Patient Priorities–Aligned Care for Older Adults With Multiple Conditions

JAMA Network Open, Год журнала: 2024, Номер 7(1), С. e2352666 - e2352666

Опубликована: Янв. 23, 2024

Importance Older adults with multiple conditions receive health care that may be burdensome, of uncertain benefit, and not focused on what matters to them. Identifying aligning patients’ priorities improve outcomes. Objective To assess the association receiving patient (PPC) vs usual (UC) relevant clinical Design, Setting, Participants In this nonrandomized controlled trial propensity adjustment, enrollment occurred between August 21, 2020, May 14, 2021, follow-up continuing through February 26, 2022. Patients who were aged 65 years or older 3 more chronic enrolled at 1 PPC UC site within Cleveland Clinic primary multisite practice. Data analysis was performed from March 2022 2023. Intervention Health professionals guided patients identification values, outcome goals, preferences, top priority (ie, problem they most wanted focus because it impeded their goal). Primary clinicians followed decisional strategies (eg, use as communication decision-making) decide stop, start, continue. Main Outcomes Measures outcomes included perceived treatment burden, Patient-Reported Measurement Information System (PROMIS) social roles activities, CollaboRATE survey scores, number nonhealthy days (based healthy home), shared prescribing decision quality measures. Follow-up 9 months for patient-reported 365 days. Results A total 264 individuals participated, 129 in group (mean [SD] age, 75.3 [6.1] years; 66 women [48.9%]) 135 75.6 [6.5] 55 [42.6%]). Characteristics sites balanced after score weighting. At follow-up, there no statistically significant difference burden groups multivariate models (difference, −5.2 points; 95% CI, −10.9 −0.50 P = .07). participants almost 2.5 times likely than endorse decision-making (adjusted odds ratio, 2.40; 0.90 6.40; .07), experienced 4.6 fewer (95% −12.9 −3.6 days; .27) compared participants. These differences significant. PROMIS Social Roles Activities scores similar 2 follow-up. Conclusions Relevance This priorities-aligned showed benefit CollaboRATE. While findings significant, point estimates suggested hold promise improving these Randomized trials larger samples are needed determine effectiveness care. Trial Registration ClinicalTrials.gov Identifier: NCT04510948

Язык: Английский

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Effects of Implementation of a Supervised Walking Program in Veterans Affairs Hospitals

Annals of Internal Medicine, Год журнала: 2023, Номер 176(6), С. 743 - 750

Опубликована: Июнь 1, 2023

Background: In trials, hospital walking programs have been shown to improve functional ability after discharge, but little evidence exists about their effectiveness under routine practice conditions. Objective: To evaluate the effect of implementation a supervised program known as STRIDE (AssiSTed EaRly MobIlity for HospitalizeD VEterans) on discharge skilled-nursing facility (SNF), length stay (LOS), and inpatient falls. Design: Stepped-wedge, cluster randomized trial. (ClinicalTrials.gov: NCT03300336) Setting: 8 Veterans Affairs hospitals from 20 August 2017 19 2019. Patients: Analyses included hospitalizations involving patients aged 60 years or older who were community dwelling admitted 2 more days participating medicine ward. Intervention: Hospitals randomly assigned in stratified blocks launch date STRIDE. All received support according Replicating Effective Programs framework. Measurements: The prespecified primary outcomes SNF LOS, having 1 falls was exploratory. Generalized linear mixed models fit account clustering within patient-level covariates. Results: Patients pre-STRIDE time periods (n = 6722) similar post-STRIDE 6141). proportion with any documented walk during potentially eligible hospitalization ranged 0.6% 22.7% per hospital. estimated rates 13% 8% post-STRIDE. adjusted models, odds lower among hospitalized (odds ratio [OR], 0.6 [95% CI, 0.5 0.8]) compared pre-STRIDE. Findings robust sensitivity analyses. There no differences LOS (rate ratio, 1.0 [CI, 0.9 1.1]) an fall (OR, 0.8 1.1]). Limitation: Direct reach low. Conclusion: Although limited variable, occurring period had SNF, change Primary Funding Source: U.S. Department Quality Enhancement Research Initiative (Optimizing Function Independence QUERI).

Язык: Английский

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Health system approaches and experiences implementing the 4Ms: Insights from 3 early adopter health systems

Journal of the American Geriatrics Society, Год журнала: 2023, Номер 71(8), С. 2627 - 2639

Опубликована: Май 29, 2023

Abstract Background Redesigning the healthcare system to consistently provide effective and tailored care older adults is needed. The 4Ms (What Matters, Mobility, Medication, Mentation) offer a framework guide health systems' efforts deliver Age‐Friendly care. We use an implementation science characterize assess real‐world experiences with across varied systems. Methods With expert input, we selected three systems that were early adopters of engaged in different support models through Institute for Healthcare Improvement. conducted 29 semi‐structured interviews diverse stakeholders from each site. Stakeholders ranged hospital leadership frontline clinicians. Interviews covered site's approach implementation, including facilitators barriers. recorded, transcribed, deductively coded using Consolidated Framework Implementation Research. characterized decisions then inductively identified overarching themes subthemes supporting quotes. Results Health their approach, order 4Ms. themes: (1) offered compelling conceptual advancing care, but was complex fragmented; (2) complete sustained required multidisciplinary multilevel engagement; (3) strategies facilitate success culture change included top‐down communication infrastructure alongside hands‐on clinical education support. Common barriers are siloed settings impeded synergies scaling; disengaged physicians; difficulty implementing What Matters meaningful way. Conclusions Similar other studies, multifactorial domains impacting implementation. To achieve transformation, must plan attend multiple phases while ensuring work coheres under unified vision spans disciplines settings.

Язык: Английский

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Optimizing delirium care in the era of Age‐Friendly Health System

Journal of the American Geriatrics Society, Год журнала: 2023, Номер 72(1), С. 14 - 23

Опубликована: Ноя. 1, 2023

Abstract Delirium is a significant geriatric condition associated with adverse clinical and economic outcomes. The cause of delirium usually multifactorial, person‐centered multicomponent approaches for proper management are required. In 2017, the John A. Hartford Foundation Institute Healthcare Improvement (IHI) launched national initiative, Age‐Friendly Health System (AFHS), promoting use framework called 4Ms (what matters, medication, mentation, mobility). framework's primary goal to provide comprehensive practical care older adults it aligns core concepts optimal management. this special article, we demonstrate how traditional prevention model can be assessed from perspective AFHS. An example crosswalk Hospital Elder Life Program (HELP) Core Interventions 4MS, which demonstrates alignment in We also introduce useful tools create an AFHS environment Although much has been written about management, there need identify critical steps advancing overall context suggest future directions, including more prospective research assess impact on care, innovative sustainable education platforms, fundamental changes healthcare payment system adoption any setting, application community continuity delirium.

Язык: Английский

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An age‐friendly approach to primary care in an academic health system

Journal of the American Geriatrics Society, Год журнала: 2024, Номер 72(S3)

Опубликована: Март 15, 2024

Abstract Background Age‐friendly care, addressing what matters most, medications, mentation, and mobility, is a successful model for improving older adult care. We describe the initial outcomes of age‐friendly care implementation in five primary clinics an academic health system. Methods In partnership with regional quality improvement (QI) organization, we used practice facilitation to implement from July 2020 June 2023. Clinic workflows electronic record (EHR) templates were modified capture six QI measures patients ≥65 years: Documenting most Advance planning (ACP) Annual cognitive screening Caregiver referral dementia community resources Fall‐risk Co‐prescription opioid sedative‐hypnotic drugs Providers alerted if had positive screens given support tools clinical decision‐making. January–June 2023 compared year prior implementation. staff interviewed about barriers facilitators. Results All improved Geriatrics other showed ACP screening. high fall‐risk rates (≥85%). The least measure was co‐prescription opioids sedative‐hypnotics ranging 7% 39%. Implementation hinged on leadership prioritization, facilitator guidance, team buy‐in, EHR functionality, performance review. Three received Age‐Friendly Health System recognition. Conclusions A approach using some but not all measures. Future interventions will focus training high‐risk medication tapering elicitation goals.

Язык: Английский

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Evaluating the relationship between facility Age‐Friendly recognition and subsequent facility‐free days in older Veterans

Journal of the American Geriatrics Society, Год журнала: 2024, Номер 72(8), С. 2329 - 2335

Опубликована: Июнь 20, 2024

Thousands of health systems have been recognized as "Age-Friendly" for implementing geriatric care practices aligned with the "4Ms" (What Matters, Medication, Mentation, and Mobility). However, effect Age-Friendly recognition on patient outcomes is largely unknown. We sought to identify this in Veterans Health Administration (VHA)-one largest integrated United States.

Язык: Английский

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Scaling and spreading age‐friendly care: Early lessons from the VA National Age‐Friendly Action Community

Journal of the American Geriatrics Society, Год журнала: 2025, Номер unknown

Опубликована: Янв. 9, 2025

Abstract Background The Age‐Friendly Health System (AFHS) initiative seeks to improve care for older adults through assessing and acting on the 4Ms (What Matters, Medication, Mentation, Mobility). Department of Veterans Affairs (VA) joined in 2020, from 2022 2023, VA led its first Action Community, a 7‐month online educational series teach clinicians about implementing across settings. Methods Community was designed spread awareness Veterans, interprofessional team knowledge providing guided by 4Ms, support AFHS implementation multiple included synchronous webinars, Practice coaching calls, office hours. A learner experience questionnaire administered at completion Community. Results Totally 186 teams enrolled representing 78/171 (45.6%) medical centers (VAMCs), 36 US states 20 types Participants reported high rates satisfaction confidence their ability apply skills learned. Overall, 58 earned Level 1, Participant recognition, 43 also 2, Committed Care Excellence recognition Institute Healthcare Improvement. Conclusions facilitated learning supported earning offers promising model spreading other large health systems. Further work is underway evaluate impact this clinical process outcomes measures.

Язык: Английский

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Advance care planning readiness, barriers, and facilitators among seriously ill Black older adults and their surrogates: A mixed methods study

Palliative & Supportive Care, Год журнала: 2025, Номер 23

Опубликована: Янв. 1, 2025

Advance care planning (ACP) supports communication and medical decision-making is best conceptualized as part of the continuum. Black older adults have lower ACP engagement poorer quality in serious illness. Surrogates are essential to effective but rarely integrated planning. Our objective was describe readiness, barriers, facilitators among seriously ill their surrogates. We used an explanatory sequential mixed methods study design. The setting 2 ambulatory specialty clinics academic center 1 community church Northern California, USA. Participants included Older were aged 60+, self-identified Black, had received at or a member congregation. 18+ could potentially make decisions for adult. validated survey assess confidence readiness ACP. What "matters most" barriers employed questions from established materials trials. Semi-structured interviews conducted after surveys further explain results. (N = 30) surrogates 12) confident that they engage (4.1 4.7 out 5), many not ready these conversations (3.1 3.9 5). A framework with 4 themes - illness experience, social connections, interaction health providers, burden identification engagement. identified present support Future research can impact this on decision-making.

Язык: Английский

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Strategies and Outcomes of Age-Friendly Health System Implementation in Outpatient Settings: A Systematic Review

INQUIRY The Journal of Health Care Organization Provision and Financing, Год журнала: 2025, Номер 62

Опубликована: Янв. 1, 2025

The Age-Friendly Health System (AFHS) movement has spread widely in recent years, with nearly 5000 healthcare organizations across the country recognized as Age-Friendly. Despite this broad recognition, there is little focus on how AFHS are implemented and impact of implementation. objectives study were to describe strategies employed support implementation outpatient settings identify measures used evaluate effectiveness. We conducted a systematic review literature from multiple databases spanning 2015 March 2024, identified eligible studies using predefined inclusion/exclusion criteria, extracted key data (eg, design, population, strategies, outcomes/measures). ten primary care clinics (N = 8), convenient 1) cancer center 1). over 65 98 outcomes or measures. vast majority mapped components 4Ms (Mobility, Mentation, Medication, What Matters), up per M category. Five had reporting discrepancies four did not fully define outcomes. included serve clear examples for need more evidence settings. Existing research lacks strategy specification standardization present gaps opportunities advance “recognition” impact.

Язык: Английский

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4 Steps to 4Ms: A Navigation Guide for a Hospital-Based Composite Measure of 4Ms Care and the Implications for Outcomes Assessment

INQUIRY The Journal of Health Care Organization Provision and Financing, Год журнала: 2025, Номер 62

Опубликована: Янв. 1, 2025

The 4Ms Framework is the foundation of Age-Friendly Health System (AFHS) movement. While framework based on standalone evidence for each M, there limited about impact outcomes when practiced as a set. A composite measure capturing adherence to many care processes that comprise necessary but complex component closing gap. We offer navigation guide addresses key considerations developing hospital-based care. Institute Healthcare Improvement operationalizes minimum set Assessment and Act On processes. In inpatient adherence, we 4 step with associated discussion related type (eg, continuous, dichotomous), synchrony within across Ms containing these Using real-world electronic health record data process in implementation at large academic hospital, illustrate considerations, report implications sample size scoring. also present our selected measure-a dichotomous delineating all encounter-level (those needing be done only once during hospital encounter) are followed day- shift-level least 50% days. no single, standard approach create this early stage AFHS movement, organizations develop their measure(s), suggest should serve inform support progress toward meaningful measurement.

Язык: Английский

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