The number of older adults (i.e., aged ≥65 years) in the United States has been steadily increasing. In fact, this population is projected to double from 43.1 million in 2012 to approximately 83.7 million in 2050 (Pelton et al., 2017). Although the U.S. population has become increasingly older, health care delivery to older adults has been limited by coordination of care, transitions in care, duplication of services, harm from medications, and lack of a comprehensive patient-centered assessment (Fulmer et al., 2018; Pelton et al., 2017). As such, U.S. health care delivery needs to be more efficient, coordinated, and patient-centered to provide age-friendly, high-quality care to older adults in all care settings (Pelton et al., 2017).
In 2017, the John A. Hartford Foundation, Institute for Healthcare Improvement (IHI), American Hospital Association, and Catholic Health Association of the United States partnered to launch the Age-Friendly Health Systems initiative. The goal of Age-Friendly Health Systems is to improve the care and transition of older adults while preserving their dignity and encouraging independence with the involvement of family caregivers (Fulmer et al., 2018; Pelton et al., 2017). The Age-Friendly Health Systems Initiative is built on the 4Ms—What Matters, Medication, Mentation, and Mobility—of older adults. As of August 2020, the Age-Friendly Health Systems Initiative has expanded to 481 hospitals, health systems, and health care practices in the United States. In addition, more than 300 other hospitals and health care practices are taking age-friendly steps to implement this initiative through participation in Action Learning Communities or other collaborative programs offered by IHI (2019) and its partners.
Recently, the MedStar Center for Successful Aging (CSA) joined the Age-Friendly Health Systems Initiative. The CSA is an ambulatory practice that specializes in the care of older adults with complex medical, medication, and psychosocial needs. By providing interdisciplinary, person-centered care (PCC), the CSA seeks to address unique needs of older adults. As a result, the CSA launched an implementation project that incorporated the initiative into four areas of the CSA's ambulatory clinical pathway: (a) intake packet, (b) initial interdisciplinary comprehensive evaluation, (c) risk assignment and high-risk rounds, and (d) transitions of care. The purpose of the current article is to describe the development of a practical model to implement the 4Ms in an interprofessional outpatient clinic. The article also seeks to provide examples of measures taken that can be similarly implemented in other geriatric practices looking to adopt the 4Ms framework and become part of the Age-Friendly movement with a particular focus on medication use and safety.
The CSA targeted four areas for “Age-Friendly” improvement. First, the intake packet was redesigned to explain the 4Ms framework and collect the relevant information in each domain prior to the visit.
Second, a retrospective review of the initial multidisciplinary evaluation for each patient was conducted on all new CSA patients between October and December 2018 prior to the implementation of the 4Ms framework, and then after the 4Ms framework was introduced for new patients from January to March 2019. The charts were evaluated to see if the team addressed all elements of the 4Ms framework. A patient received a yes for each measure if the following items were found in their electronic health record (EHR):
What Matters: Patient completed the “what matters” question in the intake packet, which asks them to choose an item that is most important to them regarding their medical care.
Medication: Patient was seen by the CSA's onsite pharmacist and completed a medication review.
Mentation: Patient completed any of the following cognitive screenings with a provider: Mini Mental State Examination, Montreal Cognitive Assessment, Patient Health Questionnaire, or Geriatric Depression Scale.
Mobility: Patient was seen by the CSA's onsite physical therapist OR was referred to outpatient physical therapy by a provider.
The third aspect explored in our pathway was the process for risk stratification. Risk stratification has been shown to help practices better understand their patient populations' needs, which can improve health outcomes and decrease costs by tailoring care to high-need patients (Wagner et al., 2019). The CSA looks to proactively identify such patients to prevent high-cost outcomes, such as emergency department (ED) visits. To improve this process, in the weekly high-risk rounds, the team began to present the risk assessment for each new patient for each component of the 4Ms framework. To evaluate this process improvement, surveys were distributed before and after implementation of the 4Ms framework during rounds. The same survey was given at both time points. The purpose of the survey was to gain feedback from the participating team members on their engagement with the 4Ms measures and to identify any gaps in communication that exist when assigning risk levels and coordinating care plans.
The final area of improvement was medication safety. As part of the comprehensive evaluation, the pharmacy team identified high-risk medications for the new patient. The team opted not to use the Institute for Safe Medication Practices (ISMP; 2019) high-alert medication list to provide a more comprehensive list of high-risk medications known to increase morbidity and mortality in older adults (American Geriatrics Society 2019 Beers Criteria Update Expert Panel, 2019; O'Mahony et al., 2015). In addition, we worked with our hospital outpatient pharmacy to provide multi-dose packs in a customized, easy-to-open packet. This initiative was a collective effort taken by the entire outpatient pharmacy at MedStar. The packets are clearly marked with the time of day and date for taking the medications, so it is easy to keep track of scheduled changes. These efforts are to improve medication compliance, particularly for older adults with medication adherence issues identified through medication reviews and high-risk rounds.
The intake packet was modified to incorporate these measures in greater detail.
What Matters. The intake packet asks patients to identify from a list the life value that matters most to them. The intake packet includes questions that reference an individual's lifestyle, such as one's living environment, whether they participate in social activities, and whether they have a caregiver. The purpose of including these questions is to assess the status of one's current social condition and to initiate conversations during clinical encounters that encourage patients to discuss elements of their life that matter most to them.
Medication. The packet prompts patients to list their current medications (including dosage and frequency) and requests that they bring all medications to the visit for reconciliation with an on-site clinical pharmacist.
Mentation. The packet identifies any cognitive changes an individual may be experiencing, such as getting lost, changes in behavior, or increasing withdrawal from social activities.
Mobility. The intake packet assesses a person's functional status, asking if the individual has fallen in the past 1 year, whether they use any devices to help with their mobility, and if they have a fear of falling.
Initial Interdisciplinary Comprehensive Evaluation
During the pre-intervention period, there were a total of 67 new patients seen at the CSA. Of these patients, 55% received a mobility screen, and 82% had a mental examination. Eighty-five percent of patients worked with a pharmacist to manage their medications, and 94% of patients addressed what mattered to them. During the intervention period, a total of 55 new patients were seen at the CSA. Following the same criteria, 69% of patients received a mobility screen, and 85% had a mental examination. Eighty-five percent of patients worked with a pharmacist to manage their medications, and 69% of patients addressed what mattered to them. The decrease in the amount of patients being screened for “What Matters” is attributable to the failure of receiving and uploading in-take packets to our EHR.
Risk Assignment and High-Risk Rounds
With the 4Ms in mind, the team restructured how they identify the highest risk patients who are discussed weekly during high-risk rounds. Using an Age-Friendly approach, the team defined high-risk patients as those who: (a) had two hospitalizations in the past 6 months, or three or more hospitalizations in the past 1 year; (b) are at high risk for health care complications and necessitate intensive interdisciplinary care coordination to ensure all 4Ms are being addressed and monitored; and (c) have an end-stage disease without a palliative plan, requiring a conversation regarding patients' views on their quality of life and what matters most to them.
The clinical team in collaboration with community partners (e.g., Meals on Wheels, Community Health Advocate) met weekly to discuss the aforementioned patients to strengthen the care coordination across disciplines. High-risk rounds were modified to explicitly include the 4Ms model in these discussions. Table A (available in the online version of this article) describes the roles of the team members involved in these conversations and how their work contributes to providing 4Ms care to these high-risk patients.
Overview of High-Risk Rounds
After the introduction of the 4Ms framework, more providers responded usually or sometimes to the question of discussing the 4Ms during high-risk rounds than they did before the 4Ms framework was introduced to this weekly meeting (Figure 1).
Results before and after the introduction of the 4Ms framework to high-risk rounds discussions (N = 11).
In addition, after introducing the 4Ms framework, more providers responded usually or sometimes to understanding the interventions and care plans going forward than they did prior to using the 4Ms in practice. This finding suggests that the 4Ms framework can be used as a guide to help providers more clearly communicate their plans of care to interdisciplinary team members (Figure 2).
Additional results of pre- and post-implementation of 4Ms framework to high-risk rounds (N = 11).
High-risk medication classes were identified for new patients during their first visit, as well as their subsequent visit to the CSA (Figure 3). During the first visit for new patients, the most common high-risk medication class identified was nonsteroidal anti-inflammatory drugs (NSAIDs) (n = 42), followed by anticholinergic medications (n = 21) and opioids (n = 17). The subsequent visit for patients displayed a similar trend with the most common high-risk medication class being NSAIDs (n = 36), followed by anticholinergic medications (n = 16) and opioids (n = 14).
Identification of high-risk medications during first and second patient visits to the Center for Successful Aging.
During a 6-month timeframe, we were able to track 14 older adults who were involved in the medication management packaging program. Within this cohort, there was an improvement in medication adherence and simplification of medication regimens (e.g., number of medications, number of doses per day). In addition, we saw a reduction in hospitalizations and re-admissions.
The intervention described may serve as a model to begin to integrate the 4Ms into interdisciplinary ambulatory practice. The comprehensive care of aging individuals requires experts from multiple professions (Flaherty et al., 2019). We incorporated the 4Ms framework into our high-risk rounds explicitly to improve the identification of needs across each domain and improve communication among team members within the health system as well as the community. It is essential to involve community partners, such as Meals on Wheels, as fostering these relationships paves the way for age-friendly measures to go beyond just health system settings. These “age-friendly environments” can help make social and/or physical environments more conducive to older adults' health, well-being, and ability to age in place and in the community (Greenfield et al., 2015).
PCC and prioritizing what matters most to patients are also important elements of age-friendly environments. However, ongoing work is needed in ambulatory care settings to document and track “what matters” to individuals in the EHR if efforts to improve PCC are to be made sustainable. Studies have shown that delivering high-quality care by multidisciplinary teams requires person-centered health records (Prodinger et al., 2018). Providers at the CSA are currently working on methods to incorporate and document “what matters” in a structured way within the EHR system to achieve truly patient-focused records.
With respect to medication safety, interprofessional teams that include pharmacists have been shown to have an overall positive impact on the care of older adults (Lee et al., 2013; Nguyen & Martínez, 2020; O'Sullivan et al., 2016; Walsh et al., 2016). For example, increasing attention and resources toward medication safety have been vital to helping older adults and their caregivers (Kurup et al., 2020). In addition, a meta-analysis examining interventions to reduce adverse drug reactions (ADRs) in older adults found that pharmacist-led interventions reduced ADRs by 35% compared to 21% with non-pharmacist-led interventions (Gray et al., 2018). Pharmacist involvement in medication management is associated with reduced ADRs, hospitalizations, and ED visits, as well as cost savings from discontinuing or switching to less costly drug therapy (Cobb, 2014; Pellegrin et al., 2017), which was reinforced by our work.
Implications for Nurses as Members of the Interdisciplinary Team
The current work illustrates the importance of communication and PCC among all team members, especially nurses. It is widely known that nurses are well-positioned in the health care system to ensure optimal outcomes for patients and families (Smolowitz et al., 2015). Nurses are particularly essential to the care of older adults, as they contribute significantly to the planning and delivery of health care services to this population (Baumbusch et al., 2016). As our nation's population continues to age, nurses will be key to ensuring readiness in meeting older adults' needs by coordinating patient care across disciplines. The nurses and nurse practitioners on our team are exemplars of this care coordination, as their contributions during high-risk rounds and patient evaluations have strengthened the quality and comprehensiveness of care we provide to our older adult population.
The Age-Friendly Health Systems Initiative demonstrates a meaningful step toward providing high-quality, PCC to older adults. By focusing on the 4Ms, the initiative allows health care professionals to better coordinate care and craft a comprehensive plan that is centered around “what matters.” These quality improvement approaches represent preliminary steps that can be taken by other ambulatory care practices to implement the 4Ms in impactful ways. The CSA will continue to partner with key stakeholders to meet the needs of older adults and incorporate the Age-Friendly Health System principles.
- American Geriatrics Society 2019 Beers Criteria Update Expert Panel. (2019). American Geriatrics Society 2019 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 67(4), 674–694 doi:10.1111/jgs.15767 [CrossRef]
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Overview of High-Risk Rounds
|Topic||Responsible Team member||Discussion Points|
|CLINICAL PICTURE||Nurse practitioner / Geriatrician||Overview of the patient's condition and recent encounters|
|WHAT MATTERS||Nurse practitioner / Geriatrician||Values, preferences, and goals in context of the clinical situation|
|MEDICATION||Pharmacist||High risk medications or management issues|
|MOBILITY||Physical therapist||Current functional status/change|
|MENTATION||Nurse practitioner / Geriatrician||Dementia, delirium, and/or depression impacting current care|
|PSYCHOSOCIAL/SOCIAL DETERMINANTS||Social worker / Community Health Advocate||Barriers to care preventing progress with clinical situation|
Interventions since last meeting (what worked, what did not work)
Targets for intervention
MOWa, TOCb, PATCHc
Any scheduling or follow up needs