developed confidence around data collection and quality improvement. Most importantly, our care improved as we focused on reliable and consistent performance. Enhanced visibility and legitimacy within our own system led to support for expanding our programs. Linking our work to our city’s community-based initiatives yielded new partners and a much-needed grass roots perspective.
From this work, we have learned:
- Don’t try to plan the entire project in advance. Take one small step at a time and regroup as needed.
- Don’t get hung up on the purity of your outcomes data. This isn’t research. Instead, you need “good enough” data to show your impact and make decisions about appropriate next steps.
- Include non-clinician champions in the planning and scaling of the work. Specifics may vary by the project and site. For example, people from quality, finance, IT, strategy, and administration are often critical for success.
- Build up all the good will you can. Take every available opportunity for favorable publicity for your group and your institution.
- Ask for advice and support early and often. In our case, this came from the Age-Friendly Health Systems initiative.
Recently, the Public Health Institute of Western Massachusetts and Live Well Springfield (a coalition of community organizations and educational and health care institutions) hosted a forum celebrating a milestone in Springfield’s history. That morning, Baystate Health’s three community health centers and its flagship hospital, Baystate Medical Center, were recognized as the first Age-Friendly Health System Committed to Care Excellence sites in the nation. At the same time, the city committed to being an AARP Age-Friendly community and was awarded recognition as a dementia-friendly community by the Massachusetts Council on Aging. For the first time, a community had achieved the trifecta: an age-friendly and dementia-friendly city that includes an Age-Friendly Health System. The festive occasion at the local senior center involved a wide range of attendees, including the mayor, health system leaders, community activists, and older adults from the community. This appropriately reflected the broad-based team effort required to reach this goal.
We made mistakes and adjusted accordingly as we did our age-friendly work and our colleagues and community were always there to help. We grew along with the programs and now feel a real sense of accomplishment. This collaboration has been one of the most satisfying professional and personal experiences for us in many years.
Maura Brennan, MD, is Chief of the Division of Geriatrics, Palliative Care and Post-Acute Medicine at Baystate Health.
The AHA Age-Friendly Health Systems Action Community begins September 2019. To learn more, check out the Age-Friendly Health Systems initiative.