Primary care practitioners find their role in systemwide efforts to care for those 65 and older.
Imagine a primary care practice whose care team is just as concerned about what matters to their patients as they are about what’s the matter with them.
There’s nothing stopping primary care teams from adopting such an approach in their offices today. But those who can collaborate with like-minded providers in their health systems – i.e., acute-care hospitals, emergency departments, post-acute facilities or rehab centers – may find it easier to create and sustain an “age-friendly” approach in the doctor’s office.
“Already, hospital systems are seeing the positive impact of geriatric specialty care in emergency settings and operating rooms,” Shelley Lyford, CEO and chair of West Health, was quoted as saying in January 2023 when the nonprofit foundation and San Diego-based Sharp HealthCare announced a partnership to create an “age-friendly” care model spanning the entire healthcare network. “Just think of the impact when that level of care extends throughout the entire system in an intentional and coordinated manner.”
Age-Friendly
“Age-Friendly Health Systems” is an initiative of The John A. Hartford Foundation and Institute for Healthcare Improvement (IHI) in partnership with the American Hospital Association and the Catholic Health Association of the United States. It is intended to align safe, equitable, evidence-based care with what matters to the older adult and their family caregivers. As of January 2024, there were about 3,800 IHI-recognized Age-Friendly Health System participants, each of which aims to reliably practice four evidence-based elements of high-quality care, the 4Ms:
- What Matters: Knowing and aligning care with the older adult’s specific health outcome goals and care preferences, including, but not limited to, end-of-life care, and across settings of care.
- Medication: Using age-friendly medication that does not interfere with What Matters to the older adult, Mobility or Mentation.
- Mentation: Identifying, treating and managing dementia, depression and delirium.
- Mobility: Ensuring that the older adult moves safely every day to maintain function and do What Matters to them.
Sharp HealthCare
Diane Wintz, M.D., a Sharp HealthCare critical care specialist and medical director of the Trauma Program at Sharp Memorial Hospital, helped forge the alliance with West Health after observing how older patients often struggle to recover from traumatic injuries or illnesses. These patients typically enter the healthcare system through the emergency department or for a planned operation, and some experience loss of function and independence after discharge.
“Injuries and illnesses in older patients can have immediate, permanent consequences on their independence and mobility,” Dr. Wintz said at the time the partnership with West Health was announced. “We see the best results when there’s an exceptional level of teamwork across departments and specialties. We want to see emergency teams, surgeons, pharmacists and primary care providers taking collaboration to a whole new level for our older patients.”
Prior to January 2023, Dr. Wintz had started an interdisciplinary “Generational Care” program at Sharp Memorial Hospital now under the name John M. Sachs Family Center for Generational Health. With support from West Health, all hospital emergency rooms in San Diego – including Sharp’s emergency departments – have already achieved Geriatric Emergency Department accreditation from the American College of Emergency Physicians. Sharp is also seeking Geriatric Surgery Verification from the American College of Surgeons.
“Traditional healthcare models function to provide care based on what the illness or injury needs, rather than on what the individual needs,” Dr. Wintz told Repertoire in an email. “For example, in a traditional model, if a 90-year-old arrives at 2 a.m. with a cervical spine injury, that patient may travel to MRI in the middle of the night and then get to a room, where he or she is interviewed by bedside nursing, missing an entire night of sleep and making delirium more likely to occur.”
In the generational health model, this same patient would be prioritized to a bed, tucked in, and allowed to sleep in an uninterrupted fashion, she says. MRI may be deferred if it is not anticipated to lead to a distinct change in the care plan. “If the patient were to need surgery, extensive conversation about recovery would take place, including any future limitation to the care plan if things did not go well or if recovery was not amenable to the patient. Mobility and cognitive maintenance would be priorities for hospitalization.”
The emergency department plays a key role because decisions are made there for admission or discharge to the home environment, says Dr. Wintz. “Patients who are 65 and older may have vulnerability or frailty that affects that decision process, so we have established a care pathway for nursing and physicians to evaluate specific aspects of their health to make decisions. This pathway applies interventions, such as early mobilization and intense discussion on what matters, so that we can determine if the patient would be best served by admission or by care outside of the hospital.”
Dr. Wintz began her surgical training in 2006 in a large metropolitan city, where most of the patient population was young and injured in car accidents, motorcycle accidents, or stabbings and shootings. “It was rare for me to care for someone over the age of 65,” she says. “As the years of training went on and I matriculated into my own practice in another state, the population also started to change. Although I was still managing mostly young patients with major injuries, I started to notice an [increase] of a much older population. Trauma surgeons across the nation were seeing older patients, and their practices had to evolve to accommodate the volume and the intricacies of the care needs.
“I started to grow an interest in caring for the older population. It was a new challenge for me – managing the underlying diseases, talking about issues relating to end of life, addressing changing levels of independence, and putting the medical care into the context of that patient’s goals for self. Patients 65 and older now encompass a third of my practice.”
The success of Sharp HealthCare’s generational program rests on culture change across the health system, including primary care, says Dr. Wintz.
“Our main strength is the institution of cultural change in providing healthcare to older adults. Surgeons and providers across several specialties have openly commented on their appreciation of the program despite initial hesitation. Breaking down barriers, integrating silos, changing culture, and maximizing trust and partnership have required constant commitment. The Generational Health team has taken this seriously and has inspired excitement and interest at a very difficult time in healthcare. We are fully invested in the process because we have seen overwhelming success in terms of outcome and a spreading equality for the most vulnerable group of patients.”
Speaking of the Sharp HealthCare/West Health partnership, West Health Institute Chief Medical Officer Zia Agha, M.D., told Repertoire in an email, “We have a rapidly growing and diverse aging population both in California and across the nation, and chronic disease and other issues travel with age and span the care continuum. Programs like this one are structured to break down the silos and approach issues holistically and are already being embraced by physicians, other health professionals, hospital personnel and patients. The best outcomes occur when care is coordinated, connected, and individualized wherever it occurs – clinic, emergency room, hospital, lab or office – and that is what we’re setting out to do with our partnership.”
RUSH
RUSH, a Chicago-based healthcare system comprising four medical centers and hospitals as well as over 140 physician practices, is an IHI-recognized Age-Friendly Health System. Through the RUSH Center for Excellence in Aging, the system is working to incorporate the 4Ms in some of its clinics and across the health system.
“Identifying and documenting what matters to an older adult is challenging for RUSH and most other health systems,” says Erin E. Emery-Tiburcio, Ph.D., ABPP, co-director of the Center for Excellence in Aging. “Having conversations about what is most important and assuring that the care plan is consistent with what matters takes time and is challenging to fit into tight primary care windows.”
The RUSH Center for Excellence in Aging recently revised the Medicare Annual Wellness template in its systemwide electronic health record to reflect the 4Ms, she explains. In addition, the 4Ms have been built into RUSH’s Virtual First clinic, which provides telehealth services and some in-person services as needed. “[E]very patient seen in the clinic has the 4Ms addressed, reducing inequities in standard primary care,” she says.
Because age-friendly care rests on patient input, RUSH Center for Excellence in Aging has developed tools such as patient brochures to help older adults think about and communicate what matters to them. “We are also partnering with our Virtual First clinic and Rush Generations older adult council to enhance the tools they use to assess What Matters via the patient portal,” says Emery-Tiburcio. To help support its healthcare teams, RUSH offers them continuing education about the 4Ms and is working to integrate the 4Ms into the colleges in RUSH University as well.
“Our goal is that every student and every clinician at RUSH will implement the 4Ms with every older adult in our health system. We have a way to go to get to that goal, but the RUSH Center for Excellence in Aging is committed to that endeavor.”