Photo by pina messina | Unsplash
One afternoon a week, the Acute Care for Elders (ACE) unit at the University of Alabama at Birmingham (UAB) Hospital has a “move and groove” event with a music therapist. The activity not only helps patients with their flexibility and mobility, it can also have unexpected benefits. It is part of the effort UAB started in 2008 to improve care for older adults.
In 2018, when UAB heard that IHI and the John A. Hartford Foundation were launching the first Age-Friendly Health Systems Action Community, they knew they wanted to be involved. “We’d been working toward this goal for a decade,” said Kellie Flood, MD, Associate Chief Medical and Quality Officer for Geriatrics and Care Transitions at UAB Hospital. “We were thrilled to get in the first cohort.” The 4Ms Framework for Age-Friendly Care (see Figure 1) — What Matters, Medication, Mentation, and Mobility — aligned perfectly with what they were doing.
Figure 1: The Age-Friendly Health Systems 4Ms Framework
All the 4Ms are interdependent and mutually reinforcing, so it can be hard to talk about one without discussing the others. But UAB has made notable progress on how they prescribe and deprescribe medications. They started by creating electronic flags for some of the higher-risk medications for older adults, such as antihistamines and sedatives. In the electronic health record (EHR), they introduced pop-up flags for patients age 65 and older that did more than provide warnings. To avoid the risk of alert fatigue, the electronic flags also suggested useful alternatives.
The ACE unit holds a daily team meeting that includes a pharmacist. They scan the medication list for every older adult, looking at where a lower dose might be appropriate and which medications should be avoided altogether.
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Flood, along with fellow members of the UAB Hospital Department of Interprofessional Practice and Training, then began to disseminate the ACE Unit care processes throughout the hospital through collaboration with other departments. They soon found the surgical departments were eager to collaborate. They meet and discuss their order sets, ensuring that they are age-friendly. “We have fabulous physician partners,” said Flood. For example, they formed a team with orthopedic surgeons to work on an orthopedic surgery order set. They identified risky medications and considered potential alternatives. Most recently, they worked with urogynecology and gynecology-oncology surgeons to adjust their order sets. Afterward, based on some pilot data, the use of inappropriate medications appeared to decline significantly.
“Partnering with our surgeons has been one of the highlights of our age-friendly journey. It’s such a win-win for everyone, including the patients,” said Flood. “I think the key [to the partnership] is we don’t go in and tell a group of GI surgeons or orthopedic surgeons what to do,” Flood continued. “We’re all working toward the same goal, so we develop the age-friendly improvement strategies together.”
UAB also partnered with an organization in Wisconsin to make scanning the EHR for potentially inappropriate orders or administration of high-risk medications easier and faster. “For 26 patients, it would take me an hour and a half to look into each of their electronic charts,” said Flood. With this tool, “I can get all of that information for all of those patients in 30 seconds.”
Flood has learned several key lessons about improving care for older adults in her system:
- Engage stakeholders. Encourage them to own the work. “[Stakeholders have] got to want it, it’s got to be their idea,” Flood said. Moreover, “Don’t tell your stakeholders what to do, go and listen. They’re going to say something that age-friendly care will fix. Readjust your framing to their pain points.” Added Flood, “The easy part is we all have the same goals: reduce falls, delirium, mortality, length of stay.”
- Work with those who want to work with you. Beginning age-friendly work “can seem overwhelming, so go where you’re wanted,” Flood advised. For example, when orthopedic surgery called, Flood’s team shifted their plans to accommodate them.
- Make it easy to do the right thing. “The frontline staff has to be involved in determining what the change will be because it has to fit in their workflow,” said Flood.
Flood noted that, like all improvement work, making care more age-friendly is a continuous process. “You always have to be on the lookout, double-checking that the processes you put in place are still in place.” She added, “This is a lifelong journey, but it’s also fun and rewarding. Be sure and celebrate your team and their successes along the way.”
One of those successes was evident one day when Flood was the geriatrician on duty on the ACE unit, doing her charting in the same room as the “move and groove” session. “I was so uplifted by the music. I always find myself singing along,” she recalled. Then suddenly she saw a younger woman, the daughter of one of the older adults, start to tear up. Flood went over to her and said, “Are you OK?” The daughter explained that her mother had just come from another hospital and had been downcast, uncommunicative, and barely mobile. Now she was dancing. She told Flood, “You guys have given me my mother back.”
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