Creating Age-Friendly Care

Size: px

Start display at page:

Download "Creating Age-Friendly Care"

Pamela Simmons
5 years ago
Views:

1 Creating Age-Friendly Care Catherine Mather, MA, Director, IHI June 11, 2018

2 Scope of the Problem The population of older adults (65+) is quickly increasing around the world. Older adults often have complex medical and social issues, do not reliably receive necessary and evidence-based care, and are needlessly harmed across health care settings. There are numerous effective, evidence-based models for geriatric care, but most reach only a portion of older adults who could benefit from them.

3 The Know-Do Gap What we know What we do Yesterday Today Tomorrow

4 What is Our Aim? The John A. Hartford Foundation and IHI have adopted the bold and important aim of establishing Age-Friendly Care in 20 percent of US hospitals and health systems by An Age-Friendly Health system is one where every older adult: Gets the best care possible; Experiences no healthcare-related harms; and Is satisfied with the health care they receive.

5 Where Did We Start? Reviewed 17 evidence-based models and programs serving older adults: What population is served? What outcomes were achieved? What are the core features of the model?

6 July August discrete core features identified by model experts in prework Redundant/similar concepts removed and 13 core features synthesized by IHI team Expert Meeting led to the selection of the vital few : the 4Ms

7 The Four M s What Matters: Knowing and acting on each patient s specific health goals and care preferences Medication: Optimizing medication use to reduce harm and burden, focused on medications affecting mobility, mentation, and what matters Mentation: Identifying and managing depression, dementia and delirium across care settings Mobility: Maintaining mobility and function and preventing complications of immobility

8 Evidence Base 8 What Matters: Asking what matters and developing an integrated systems to address it lowers inpatient utilization (54% dec), ICU stays (80% dec), while increasing hospice use (47.2%) and pt satisfaction (AHRQ 2013) Medications: Older adults suffering an adverse drug event have higher rates of morbidity, hospital admission and costs (Field 2005) 1500 hospitals in HEN 2.0 reduced 15,611 adverse drug events saving $78m across 34 states (HRET 2017) Mentation: Depression in ambulatory care doubles cost of care across the board (Unutzer 2009) 16:1 ROI on delirium detection and treatment programs (Rubin 2013) Mobility: Older adults who sustain a serious fall-related injury required an additional $13,316 in hospital operating cost and had an increased LOS of 6.3 days compared to controls (Wong 2011) 30+% reduction in direct, indirect, and total hospital costs among patients who receive care to improve mobility (Klein 2015) References at end of slides

10 Design to Achieve National Scale Activity: Campaign spreads to care sites Stage 0: Developin g the Prototype Activity: Literature review & Expert meeting Output: Age Friendly Prototype Stage 1: Testing the Prototype Activity: Prototype testing with five systems & scaling within those five Output: Age Friendly Model & Scale-up Guidance Stage 2 Scale-Up Output: Age Friendly Health Systems with evidence of improved outcomes for older adults Testing the Prototype for refinement Scaling up the Prototype in the five prototyping systems Action Communities

11 Pilot Testing (April 2017 February 2018) Tested the 4Ms in 26 pilot sites across the 5 systems Learning system: Coaching around improvement science and testing with all 26 sites 4 workshops (April, June, October 2017, Feb 2018) Monthly all team calls Quarterly Advisory Group calls Refined the content theory into a change package & how-to guide Developed a common measurement frame and tested with pilot sites Led dissemination efforts to raise awareness about the AFHS Unexpected & wonderful! Multiple systems eager to join! Developed a quarterly call series for Friends of Age-Friendly Engaged Catholic Health Association of the United State alongside American Hospital Association

12 February, 2018: Age-Friendly Health System prototype informed by testing Age-Friendly Health Systems What Matters: Know and act on each older adult s specific health outcome goals and care preferences across settings Medications: If medications are necessary, use Age- Friendly medications that do not interfere with What Matters, Mentation, or Mobility Mentation: Identify and manage depression, dementia, and delirium across care settings Know the health outcome goals and care preferences of older adults for current and future care, including but not limited to end of life Align all care and decisions with the older adult s specific health outcome goals and care preferences Engage the older adult and the health care team in determining whether medications are impacting the older adult s Mobility, Mentation, and/or What Matters; if so, create a shared responsibility to de-prescribe or adjust the dosage Make medication decisions in partnership with the older adult, family, and health care team, and identify options that support What Matters, Mentation, and Mobility Know if an older adult has dementia and/or delirium Manage the factors that contribute to delirium Treat and manage dementia by understanding the underlying needs of older adults with dementia to keep them safe Know if an older adult is depressed, and treat and manage depression Mobility: Ensure that older adults at home and in every setting of care move safely every day in order to maintain function and do what matters Create an environment and culture that enables, supports, and encourages mobility Identify and treat underlying contributors to immobility and fall injuries

13 Guides for spread in health systems Age-Friendly How-to-Guide for the 4Ms Age-Friendly Measurement Guide Leaders Guide to Age-Friendly Health Systems Age-Friendly Business Case Age-Friendly Business Case by Health System

Expected Achievements: Number of older adults Reached with 4Ms in 2018 Through Scale-Up 51,053 older adults Total number of older adults the health system teams have pledged to reach with

14 Expected Achievements: Number of older adults Reached with 4Ms in 2018 Through Scale-Up 51,053 older adults Total number of older adults the health system teams have pledged to reach with age-friendly care by May ,993 older adults Total number of older adults the health system teams have pledged to reach with age-friendly care by December 2018 Sites of care: Hospital, Primary Care, SNF, Clinics, Home Health, Hospice, Assisted Living Trinity Team Trinity Teams Ascension Teams Providence Team Kaiser Permanente Team Anne Arundel Team

15 Changes to become Age-Friendly system-wide Support frontline teams to adopt 4Ms of Age-Friendly Health system Board and C-suite commitment to AFHS Integration into strategic plan & executive dashboard measures Evidence-based clinical changes (4Ms) integrated into front-line clinical practice Patient, family & caregiver participation in governance and relevant committees Formal partnership with community organizations Routine board agenda item Executive compensation incentive Letter of commitment Appears in 2019 strategic plan Resourcing plan for AFHS Primary pt outcome & system quality measures stratified by age Develop awareness & skills in 4Ms EHR integration of 4Ms Workflow integration of 4Ms Job role integration of 4Ms Major care pathways include 4Ms Older adult representation in Board committee Older adult, family, caregiver engagement in practices committees & clinical governance Clear service navigation partners identified by system Preferred partnerships with social service providers for older adults

16 Continuing to build evidence 16 7-month Action Community starting in September Focused on two care settings Hospital-based Care Ambulatory/ Primary Care

September 2018 March 2019 17 Participate in 90 minute interactive webinars Monthly content calls focused on 4Ms Opportunity to share progress with other teams by brief case study Test Age-Friendly

17 September 2018 March Participate in 90 minute interactive webinars Monthly content calls focused on 4Ms Opportunity to share progress with other teams by brief case study Test Age-Friendly interventions Test implementing specific changes in your practice Submit data on a standard set of Age-Friendly measures (brief) Submit a data dashboard on a standard set of process and outcome measures Option to join two drop-in coaching sessions Join other teams for measurement and testing support. Leadership Track to Support Scale-Up

18 FAQ (More info in prospectus) 18 What is the benefit? At the end of 7 months, your organization will have implemented key changes of an Age-Friendly Health System and have generated initial evidence of benefit to the older adults you serve. You ll also be a national leader part of the first public cohort of organizations on their way to becoming Age-Friendly What is the cost? There is no financial commitment to participate. You are required to allocate appropriate time to staff so that they can participate in all required program activities How do we join? Submit a letter of interest signed by your organization s leadership Assure appropriate staffing resources are available Attending orientation webinars in May, June, or July

19 Macroenvironmental changes to motivate Age-Friendly Health System spread Regulation, measurement and new standards-based review Create an enabling environment for health systems to pursue Age- Friendly Health system Information technology integration support AFHS practices Policy-enabled payment drives business case for AFHS Patients & consumers actively demand their system become an AFHS Educational & facilitation services available to help enable health systems to become AFHS

20% of hospitals and health systems are Age-Friendly States and

Associations Older Adults & Caregivers Health Systems Geriatric

20 20% of hospitals and health systems are Age-Friendly States and Communities Workforce Health System Associations Professional Associations Older Adults & Caregivers Health Systems Geriatric Care Programs Certification & Accreditation Payers EHR and other IT products IHI, with The John A. Hartford Foundation, as convener of stakeholders, designer of campaign, organizer of stakeholders

The Art of Communicating Geriatric Vital Signs (An Age Friendly Health System Approach) Michelle Moccia DNP, ANP-BC, CCRN Program Director, Senior ER St. Mary Mercy Hospital Livonia, MI michelle.

21 The Art of Communicating Geriatric Vital Signs (An Age Friendly Health System Approach) Michelle Moccia DNP, ANP-BC, CCRN Program Director, Senior ER St. Mary Mercy Hospital Livonia, MI President, GAPNA Acknowledgments: EMRAP program (Eric James, Fatima Saad, Michael Mastrogiovanni, Lainey Gossett, Jessica Cristiu, Jordan Ansheurser, Daniella Gomez Zubieta, Niveen Elder, Belinda Dokic, (Six Sigma)

22 Learning Objectives 1. Identify effective strategies to improve communication of positive Geriatric Vital Signs (Delirium, Depression, Dementia) 2. Describe the importance of rapid cycling PDCA (Plan, Do, Study, Act) to implement change

Trinity Health s 22-state diversified system $17.6B In Revenue 1.3M Attributed Lives $1.1B Community Benefit Ministry 131K Colleagues 7.5K Employed Physicians and Clinicians 25.

23 Trinity Health s 22-state diversified system $17.6B In Revenue 1.3M Attributed Lives $1.1B Community Benefit Ministry 131K Colleagues 7.5K Employed Physicians and Clinicians 25.6K Affiliated Physicians 93 Hospitals* 22 Clinically Integrated Networks 13 PACE Center Programs 109 Continuing Care Locations *Owned, managed or in JOAs or JVs Trinity Health 23

24 Our Community: The SJMHS Regional service area and most of SE Michigan continues to see % of people 65+ increase

25 Population Change by Age Group 24% of the population in SE Michigan will be elderly (65+) in An Aging Region: ,884-14,418-10, , ,247 Counties Included in Data Set: Livingston Macomb Monroe Oakland Washtenaw Wayne -48, , , , , , , , , ,000 Source: SEMCOG 2040 Forecast

0% Counties Included in Data Set: Livingston Macomb Monroe Oakland Washtenaw Wayne 20.0% 0.0% -20.

26 Percent Population Growth by Age Group: 86% increase for 65+ and 12% decrease <65 Represent 37% of current ED visits; 52% hospital discharges Population Growth by Age Group % 85.5% 80.0% 60.0% 40.0% Counties Included in Data Set: Livingston Macomb Monroe Oakland Washtenaw Wayne 20.0% 0.0% -20.0% % -11.4% -11.0% Source: SEMCOG 2040 Forecast 65+ populations have the highest use rates for various health care services

27 ED visits across the Nation ED can be sole source for medical care PCP lack of availability Primary care offices with business hour (closed on week-ends) Direction from answering recording Homeless Psychiatric illness ED is open 24/7 even on holidays and week-ends.

ED: Front porch of community Geriatric EDs Uniquely

Recognize inpatient care may be detrimental ED usual care

conditions Identify age related changes Staff education 4

28 ED: Front porch of community Geriatric EDs Uniquely positioned to improve care Opportunity to set the stage Recognize inpatient care may be detrimental ED usual care modified with their needs in mind Screen for high-risk conditions Identify age related changes Staff education 4 M s: Mobility, Medication, Mentation, Matters (Age Friendly Health System)

Senior (Geriatric) ER (more than a space) Address health & social needs Screenings: identify seniors at risk for safety and poor outcomes Not often captured with a medical screening Assess Geriatric

29 Senior (Geriatric) ER (more than a space) Address health & social needs Screenings: identify seniors at risk for safety and poor outcomes Not often captured with a medical screening Assess Geriatric Vital Signs 3 D s (mentation) Status enables HCP to provide specific plan of care

30 Geriatric Vital Signs: 3 D s Delirium Dementia Depression Common and undetected Screening provides baseline for future visits Unreported can lead to adverse outcomes

DELIRIUM A Medical emergency High morbidity and mortality $38 billion and $152 billion in health-related costs annually 7% to 10% in ED Most prominent risk factor in dementia Evaluation & management

31 DELIRIUM A Medical emergency High morbidity and mortality $38 billion and $152 billion in health-related costs annually 7% to 10% in ED Most prominent risk factor in dementia Evaluation & management critical Unrecognized more likely to die at 6 months compared with recognized (30.8% vs 11. 8%) JAGS.2014 March: 62,(3): SAEM Geriatric Emergency Department Guidelines 2013 Nat Rev Neurol April ; 5(4): doi: /nrneurol Kuma and colleagues. 2003

32 Confusion Assessment Method (CAM)

33 Failure to Recognize Major Prognostic Implications Cognitive and functional decline Longer LOS Greater healthcare use Increase in institutionalism Cost equivalent to CHF and COPD

34 The Cost of Not Knowing and Acting Case 1 34

35 Dementia: Significant burden to health care Sixth leading cause of death in U.S. AD: fifth leading cause of death Frequent and potentially avoidable hospitalizations and ED visits Early diagnosis allows a care plan for the future Medications

36 Determining Cognition: OMCT The Orientation Memory Concentration Test (also referred to as the Blessed Test and Six-item Cognitive Impairment Test) Endorsed by AGS, ENA, SAEM, and ACEP newly published "Geriatric Emergency Guidelines" as a screening test to use in older adults elines.pdf

37 Orientation Memory Concentration Test

38 The Cost of Not Knowing Not Acting Case 2 38

Geriatric Depression: Stats and Prognostic Implications Common late life nearly 5 million Not a normal part of aging Major health issue Often reversible with prompt and appropriate treatment.

39 Geriatric Depression: Stats and Prognostic Implications Common late life nearly 5 million Not a normal part of aging Major health issue Often reversible with prompt and appropriate treatment. Untreated = poor outcomes Suicide Rate: approximately 1 in 12 (all ages) Older adults 1 in 4 (every 90 minutes) Higher rate of suicide completion (Omega (Westport) 2013;66(2): CDC WISQARS

40 Geriatric Depression Scale (Rinaldi P 1, Mecocci P, Benedetti C, Ercolani S, Bregnocchi M, Menculini G, Catani M, Senin U, Cherubini A. (2003). Validation of the fiveitem geriatric depression scale in elderly subjects in three different settings. Journal of American Geriatric Society, 51 (5): 694-8).

41 Self-Harm Risk

42 The Cost of Not Knowing Not Acting Case 3 42

43 Art of Communicating A3 form PDSA Process flow Run/Control Charts 43

45 PDSA 45

Process Improvements PDSA cycles Email results Weekly Run charts Betty White Reminder Reached out to Patient IDT EMR request ED "H"

47 Process Improvements PDSA cycles results Weekly Run charts Betty White Reminder Reached out to Patient IDT EMR request ED "H" icon handoff form Avoid using abbreviations Reach out to other SJMHS EDs on their process Yellow hand added to top of all computers

48 48 Communicating Delirium Vital Sign 7 months

49 49 Communicating Cognitive Impairment VS 7 months

50 Communicating Depression Vital Sign - 7 months 50

51 Introduce Yellow Hand-off Form 51

52 DELIRIUM : 3/5/17-2/21/18 n= 282 (Yellow arrow = implementation Handoff form) 52 Delirium RN Notification to ED PHY Delirium PHY docum. in progress % UCL=107.68% % UCL=129.62% % % 90.00% 85.00% % 80.00% _ X=81.08% 80.00% 85.00% _ X=76.92% 70.00% 60.00% 60.00% 40.00% 50.00% MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB LCL=54.49% 20.00% MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB LCL=24.21%

53 DELIRIUM ADMIT DIAGNOSIS 53 Delirium Admit DX order % UCL=101.34% 80.00% 85.00% 60.00% _ X=52.50% 40.00% 20.00% 0.00% MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB LCL=3.66%

54 OMCT COGNITIVE IMPAIRMENT n= 359 OMCT RN notf. to ED PHY OMCT PHY Documentation % UCL=108.82% % UCL=97.04% % 90.00% 90.00% 85.00% 80.00% 85.00% 80.00% 70.00% _ X=71.58% 70.00% 60.00% _ X=61.50% 60.00% 50.00% 50.00% 40.00% 40.00% 30.00% MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB LCL=34.35% 30.00% 20.00% MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB LCL=25.96%

55 DEPRESSION: n= GDS RN Notification to ED PHY GDS PHY Documentation % % 90.00% UCL=93.73% % UCL=101.05% 80.00% 85.00% 90.00% 85.00% 70.00% 80.00% 60.00% _ X=58.92% 70.00% _ X=65.75% 50.00% 60.00% 40.00% 50.00% 30.00% 40.00% 20.00% MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB LCL=24.10% 30.00% MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB LCL=30.45%

Yellow hand off form usage summary 56 DELIRUM Form Use N RN to Physician Physician

(11/29/17-2/28/18) DEMENTIA (OMCT) Pre-Intervention (9/27/17-11/28/2018) First 3 Months

58% 31.25% Form Use N RN to Physician Physician Documentation D/C Instructions N/A 64 57.

59% DEPRESSION Pre-Intervention (9/27/17-11/28/2018) First 3 Months (11/29/17-2/28/18) Form

56 Yellow hand off form usage summary 56 DELIRUM Form Use N RN to Physician Physician Documentation Admitted With Diagnosis Pre-Intervention (9/27/17-11/28/2018) First 3 Months (11/29/17-2/28/18) DEMENTIA (OMCT) Pre-Intervention (9/27/17-11/28/2018) First 3 Months (11/29/17-2/28/18) N/A % 50.00% 28.85% YES % 78.38% 62.16% NO % 39.58% 31.25% Form Use N RN to Physician Physician Documentation D/C Instructions N/A % 28.13% 7.81% YES % 71.74% 19.57% NO % 30.16% 1.59% DEPRESSION Pre-Intervention (9/27/17-11/28/2018) First 3 Months (11/29/17-2/28/18) Form Use N RN to Physician Physician Documentation D/C Instructions N/A % 38.79% 6.03% YES % 70.37% 20.37% NO % 25.24% 5.83%

57 Delirium 3/28-5/22 57 Delirium (CAM) N ED RN to ED Physician Notification ED Physician Documentation in MDM ED Physician Admitted w/ Diagnosis 3/28-4/3 7 6/7 (85.71%) 5/6 (83.33%) 4/6 (66.66%) 4/4-4/10 5 4/5 (80%) 4/4 (100%) 3/4 (75%) 4/11-4/17 2 1/2(50%) 1/1(100%) 0/1(0%) 4/18-4/24 2 2/2(100%) 1/2(50%) 1/2(50%) 4/25-5/1 4 2/4 (50%) 2/2(100%) 1/2(50%) 5-2-5/8 1 1/1 (100%) 1/1 (100%) 0/1 (0%) 5/9-5/15 7 5/7 (71%) 5/5 (100%) 2/5 (40%) 5/16-5/22 2 2/2 (100%) 2/2 (100%) 0/2 (0%) 85% 75-84% 50-74% <50%

58 Depression 3/28-5/22 58 Possible Depression (GDS) N ED RN to ED Physician Notification ED Physician Documentation in MDM ED Physician Discharge instructions 3/28-4/3 17 8/17 (47.06%) 5/8 (62.5%) 2/4 (50%) 4/4-4/ /14 (71.4%) 6/10 (60%) 6/10 (60%) 4/11-4/ /13(38%) 5/5(100%) 1/3(33%) 4/18-4/ /11(91%) 6/10(60%) 1/3(33%) 4/25-5/1 7 5/7(71.4%) 5/5(100%) 2/2(100%) 5/2-5/8 14 7/13 (54%) 8/8 (100%) 2/3 (66%) 5/9-5/15 5 2/4 (50%) 2/2 (100%) 1/1 (100%) 5/16-5/ /10 (60%) 5/6 (83%) 1/1 (100%) 85% 75-84% 50-74% <50%

59 Cognitive Impairment 3/28-5/22 59 Cognitive impairment (OMCT) N ED RN to ED Physician Notification ED Physician Documentation in MDM ED Physician Discharge instructions 3/28-4/3 6 3/6 (50%) 3/3 (100%) 1/3 (33.33%) 4/4-4/10 8 7/8 (87.5%) 4/7 (57.14) 3/4 (75%) 4/11-4/ /10 (90%) 7/9 (77%) 3/3 (100%) 4/18-4/24 4 4/4(100%) 1/4(25%) 0/2(0%) 4/25-5/1 9 9/9(100%) 6/9(66.6%) 4/4(100%) 5/2-5/8 4 3/4 (76%) 2/3 (66%) 1/2 (50%) 5/9-5/15 8 4/8 (50%) 4/4 (100%) 3/5 (60%) 5/15-5/22) 15 13/15 (86%) 9/13 (69%) 3/5 (60%) 85% 75-84% 50-74% <50%

60 How can you help improve communication? Avoid common missteps in solving problems Try not to assume You know what the problem is before seeing what s happening You know how to fix the problem without understanding the root causes The 1 st action plan you develop will address the problem perfectly

61 In conclusion: To help improve communication Everyone is on the same page Start small, analyze, and then scale up Leadership buy in Share metrics and ask why? Evaluate PDSA with every new change EMR enhancements Storytelling Acknowledge, Celebrate

The Art of Communicating Geriatric Vital Signs (An Age Friendly Health System Approach)

The Art of Communicating Geriatric Vital Signs (An Age Friendly Health System Approach) Michelle Moccia DNP, ANP-BC, CCRN Program Director, Senior ER St. Mary Mercy Hospital Livonia, MI michelle.moccia@stjoeshealth.org