The Center for Health Equity Research and Promotion (CHERP) at Philadelphia's Crescenz VA Medical Center has received a $5 million, 5-year grant from the VA Quality Enhancement Research Initiative (QUERI) for the implementation of "Age-Friendly Health System" (AFHS) concepts throughout 54 VA health facilities across Pennsylvania.
The initiative will address issues across a variety of care settings, including patients' homes, to promote safe care, support caregivers, better meet the needs of Veterans living in the community, and reduce the number of days spent in a hospital or long-term care facility.
AFHS is an integrated framework of evidence-based principles related to elder medical care pioneered over the last five years by the John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI). AFHS is now used in more than 100 health systems across the country.
In a video on the website of the Institute for Healthcare Improvement, Mary Tinetti, M.D., chief of geriatrics at the Yale School of Medicine and Yale-New Haven Hospital, gave a definition of age-friendly health systems. “Being an age-friendly health system means that everyone involved in the healthcare of older adults, from the person who cleans the room or greats you at the desk, the nurses, the doctors, therapists, everybody understands what is important to you as an individual, and that as we you get older, we accumulate more conditions, that we value different things, and that what matters most to me may be what different than what matters to you,” Tinetti said.
“We have different social and cultural things that matter to us and should be included in our care and decision making. It is not just about treating the diseases,” Tinetti added. “Everybody that is part of an age-friendly health system should understand that healthcare is not just treating diseases; it is treating patients who may have diseases but have other things going on as well. You have to understand with aging, people do accumulate more conditions so they become more complex. They vary in what matters most to them.”
The implementation of Age-Friendly Health Systems involves establishing a synergistic framework of four areas of evidence-based practices to guide overall care for elderly patients. Known as the "4Ms," and in simple laymen's terms, these are:
1. What Matters, or understanding the patient's care preferences and goals. This includes routine screenings for fragility before surgery as well as across all other settings of care, including end-of-life.
2. Medication, or the use of medications in ways that do not interfere with What Matters to the patient or his or her mobility or mental acuity across all settings of care.
3. Mentation, or the prevention, identification, and effective management of dementia, depression and delirium across all settings of care.
4. Mobility, or promoting patients' safe physical movement every day in ways that help to maintain function and independence.
The hospitals and health care practices recognized by IHI as Age-Friendly Health Systems — Committed to Care Excellence have shown exemplary alignment with the elements of the 4Ms Framework by reporting the number of older adults reached with the 4Ms over at least a three-month time period. Age-Friendly Health Systems Participants are hospitals and health practices that have formally committed to putting the 4Ms into practice and had IHI review their plans.
In 2017, the Hartford Foundation and IHI teamed with the American Hospital Association and the Catholic Health Association of the United States to work toward the goal of rapidly spreading the 4Ms Framework for Age-Friendly Care to 20 percent of U.S. hospitals and medical practices by 2020.
Five pioneer health systems stepped forward to work with IHI to test ideas and learn what it takes to be an Age-Friendly Health System:
• Anne Arundel Medical Center (Annapolis, MD)
• Ascension (St. Louis, MO)
• Kaiser Permanente (Oakland, CA)
• Providence St. Joseph Health (Renton, WA)
• Trinity Health (Livonia, MI)
As of April 2020, 162 hospitals and healthcare practices have been recognized by IHI as Age-Friendly Health Systems.
Pennsylvania's VA facilities constitute one of 22 Veterans Integrated Services Network (VISN) areas covering the 50 states. VISN4 -- Pennsylvania -- will serve as the test bed for the VA's first AFHS implementation. VISN4 serves more than 300,000 veterans.
The Pennsylvania VA project will be led by co-principal investigators and core CHERP investigators Robert Burke, M.D., M.S., Judith Long, M.D., and Rachel Werner, M.D., Ph.D., and the University of Pittsburgh's Daniel Hall, M.D.
"Research shows that having unmet care needs among older adults accelerates cognitive and physical decline, leads to poorer health, and increases risks for more frequent hospitalization and nursing home use," said Burke, director of Research for the Hospital Medicine Section and an assistant professor of Medicine at Penn's Perelman School of Medicine, in a statement. "With 62 percent of the VISN4 Veteran population over the age of 65, this funding provides the opportunity to transform our care system-wide, and to create a model to share across the VA.”
A 2019 article in the Journal of the American Geriatrics Society indicated that in the first rounds of AFHS pilot projects, one potential impediment to smooth implementation was hospitals' and other providers' lack of standardized electronic medical records. It noted the Veterans Health Administration has such a standardized records system that can seamlessly communicate patients information across its entire national network of health facilities and that "nongovernmental systems have much to learn from (the VA's) progress."
