Age-Friendly Health System Framework Advances Geriatric Care

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In late 2019, Massachusetts General Hospital adopted a new philosophy of care, Age-Friendly Health Systems in order to best care for older adult patients—whose population is expected to double in the next 30 years.

"As adults' age increases, so do the number and complexity of their needs," says geriatrician Sharon Levine, MD, section head of Geriatric Medicine at Mass General's Division of Palliative Care and Geriatric Medicine. "Age-friendly health system framework is a philosophy to guide older adults through their care at Mass General in the ways that matter the most to them and provide the greatest benefits."

Dr. Levine and Donald M. Berwick, MD, of the Institute for Healthcare Improvement, which developed the age-friendly health system framework, explained how the framework will help Mass General's patients and families in a recent Senior Health COVID-19 Town Hall.

What Is an Age-Friendly Health System?

The age-friendly health system framework strives to optimize care for older adults by:

• Following a set of evidence-based practices
• Causing no harm
• Aligning all care with what matters to the older adult and their family

Age-friendly health systems employ evidence-based practices called the 4Ms. "The 4Ms are not a program, but a framework to infuse practices that matter to older adults," says Dr. Levine.

Practiced as a set, the 4Ms are:

• Doing what Matters for the patient—knowing each patient's specific health outcome goals and personal preferences and aligning care to meet those goals. The simple practice of asking the patient what matters to him or her is the underpinning of the 4M framework, says Dr. Levine. Asking family and caregivers what matters to the patient adds dimension to a plan of care
• Medication—if necessary, should be age-friendly and in accordance with what matters to the patient and his or her mentation and mobility. Including this factor in the 4Ms helps prevent prescribing too many medications, inappropriate medications or incorrect dosages for older adults
• Mentation—preventing, identifying, treating and managing dementia, depression and delirium across all settings of care
• Mobility—focusing on ensuring that older adults move safely every day so they can continue doing what matters to them

Practicing all 4Ms in concert is essential because addressing one likely impacts the other three. Dr. Levine offers an example of medication: "Some medications may make people more confused, affecting mentation. Some may make people more likely to fall, impacting mobility. If patients say they do not want to take a cabinet full of medications, that addresses what's most important to them," she says.

She adds that a fifth "M" could be "multicomplexity" as the majority of frail, older adults live with many concurrent chronic illnesses and need assistance with all 4Ms.

Early Learnings on Becoming an Age-Friendly Health System

Mass General adopted the 4M framework in late 2019. Just as leaders were preparing to infuse the philosophy's framework into existing processes and protocols, COVID-19 forced a pause. Despite the limitations posed by the pandemic, Dr. Levine says the Mass General team has made strides toward the final designation of age-friendly health systems—Committed to Care Excellence.

She offers these early lessons:

Find the right stakeholders to form an interdisciplinary advisory board. Mass General has multiple existing initiatives already addressing geriatric health. "A needs assessment revealed a host of fantastic endeavors around the institution with stakeholders who could become part of our advisory board," says Dr. Levine. "We have representatives addressing every part of an older adult's care, both inside and outside the hospital." She stresses the importance of having nurses and nursing leadership, pharmacists, and physical and occupational therapists at the table and gaining buy-in from top leadership.

Do not be afraid to start small. An age-friendly health system is the product of a series of small quality improvement cycles. "Age-friendly helps us assess where we are within the 4M domains, then measure growth with small process improvement cycles," Dr. Levine says. "We determine the need, implement a change and adjust as necessary."

The IHI counsels health care systems to use the PDSA cycle (Plan, Do, Study, Act) to test changes by:

1. Developing a plan to test the change (Plan)
2. Carrying out the test (Do)
3. Observing and learning from the consequences (Study)
4. Determining modifications to the test (Act)

One example of a PDSA cycle is the Mass General Senior Health Clinic's aim to increase documentation of serious illness conversations in patients' charts. Leaders at Mass General tested a simple intervention in patients' EPIC charts: a one-click navigation to the Advanced Care Planning module for providers to document the serious illness conversation.

"This metric started at a very low percentage (2%) and grew to 40%," says Dr. Levine. "This shows that a small intervention can make a difference. The goal of continued PDSA cycles is to get us to 100% documentation."

As leaders at Mass General are resuming their work on the age-friendly health system, Dr. Levine says many more improvement cycles throughout the system are now in process. "Our plan is to incorporate the 4Ms into the existing care rather than layer it on top—to stitch it in as part of the fabric."

The team has partnered with clinical pharmacy colleagues John Marshall, PharmD, BCPS, BCCCP, FCCM and Jennifer Koehl, PharmD, BCPS, in the AFHS Geriatric Medication History and High Risk Medication Reconciliation Project, which already reviews the medication list and presence of dementia in patients 65 and older in the emergency department who are being admitted to the inpatient service. By adding "what matters" and "mobility," they will have a 4Ms database that would allow to add quality interventions across sites of care.

The Memory Care Initiative supports primary care providers' patients through complete assessment and care plan development for their patients living with dementia and their care partners. In the age friendly model, the PDSA cycle implements a chart review to make sure all 4 Ms are being documented and addressed with small interventions to increase documentation.

Mass General's Vision for Age-Friendly Health Care for Older Adults

The age-friendly health system is a "team sport" that addresses all domains that help older adults succeed before they get to the hospital, while they are there, and when they go home or to another site of care.

"It takes a village," says Dr. Levine. "And Mass General is a large organization with many sites of care."

Co-managing complex patients with specialists at sometimes geographically distant places can create a disjointed experience. Employing the 4Ms of the age-friendly health system framework at Mass General will help guide and personalize older adults' care through myriad systems and services.

"If we stress what matters to patients and link their wishes to their medication, mentation and mobility, we can improve care and outcomes," Dr. Levine says.

Learn more about Palliative Care and Geriatrics at Mass General

Refer a patient to Geriatric Medicine at Mass General