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All clinicians — not just geriatricians — should understand how to provide the best care possible for older adults.
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What Every Clinician Should Know About Improving Care for Older Adults

By Kedar Mate | Wednesday, June 5, 2019

Age-friendly organizations provide safe, high-quality care that matches what matters most to an older adult. Since 2017, over 120 health systems in 300 locations in 37 states have joined the Age-Friendly Health Systems initiative. In the following interview, IHI Chief Innovation & Education Officer Kedar Mate, MD, describes why it’s important for all clinicians — not just geriatricians — to understand what age-friendly care means on a human level.

What does it mean to provide age-friendly care?

The goal of the Age-Friendly Health Systems initiative is to bring the fundamentals of better geriatric practice to every single patient, in every single care setting, in every single clinical encounter between an older adult and a care provider.

Whether older adults are in hospitals or ambulatory care practices, we don’t necessarily do a great job of addressing what matters to them and attending to the fundamentals around better geriatric practice. Age-friendly care addresses the four elements (or what we call the 4Ms) of an Age-Friendly Health System:

  • Understanding what matters to the older adult;
  • Reducing or eliminating the medications that are not helping;
  • Mobilizing to improve function; and
  • Focusing on mentation and cognitive status.

The evidence shows that doing these four things reliably will improve outcomes and satisfaction for older adults.

What does age-friendly care personally mean to you?

Unfortunately, I’ve seen plenty of indignities and poor care interactions — the opposite of an age-friendly system — in my practice and in my own family’s experiences. 

I saw my grandmother poorly treated. One of her physicians basically said that she was old and didn’t merit significant pain control when she suffered from very painful vertebral compression fractures. She had very specific pathologies that could have benefited from a modest amount of analgesia and physical therapy that would have gotten her back to what mattered to her. What mattered to her was being able to do basic functions that she enjoyed doing — like taking care of some of the cooking and cleaning — because they made her feel like she was a meaningful contributor to the family.

In the absence of being able to do those things, she signed off. She was severely depressed, not eating, and not drinking. When I got the call to visit her because she was dying, I got on a plane.

The family was gathered around her bed, singing prayers, and blessing her as she was moving off. I talked to her about what was happening. She wasn’t looking for heroic measures.

When I talked to her provider, I found essentially a dismissive, ageist view. “Let her go,” was the message I got. Well, I didn’t let her go. 

I’m an internist, so I got to be her doctor for about 10 days. I titrated her pain medicines, gave her dietary supplements, started her on an antidepressant, and arranged for a physical therapist. Within two weeks, she was sitting up, eating, drinking, and conversing. She started to do the things that she enjoyed doing, like cooking, cleaning, being with the family, and taking care of her great-grandkids. 

An age-friendly system would have asked my grandmother what mattered to her and would have adjusted her care based on what she wanted, which was to return to the activities that gave her meaning in her life. She lived for 10 years after that moment on what could have been her deathbed. She had a chance to meet her great-grandkids and be a guide to me. An age-friendly system, to me, is about ensuring that my grandmother and others like her have a chance to give all that they want to give to the world.

Does asking patients what matters most to them help clinical decision-making?

Absolutely. It’s an invitation into a co-production dialogue. And when you start to co-produce, you potentially do two things: 1) simplify the decision-making itself and 2) leverage more of what can help with the patient’s restorative or therapeutic journey. The evidence shows that patients, by and large, choose the simpler, often less expensive care pathway than what we might choose on their behalf. And if you engage the patient’s family, and the community that supports the patient and their family, you’re tapping into more wisdom, capability, time, and other assets you would not have known about without asking. Asking what matters unlocks all of that.

What have you heard from teams about the challenges of putting all the 4Ms into practice?

When we started talking about the 4Ms together — what matters, medications, mobility, and mentation — the first thing we heard was, “What about this fifth ‘M’? What about multi-morbidity? What about malnutrition? What about X, Y or Z?”

To be sure, there are other evidence-based elements of effective care models that ought to eventually become part of what it means to provide age-friendly care. I think of the 4Ms as “age-friendly 1.0” and in the future I’m sure there will be additions to incorporate, but we wanted to start with the essence of what it takes to get to better care. The 4Ms are each individually evidence-based and they are derived from the best in class geriatric practice models. We studied 17 geriatric practice models that had the best evidence available (randomized studies or controlled experiments) and we sought the “active ingredients” of those models — what made them work to improve care for older adults. We found over 90 active ingredients, but there were many redundancies and similar concepts, so we pared them down to 13 elements. With advice from researchers, primary investigators, and health systems, we eventually decided on the 4Ms because reliably spreading this country-wide required simplicity.

The second question we heard — almost in the same breath — was, “Why can’t we just do one of these? Why can’t we focus on mentation and just get this one thing right?” Or we heard things like, “We already have a medication stewardship program for high-risk medications, so why not just focus there?” 

But one of the beauties and the strengths of the 4Ms — and the Age-Friendly initiative in general — is that the four elements are self-reinforcing. To work on any one of the four Ms typically results in teams addressing the other three.

There’s no way to start on mentation, for example, and focus on delirium, dementia, or depression, and not work on medication because there are meds that complicate cognition. To work on mentation and not work on mobility is potentially putting someone at risk. To not understand what matters to a patient is foundational and important to the other three. If you’re working on medications, you’re having an impact on mobility and mentation. In fact, it may be impossible to work on any one of the 4Ms effectively without working on the other three. And we now have data from some of the pilot teams that shows that, when we apply these elements together, they create positive impact for patients and families.

Hundreds of teams across the US are now working on the 4Ms. When did you first realize this work might catch on?

Very early on, we visited a clinician at Providence St. Joseph’s in Oregon. She was a senior geriatrician who had been practicing for a while. She said, “I’ve started using the 4Ms as a mental checklist. At the end of a patient encounter with an older adult, I run these four things through my head and make sure that that we’ve talked about and addressed them all.” 

That’s the moment I knew. When [the 4Ms] become almost reflexive and embedded in a clinician’s thinking, that’s reliability at the highest level. That’s what we’re aiming for. “I can’t end this encounter without addressing these four things.”

What should all clinicians — not just geriatricians — understand about providing the best care possible for older adults?

I am not a geriatrician, although I’ve now spent a lot of time looking at the geriatric literature and understanding what it takes to take better care of older adults. As a general internist, I can say that internists, general practitioners, general surgeons and others often make assumptions about how to take care of older adults because we see a lot of older adults in our practice environments. I think we have to express some professional humility around caring for older adults because the truth is that there is a lot of knowledge about the care of older adults that we don’t have at our fingertips.

A framework like the 4Ms can be very helpful to us. Just as the physician at Providence St. Joseph’s found, it’s a simple mental model we can use to understand what the risks are for older adults. Using the 4Ms helps us address some of the key factors that a specialist geriatrician would help us answer. It is not a substitute for geriatric specialty care, but it can get us started on the right pathway more rapidly and in environments where we don’t have ready access to geriatricians. 

How will providing age-friendly care help address health inequities?

Age itself is a basis for significant discrimination in our systems. There can be a belief that when somebody reaches a certain age — or a certain level of disability — that they become somehow less deserving of attention or care. For example, my grandmother suffered for months at the hands of an ageist clinical community that had just given up on her because she was older.

There are also intersectional ways of thinking about inequity. Racism, for example, may compound ageism. Unless you pay attention to this compounding effect of multiple layers of discrimination and inequity in your design and the way you address your population, you won’t stand a chance of making a difference.

We’ve added to our Age-Friendly measurement set. We consider it an advanced measure because we’re not sure everybody’s going to be able to report on this data in the near term, but we’re suggesting teams not only stratify their data by age, but also by race and ethnicity to understand the impact of the Age-Friendly Health System application. We not only want to close an ageist gap, but we also seek to close a gap in race-based ageism.

What is an example of how the Age-Friendly Health Systems initiative is changing care for older adults in ways we haven’t seen before?

One of the systems we started working with early on, started measuring outcomes of the impact of the Age-Friendly Health Systems initiative on their population. They decided to measure reductions in readmissions, length of stay, and ED use. Many organizations do this, but they very beautifully merged those three measures and reframed it in a way that matters to older adults. They called it the “what matters most” measure because they’re calculating time given back to patients.

When they compared length of stay, readmissions, and ED use to the secular trends, they found they had given over 10 years of time back to their patients by applying age-friendly principles and practices in their care environments. That’s the way to make a real contribution to patients’ lives.

Editor’s note: This interview has been edited for length and clarity.

(Having difficulty watching this video? Watch on YouTube.)

You may also be interested in:

  • WIHI podcast - Assessing the Value of Age-Friendly Health Care on June 13, 2019. Join live from 2:00-3:00 PM ET or download from ITunes.

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