‘What matters most’ to patients is key for Age-Friendly Care

By Jay Bhatt, D.O., managing director of the Deloitte Center for Health Solutions, Deloitte Services LP 

The US health care system wasn’t designed to meet the unique needs of older adults. While the average life span in the US is 77.9 years, Deloitte calculated that Americans are living just 65.9 years (or 85% of their years) in good health. However, many Americans have the potential to live up to 95% of their years in good health and live to be nearly 90 years old (see Employers can spark healthy aging.) The Age-Friendly Health Systems initiative is intended to evaluate hospitals’ progress toward improving the care they provide to patients who are age 65 or older.¹ Among other things, the measure calls for hospitals to have protocols in place based on the 4Ms framework (what Matters, Medications, Mobility, and Mentation). The measure aligns with Deloitte’s vision for The Future of Health.

This two-part series explores the evolution of age-friendly care and looks at the challenges and benefits for health care organizations as they change the way they care for older adults. I first spoke with Terry Fulmer, Ph.D., RN, FAAN, president of The John A. Hartford Foundation, which is dedicated to improving the care of older adults (see 7 questions for Terry Fulmer). Next, I spoke with Nimit Agarwal, M.D., MBA, FACP, AGSF, director of Geriatric Medicine at Banner–University Medical Center Phoenix (Arizona).

Part 2: Implementing an Age-Friendly Care model: A conversation with Dr. Nimit Agarwal.

In 2017, Banner Health introduced its Age-Friendly Health System program at its academic medical centers in Phoenix and Tucson. This initiative was spearheaded in Phoenix by the newly-established Division of Geriatric Medicine at Banner University Medical Center, the academic medical center for Banner Health in affiliation with University of Arizona. Within a year of its inception, the division began piloting the Age-Friendly Health System program.¹ Below is an excerpt from my conversation with Dr. Agarwal, who is leading this initiative at Banner–University Medical Center in Phoenix:

Jay: How has your program changed since you started it?

Nimit: In geriatric medicine, we make every effort to understand the “person” in our patient. Instead of asking, ‘What is the matter with you?’ we ask, ‘What matters to you?’ What matters to a person might be, being able to go to the grocery store on their own. Or, they might just want to get their shortness-of-breath under control so they can continue to live independently. We try to get to the ‘what Matters’ part of the 4Ms first. Then we look at the other 3Ms (Mentation, Medication, and Mobility). Mobility is a challenge for many of our older patients. The traditional thinking has been to prevent hospital falls, and that is important. However, confining a patient to a bed when they have a high risk of falling can lead to deconditioning and an increased risk of delirium. So, we created a clinical practice for early mobility. Nurses assess the patient’s safety for mobility at admission and determine if adequate mobility interventions are in place. We are currently working to improve our clinical practice for delirium identification and management.

Jay: How do you think this initiative has been received by patients and their families?

Nimit: I think patients love it. Many of them are experiencing it for the first time. Instead of hearing a physician tell them, ‘This is what we are going to do for you’, our physicians ask questions like, ‘What is your expectation from this hospital stay?’ and ‘How can we make this a better experience for you?’ While they are conducting diagnostics and treating the patient, they are also guiding them and their families and explaining that delirium and deconditioning are common in a hospital setting. We want to be sure they can do their ADLs [activities of daily living]. This might include sitting in a chair during meals, going to the bathroom independently, or taking a walk through the hospital. It does create more work for staff, but we are educating our nurses and getting them additional support when needed. I think we have a good culture and a good climate to make this all possible.

Jay: What can a health care organization do to help older adults navigate their needs?

Nimit: Older adults can be categorized into three broad groups. Some older adults are fit and might run or go on regular bike rides. We would treat those patients with the disease-based guidelines that we use for treating younger patients. Then there are patients who might have severe frailty or multiple comorbidities that could limit their life expectancy. The goal for those patients might be symptom control. Then, there is a large group of patients who have some degree of frailty and comorbidities. This is a group that should have their health priorities understood in a systematic fashion. We have to be sure we are not over-treating or under-treating them. Identifying the most appropriate treatment for each patient is important.

Jay: Can you explain the term, ‘frail older adult’ and how it is used in a clinical setting?

Nimit: Frailty is an important concept when talking about older adults, but it can be difficult to measure. In simple terms, frailty is a person’s ability to fight a new illness or an acute medical event, compared to someone who is not frail. There are various ways of looking at frailty. There is physical frailty, but there is also cognitive frailty. Frail older adults may be at higher risk for complications as compared to fit older adults. If you are managing a frail older adult, you should consider the intervention and whether it could create additional challenges for that person. Not all older adults are frail. People sometimes wind up in the hospital because they are sick and might be in the worst state possible. It is easy to categorize them as being frail. But before coming to the hospital, that patient might have been very active. Maybe they went on regular hikes or did mountain climbing.

Jay: How are you complying with the new CMS Age-Friendly Hospital measures² at Banner? What are the challenges?

Nimit: I am leading the inpatient aspect of the Age-Friendly Care at Banner along with several colleagues. Our immediate goal is to build awareness about the measures and create policies and procedures to ensure compliance. We want to bring several clinical practices that connect to the 4Ms of Age-Friendly Care under a single umbrella. I have talked with several teams nationally in [California and Texas] that are also working on meeting the CMS measures. Anyone who is involved in the care of older adults—physicians, nurses, nurse practitioners, pharmacists—should consider connecting to the Age-Friendly movement. There is generally an understanding that disease-based care alone is not the answer. There should be a holistic approach to care.

Jay: What do you see as some of the more challenging aspects of the Age-Friendly measures?

Nimit: Finding out what matters to the patient is one of the biggest challenges. You have to identify the patient’s goals and values, and that can take time and effort. It involves doctors and nurses getting to know the patient as a person. Health care is a fast-paced industry. Having the skill to ask appropriate questions is a challenging aspect, but also an important one. The ‘what matters’ conversation is not yet a consistent part of the electronic medical record, but EMR companies are working on ways to add it. It is not like documenting a lab value or a vital sign, which can be easily reviewed in the EMR.

Jay: How should the workforce and clinicians be encouraged to get on board to advance this work?

Nimit: As a geriatrician, I’m enthused about the measures, but getting the whole team to move forward requires culture change. At Banner, we follow a systematic approach—define, design, and implement. We gather key stakeholders from several teams including nursing and physician teams (e.g., ER physicians, cardiologists, hospitalists, geriatricians, palliative care). Together, we define the challenge and then create an evidence-based management protocol. It goes through several committees so that all stakeholders have their input. Once the clinical practice is defined, we go through the design phase to determine how to make it possible. Do we have the resources? Do we need to add resources? After the design process, we go into the implementation phase, which requires creation of educational materials, patient-and staff-facing awareness information, and measurable metrics. It is difficult to manage and improve something if you are not measuring it.

Jay: Can you offer an example of how that process works?

Nimit: We developed our early mobility clinical practice about five years ago. During the define phase, we worked with the clinical practice to identify the tool that would be used for screening patients. Then we defined the intervention. During the design phase, we identified the resources we would need. We are now two years into the implementation phase. We have seen tremendous improvement in outcomes—such as a reduction in discharges to skilled nursing facilities compared to home, reduction in length of hospital stay, and even reduction in utilization of therapy staff as our nurses are engaged in early mobility interventions for our patients.

Jay: We are seeing increased use of artificial intelligence (AI) in hospitals (see Overcoming generative AI implementation blind spots in health care). Do you think there is a role for AI in caring for older adults?

Nimit: Absolutely. We are working with the University of Arizona, our academic partner, on an AI tool that will help identify delirium in the hospital setting, as well as in the outpatient setting. This is a tool that we call SEVA—Seniors, Electronic Virtual Assistant. We can also use smart watches to track a patient’s mobility and sleep patterns. AI can pull information from a patient’s medical record that connects to the 4Ms. AI can also securely transcribe conversations a physician has with a patient—such as the ‘what matters’ discussion—and add it to the EMR.

Jay: What advice would you give to hospital executives who are trying to incorporate Age-Friendly Care into their strategy?

Nimit: I think it is important to balance high-quality health care delivery, the patient experience, and financial viability. Patients who get delirious during a hospital stay typically have longer stays.³ If patients don’t stay mobile in the hospital, they have increased risk of becoming deconditioned, which can lead to an increased fall risk.⁴ If you know what matters to your patients, you can elevate the patient experience…the health care we provide will match their goals. Delirium and deconditioning prevention, mobility interventions, frailty identification, and safe medication prescribing can all help reduce length-of-stay and lower care costs. I think this is the right thing to do for patients. If it isn’t addressed, it can lead to hospital-acquired disabilities or lifelong limitations.

Three things to know:

1. In addition to addressing a patient’s medical issue, Age-Friendly Care focuses on understanding what matters to the patient.
2. The CMS measure requires hospitals to implement age-friendly strategies in inpatient, emergency, and surgical settings.
3. Delirium and deconditioning prevention, mobility interventions, frailty identification, and safe medication prescribing can help reduce hospital length-of-stay and lower care costs. 

Three things to consider:

1. Build awareness about the new CMS Age-Friendly Hospital measures and create policies and procedures to help ensure compliance.
2. Encourage clinicians to ask patients about their care expectations.
3. Measure the impact of Age-Friendly care initiatives (e.g., average length of stay, discharges to skilled nursing facilities compared to home).

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Endnotes:

^{1_{Banner hospitals in Western region recognized as health care leaders for older adults, Banner Health press release, April 25, 2022}}

^{2_{CMS adds Age-Friendly Hospital Measure to inpatient payment system, Healthcare Innovation, August 5, 2024}}

^{3_{Delirium: What it is, symptoms, treatment & types, The Cleveland Clinic, February 22, 2023}}

^{4_{Hospital‐associated deconditioning: Not only physical, but also cognitive, International Journal of Geriatric Psychiatry, March 2022}}

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