Perspectives on implementing an ambulatory age-friendly health system pilot project

Abstract

As part of our Age-Friendly Health System journey in the ambulatory setting, our team chose to address "What matters most" (WMM) to older adults with cancer. While aligning with goals of care discussions, identifying patient priorities during each clinic visit led us to this initiative. The Gero-oncology and Gastrointestinal Clinics had >60% patient populations >65years of age and were chosen for this pilot. Collaborating with our interprofessional partners within these clinics, our group presented to the Patient and Family Advisory Council our plan to ask a patient-centered question addressing WMM in the ambulatory clinics. This council helped us craft "WHAT IS MOST IMPORTANT TO YOU DURING THIS CLINIC VISIT?" This pilot started as low tech paper card in English/Spanish presented to patients at their visit. Initially the cards were hand tabulated by Geriatric Resources Nurses (GRNs) and categorized. Examples include medication refills, test review, and plans of care. Plan-Do-Study-Act rapid tests of change discussions occurred bi-monthly. Workflow revisions occurred with the evolution to nursing entering patient's answers into the electronic health record (EHR). The high-frequency categories became multi-selection checklist in the EHR. This information was used to ensure we had resources for GRNs to address these needs. Currently the team is exploring how the WMM categories can translate to provider notes to be addressed during each visit. As the project rolls out to other ambulatory clinics, Patient Experience will monitor patient satisfaction metrics such as i nclusion in treatment decision.