Summary
- As the older population grows, health systems must innovate to deliver high-quality and individualized support for patients and families. IHI’s Leadership Alliance convened an Aging Population Learning Series to exchange insights on this topic.
“We don’t care for people. We support people and partner with people.”
This is how Dr. Doug Eby, Executive Vice President of Specialty Services of Southcentral Foundation, describes the Southcentral Foundation Nuka System approach to working with their aging population, reflecting their intentionality around collaboration and co-creation with patients and families as opposed to doing things to or for them.
Southcentral Foundation was one of several member organizations to present during the IHI Leadership Alliance Aging Population Learning Series to share ideas and opportunities for improving services and care for older adults. IHI’s Leadership Alliance is a dynamic collaboration of health care executives who share a goal to work with one another and in partnership with patients, workforces, and communities to deliver on the full promise of the IHI Quintuple Aim.
Earlier this year, the Leadership Alliance hosted a three-part learning series focused on our aging population. In addition to Southcentral Foundation, speakers hailed from member organizations including Dartmouth Health, Jefferson Health, Northwell Health, Stanford Medicine, and Sutter Health. Topics explored in this learning series included:
1. Designing systems that provide seamless and coordinated support for the aging population.
2. Partnering with older adults to achieve healthier and more independent lives.
3. Navigating end-of-life transitions with clarity and compassion.
Each topic leveraged resources from Age Friendly Health Systems as well as The Conversation Project, an initiative of IHI that helps people share their wishes for care through the end of life. Key themes emerged across all three topics, including a focus on person-centered and relationship-based support; implementation of the 4Ms Framework of an Age-Friendly Health System; addressing social determinants and resource gaps; use of integrated and interprofessional care models; and finding new and innovative ways to co-design and partner with patients.
Person-Centered and Relationship-Based Support
Dr. Eby shared how Southcentral Foundation’s person-centered strategy is rooted in the 4Ms, a set of evidence-based elements of high-quality care: What Matters, Medication, Mentation, and Mobility. Southcentral Foundation used the 4Ms to engage patients in anticipatory guidance work, which refers to a proactive approach to help patients and families prepare for expected physical, emotional, and other changes that may occur with aging, and actively walk alongside them to co-design individualized plans that meet their needs. Primary care at Southcentral Foundation includes embedded behavioral health clinicians, pharmacists, social workers, and physical therapists, as well as embedded personalized palliative care resources for patients within primary care to avoid fragmented services.
Examples of successful models across the Leadership Alliance are deeply personalized and built around the patient’s life story, goals, and trusted relationships, with long-term continuity through known support teams. Organizations like Northwell emphasized the importance of understanding and honoring the individual goals, values, and preferences of older adults. Stanford Health highlighted their focus on people, processes, and technology, which allows them to move services upstream with the use of care coaches and their use of AI to help identify risk of mortality.
Integrated and Interprofessional Care Models
Another key theme discussed was the importance of a diverse and interprofessional team. Throughout the learning series, members spoke about the coordinated teams of physicians, nurse practitioners, social workers, and care coordinators who partner with each patient individually and designing systems to make it easy for them to receive comprehensive support. Teams are built to address all facets of well-being — cognitive, functional, emotional, and environmental — especially critical for frail older adults. Seamless transitions and comprehensive services across office, home, and virtual visits are necessary for keeping patients and families informed throughout the process. “Doctor, nurse, practitioner, social worker, and care coordinator all wrap around the care of a complex adult,” said Dr. Charlotte Carlson, Medical Director of Grove Sutter Health, illustrating the importance of serving a patient’s medical, behavioral, and social needs.
Social Determinants of Health
Key to supporting the complex needs of older patients and their families is addressing social determinants of health and resource gaps. Dr. Carlson shared Sutter Health’s work to create integrated pathways to provide services in support of patients. This included deep involvement of social workers to connect patients to housing, transportation, and community services. The social workers placed an emphasis on “de-shaming” issues — like housing or transportation insecurity — and identifying them as part of routine care. Meeting patients and their caregivers where they are is vital to supporting their needs and making sure they are able to fully engage in their care.
The Leadership Alliance learning series served to normalize conversations around aging while advancing innovative, patient-centered systems that respond to the unique needs of each individual and family. Centering patients and partnering with them in their care ensures that what matters to the patient is always top of mind. Addressing social determinants and resource gaps is key. Diverse and multidisciplinary teams serve the complex needs of patients and ensure nothing slips through the cracks. The great work shared in this series shows that it is possible to fully support all patients in their specific aging journeys, and shift narratives about aging from talking about “end of life” to “living well through the end.”
Learn more about opportunities to participate in the IHI Leadership Alliance or join the Age-Friendly Health Systems movement.
Elias Miranda is a Project Manager at the Institute for Healthcare Improvement (IHI).
Amy Weckman is a Project Director at the Institute for Healthcare Improvement (IHI)
Photo by micheile henderson
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