Age-Friendly Health System Research Articles

DATA-DRIVEN IMPROVEMENTS TO DEMENTIA DISEASE DETECTION STRATEGIES IN AN FQHC SETTING

Abstract Despite higher prevalence of dementing illnesses in Latina/o populations, detection is lower compared to white populations, compounding racial/ethnic and economic disparities. Undetected illness compromises effective delivery of primary care and impedes linkages to much needed services. Development of robust detection and culturally sensitive management of cognitive impairment is critical for adequate care of this population. The Geriatric Workforce Enhancement Program at the University of Southern California (USC) partnered with Eisner Health, a Federally Qualified Health Center, serving a primarily immigrant, Spanish-speaking, uneducated, urban older adult population, to help achieve their goal of becoming an Age-Friendly Health System to prioritize identification and management of cognitive impairment. Over 14 months, a sustainable clinic workflow was developed and implemented to detect, evaluate, diagnose, and develop care plans for patients and their care partners. Staff and provider education was delivered through didactics, workshops, case reviews, and at-elbow training. Additional efforts focused on EHR optimization and alignment of existing clinical resources. Frequency data was extracted using i2iTracks software reflecting pre and post-implementation. Results show a higher percentage of patients diagnosed with cognitive impairment in the post-implementation period (7.35%) compared to pre-implementation (4.05%). Detailed data tracking the volume of patients engaged at each step of the workflow supports meaningful analysis of barriers and opportunities for optimization, such as how and where additional resources and efforts will yield the greatest effects. Data-driven strategies such as these, strengthen efficiency and effectiveness of the collaborative process and result in sustainable outcomes for this underserved population.

REVISITING THE TEACHING NURSING HOME: IMPACT ON NURSING STUDENTS’ PERCEPTIONS OF WORKING IN LONG-TERM CARE

Abstract Revisiting the Teaching Nursing Home is a two-year pilot project to address the long-term care workforce shortage by introducing nursing students to geriatric nursing while improving quality of care within nursing homes. The initiative has multiple components: enhanced clinical rotations for nursing students with partner schools of nursing, implementation of the Institute for Healthcare Improvement Age-Friendly Health System “4M” quality improvement model, and an online learning network. Nursing students at three schools of nursing participated in the clinical rotations at regional nursing homes. The experience was limited to students in one specific course at each school of nursing. At the beginning and end of the spring 2022 semester, students rated their competence in: patient assessment, collaborating with the care team, gathering clinical information, medication review, eliciting resident values, and health promotion. Students also rated their preferences for working in long-term care and with older adults. Data from 85 responses at the start of semester and 64 responses to the end of semester survey were analyzed. Analysis of student responses found that students self-rated competencies improved in all areas except eliciting resident values. Prior to their clinical experience, students ranked working in long-term care and with older adults lower than other settings or populations. The rankings were unchanged after their clinical experiences. These initial findings suggest that although the Teaching Nursing Home Program is meeting the pedagogical goals, attitudinal shifts may require different strategies.

STRATEGIES TO IMPLEMENT AGE-FRIENDLY CARE FOR OLDER ADULTS ACROSS CONVENIENT CARE CLINICS

Abstract A growing proportion of the population in the United States are older adults, and they are frequent users of convenient care clinics. This is particularly true for older adults from systematically marginalized communities who may be at greater risk for chronic health conditions and unmet healthcare needs. These trends render convenient care clinics critical sites to reimagine the provision of care for older adults. To improve the quality of care the CVS MinuteClinic implemented the Institute of Healthcare Improvement’s Age-Friendly Health Systems 4Ms Framework (assessing What Matters, Medication, Mentation, and Mobility). Research to evaluate two interventions (reflective learning and virtual clinic participation) to improve healthcare providers’ (HCP) uptake of the 4Ms was implemented. After the interventions, HCPs were provided a self-administered online survey to capture qualitative reports of reflections on learning and implementing the 4Ms. A total of 32 providers from both groups completed the survey. Using a codebook thematic analysis approach, facilitators and barriers for implementation were identified as were HCPs’ innovative approaches to consistently and effectively implement the 4Ms. Facilitator themes were the presence of resources (e.g., peer coaches) and the perceived value of the 4Ms model. Barrier themes included time, documentation issues, workflow challenges, HCP stress, and HCP comfort. Innovation themes included designing efficient workflows, scaffolded 4Ms learning, and collaboration. These findings underscore the supports/innovations to amplify and challenges to address to support HCPs in learning and implementing the 4Ms to improve the quality of care for older adults.

CONSIDERATIONS OF AGE-FRIENDLY 4M PRINCIPLES IN DEPRESCRIBING INTERVENTIONS: A SCOPING REVIEW

Abstract The 4Ms – Medication, Mentation, Mobility, and What Matters - represent the key components in the Age-Friendly Health Systems initiative and provide a conceptual framework for research in the older adult population. Over 40% of older adults experience polypharmacy, which can be addressed by deprescribing unnecessary medications. This review aimed to assess the degree to which the 4Ms were considered in intervention design, sample selection, and outcome assessment in deprescribing trials by keyword search in six databases and snowballing. Thirty-seven of the 564 trials identified met the review eligibility criteria. Imbalanced consideration of 4Ms in the deprescribing trials was observed. Intervention design: “Medication” was considered in all trials; “Mentation” was considered in 8 trials; “Mobility” (n=2) and “What Matters” (n=6) was less often considered. By targeting providers, most of the trials lacked consideration of patient-centeredness - aligning what matters most to older adults and their families with deprescribing decision making and implementation. Sample selection: “Medication” was considered in 15 trials (e.g., samples including patients taking ≥ 5 medications or specific types of medications), whereas “Mentation” (n=6), “Mobility” (n=6) and “What Matters” (n=0) were less often considered. Outcome assessment: “Medication” was the most commonly assessed outcomes (n=33), followed by “Mobility” (n=13) and “Mentation” (n=10) outcomes, with no study examining “What Matters” outcomes. 4Ms were not purposefully considered in the intervention design, sample selection, and outcome measurement of existing deprescribing trials. Future deprescribing trials need a more balanced and complete consideration of the 4Ms in the trial design and implementation.

REVISITING THE TEACHING NURSING HOME: QUALITATIVE ANALYSIS OF NURSING STUDENTS’ CLINICAL EXPERIENCE

Abstract Revisiting the Teaching Nursing Home is a two-year pilot project to address the long-term care workforce shortage by introducing nursing students to geriatric nursing while also improving quality of care within nursing homes. The initiative has multiple components: enhanced clinical rotations for nursing students with partner schools of nursing, implementation of the Institute for Healthcare Improvement Age-Friendly Health System “4M” quality improvement model, and an online learning network. Undergraduate and graduate nursing students at three Schools of Nursing participated in clinical experiences at regional nursing homes. Students completed an “activity feedback” form after each clinical rotation at the nursing home or related activity, such as a session about the 4Ms or quality improvement/assessment. The activity feedback form asked students to share their most important takeaway and suggestions for improvement. Data from 340 feedback forms was coded qualitatively using conventional and directed content analysis using the American Association of Colleges of Nursing (AACN) Essentials for Professional Nursing Education. Multiple coders and audit trials were used to establish rigor. Students’ takeaways encompassed 7 of 8 key concepts in the AACN Essentials; Knowledge for Nursing Practice, Person-Centered Care, and Interprofessional Partnerships were most frequently mentioned. Students provided numerous suggestions for improving their clinical experiences including facilitated learning from instructors and supported engagement with nursing home staff. In conclusion, the program addressed many of the core competencies designated by AACN. One recommendation that flows from these findings is to enhance the role of clinical preceptors in the nursing home setting to facilitate mentored training.

FACILITATING CAREGIVER HEALTH AND WELLNESS: AGE-FRIENDLY HEALTH SYSTEM CARING FOR CAREGIVERS (AFHS-C4C)

Abstract Family caregivers of older adults are vital partners in health care. The health care system is uniquely positioned to connect with caregivers and help address their own needs. The Age-Friendly Health System Caring for Caregivers (AFHS-C4C) model focuses on achieving health system change by identifying and incorporating caregivers into standard health care practices while assisting caregivers with their own health and well-being. Created at Rush University Medical Center, this model was tested in six AFHS. At Rush, caregivers (n=322) were mostly female (74%) and African American (38%) or white (37%). Between baseline and follow-up, statistically significant (p<.05) decreases were observed in caregiver burden (BSFC: 18.51 to 13.82), depression (PHQ-9: 8.40 to 4.09), and anxiety (GAD-7: 7.73 to 5.15). Application of this program at additional sites has yielded important lessons learned about engagement, training needs, and sustainability. These lessons will be discussed in the context of scaling and spreading interventions nationally.

WHAT MATTERS TO OLDER SURGICAL PATIENTS AND THEIR CARERS DURING THEIR HOSPITALIZATION?

Abstract Older adults account for a growing proportion of the surgical population. We investigated patient- and carer-reported experiences of hospitalization in this group. A mixed-methods study using telephone and postal surveys of recently hospitalized vascular surgical patients aged ≥ 65 years at an acute care academic hospital. Qualitative data were thematically analyzed using a framework approach. In total 46 patients (mean age 77 years, 78% male) and nine carers were surveyed. Nine (20%) patients were frail (Clinical Frailty Scale score >4). The majority of patients reported overall they felt their views were listened to (n=42, 89%), were kept informed (n=39, 83%) and were asked about their pain level (n=37, 79%). Among the nine carers, seven reported overall they felt their views were listened to (n=42, 89%) and were kept informed (n=39, 83%). Thematic analysis of responses to open-ended survey questions about their experience of hospitalization revealed four key themes: receiving fundamental care including hygiene and nutrition, importance of the hospital environment such as sleep and meals, being informed and involved in health care decision-making, and treating pain and deconditioning to help recovery. Findings from this study identified that older adults admitted to hospital for surgical care, and their carers, highly value care that meets fundamental needs and involves them in decision-making and recovery. These priorities can be addressed through Age-Friendly Health System initiatives such as the implementation of the “4Ms” of geriatrics care: what matters, medication, mobility and mentation.

PERSPECTIVES OF UNDER-RESOURCED PATIENTS ABOUT THE MEDICARE ANNUAL WELLNESS VISIT

Abstract The Medicare Annual Wellness Visit (AWV) involves a personalized risk assessment and prevention plan to help prevent disease and disability among older adults. Though studies have shown that AWV uptake is suboptimal, little is known about the perspectives and experiences of patients completing it. Family medicine physicians are conducting AWVs at a Rhode Island pilot teaching clinic participating in the GWEP's Age-Friendly Health Systems Initiative. To evaluate perspectives of the clinic's under-resourced patients, 20 qualitative telephone interviews were conducted following their AWV. Interview recordings were analyzed for content and themes. Few patients recognized the term ‘Annual Wellness Visit’ or recognized it was significantly different from other visits: “I noticed it was a bit different, but not that different. I’m usually not covered for a visit like that by Medicare.” Mental health, mobility and medications were discussed at most of the AWVs. Some patients noticed that a physician did the medication review instead of the nurse. Patients had varying experiences of how advance directives were discussed, and some thought it unnecessary since a family member knows their preferences. A few patients were dissatisfied that their physician did not focus on their chronic or acute health problems. However, most patients “trusted” their physicians to do “whatever is necessary” for them, and were glad to have had the AWV because “instead of talking about being sick all the time, talking about how to stay well”. Recommendations for patient education to improve understanding and the experience of the AWV will be offered.

GERIATRIC PRACTICE LEADERSHIP INSTITUTE—AN INTERPROFESSIONAL TEAM APPROACH USING THE IHI AGE-FRIENDLY MODEL

Abstract According to the Institute of Medicine, immediate steps must be taken to educate and train both the current and future health care workforce to work collaboratively in addressing the diverse needs of the growing older adult population.1 Most healthcare professionals had very little education or clinical training in the care of older adults nor the most effective ways to work as a clinical team. The Geriatric Practice Leadership Institute (GPLI) is a collaboration between two universities providing inter-professional teams of early and mid-career professionals the skills and knowledge needed to leverage leadership skills to effectively work within interdisciplinary teams to provide age-friendly care to older adults. The GPLI incorporates the Institute for Healthcare Improvement (IHI) Age-Friendly Health Systems 4Ms’ Framework into the training. The GPLI is an on-line, team-based program which engages 5-7 teams each session. Module topics include Age-Friendly Health Systems, organizational culture, leading self, leading inter-professional teams, and quality improvement. Additionally, teams select and completes a quality improvement project based on the Age-Friendly Health Systems 4Ms and submits a final report and presentation. The teams are also assigned a coach for support. Continuing education credits and a micro-credential are available to participants. The GPLI has trained over 175 health care professionals during the past 7 years with teams representing ambulatory to emergency responder organizations. The GPLI has been funded by the Health Resources and Services Administration (HRSA) Geriatrics Workforce Enhancement Program grant (numberU1QHP2873), which currently covers all costs for participants.

Improving Participation in Advance Care Planning in The Guam/Micronesia Geriatric Community Through Education

The University of Guam (UOG) School of Health (SOH) received a grant in 2019 for the Guam/Micronesia Geriatrics Workforce Enhancement Program (GWEP) funded by the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services (DHHS). The vision of the grant is to transform current health systems serving the elderly and those with Alzheimer’s disease and related dementias. The framework of the 4Ms – what matters, medication, mentation, and mobility is being used to help make this vision a reality through the creation of age-friendly health systems for the elderly. The Guam/Micronesia GWEP chose to focus on what matters out of the 4Ms during years 1-3 of its grant cycle. Specifically, advance care planning (ACP) was addressed at the Guam Memorial Hospital Authority (GMHA) Skilled Nursing Unit (SNU) and in the Guam/Micronesia geriatric community. A chart review was done at the GMHA SNU, which showed low participation in ACP, 25% of the census for that time period. Several reasons for this were revealed through discussion with GMHA SNU personnel. They included lack of awareness or knowledge about ACP as well as language and cultural barriers. After training about ACP was conducted by Guam/Micronesia GWEP, chart reviewed showed participation in ACP improved to 100% at the GMHA SNU. Given this success, the intention is to continue with trainings in ACP through grant year 3 in the hopes of helping patients and their families as well as health care personnel in the Guam/Micronesia community understand how ACP helps to ensure that health care systems respect what matters most to geriatric patients and their families, and in doing so works toward establishing a more age-friendly health system. Keywords: Advance care planning; GWEP; 4Ms; Guam; Micronesia, Age-friendly health system, Elderly, Barriers to participation in ACP

Age Friendly Emergency Medicine Services: Integrating What Matters, Medications, Mobility, and Mentation into Emergency Response.

Our population is aging. The Age Friendly Health System (AFHS) initiative by the Institute of Healthcare Improvement (IHI) includes the 4 M's of What Matters, Medications, Mobility, and Mentation, and is at the forefront of older adult health care. When applying the 4M's to emergency medical services (EMS), the benefits include avoiding unnecessary transports and helping the patient stay healthy and safe in their home setting. The University of North Texas Health Science Center and other partnerships aspired to designate MedStar the first AFHS in the country within EMS practice. The Plan-Do-Study-Act (PDSA) cycle aimed at various changes with the AFHS components of What Matters and Medications within an electronic medical record (EMR) algorithm for emergency medical paramedics. Additionally, previously piloted geriatric practice leadership institute projects embedded Mentation and Mobility by including specific screenings in the EMR. The preliminary result in the PDSA described showed 52% of older adults answered health when asked What Matters most to them today. However, updated data as of January 2022, showed an overwhelming 6732 (69%) patients out of 9685 patients, answered health when asked What Matters most to them today. Additionally, the EMR identifies high-risk medications. Paramedics can now verify potential risks and develop a care plan based on the identified high-risk medications. Implementing AFHS components allows for better care delivery and outcomes as our older population is growing and embraces more complexities. The data is still novel but promising, requiring longitudinal information before conclusions can be considered. IHI is currently reviewing opportunities to expand its models of care into emergency medicine, behavioral health, and other settings. MedStar sets the example that EMS can practice the AHFS approach serving as a model for the EMS environment. We are currently awaiting feedback from IHI regarding our request to designate MedStar the first AFHS EMS practice in the country.

Integrated [Primary +] Memory Care Clinic.

The Integrated Memory Care Clinic (IMCC) is a model of care for people living with dementia directed by advanced practice registered nurses. The post-diagnosis model incorporates the expertise of nursing, social work and nurse practitioners certified in gerontology, palliative care and/or geriatric psychiatry. The Clinic nurse practitioners provide comprehensive and coordinated primary care for dementia and other stable chronic conditions and episodic care for minor acute illnesses. Care delivery is structured to maximize ongoing dialogue with patients and their caregivers during office visits and by phone and patient portal access. The Clinic provides a number of services to care partners, including an after-hours line, stage-based educational groups, and a monthly support group. The IMCC aims to reduce the overall burden of dementia by partnering with affected individuals and their caregivers in the co-production of care. Now at full capacity, the IMCC serves 525 active patients and their care partners with 1.3 FTE primary care nurse practitioners. The mean age is 78.6 years; most are female (63%); and 42% identify as a racial minority. The majority of patients are moderate (27% early-moderate; 36% late-moderate) stage of dementia clinical syndrome. The mean monthly rate of hospital admissions for ambulatory care sensitive conditions in 2022 is 1.42%. The published rate for this population is 13-15%. Finally, the model is financially neutral in a fee-for-service environment. Open in 2015, the IMCC has combined primary care and dementia care in one clinical practice. The IMCC developed strong rapport and trust with patients and families to achieve outstanding health outcomes. The model is an American Academy of Nursing Emerging Edge Runner, recognized by NCQA as a Patient Centered Medical Home, recognized as a Level 2 Age-Friendly Health System participant, and a Best Practice Exemplar by the Institute for Patient- and Family-Centered Care.

Age Friendly Care: What do Community Aging Services Professionals Need to Know?

ABSTRACT There is an increasing need for community-based health education to help older adults understand and manage their complex medical needs. Community Aging Services Professionals (CASPs) are non-medical service providers who facilitate aging in place by providing health education, socialization, and care coordination for older adults in community settings. Through in-depth interviews with 13 CASPs, this study assessed CASPs’ knowledge of older adults’ medical issues and health education needs. Our goal was to assess CASPs’ knowledge of older adults’ medical issues and health education needs and determine overlap with the Age Friendly Health System 4 Ms framework. CASPs described promoting older adults’ health by providing medical referrals, education, and advice. The interviews revealed that CASPs feel underprepared to provide requested medical support for older adults, and that both CASPs and older adults desire more clinical education to help identify and manage older adults’ medical conditions. This study established CASPs as ideal providers to receive and disseminate clinical health education for older adults aging in the community. The results also showed the 4 Ms model of age friendly care is well-received as a framework for health education in community settings.

Transformational Nurse Leadership Comes to Life: Igniting the Implementation of Age-Friendly Health Systems in CVS MinuteClinics

As the population ages, it is imperative to ensure that older adults receive evidence-based care. Age-Friendly Health Systems is a national initiative to spread the evidence-based Age-Friendly What Matters, Medication, Mentation, and Mobility Framework and is supported by the Institute for Health care Improvement. A key driver to spread this effort is the use of transformational leadership, a leadership model used by nurse practitioners at MinuteClinic, the convenient care clinics in select CVS Health Pharmacies, to implement Age-Friendly What Matters, Medication, Mentation, and Mobility care during the COVID-19 pandemic. Recommendations are provided for aligning leadership principles of front-line staff, managers, and executives to encourage the implementation of evidence-based care using the transformational leadership model.

Optimizing Older Adults' Medication Use Nurses can partner with caregivers to promote safe medication administration.

This article is the third in a series, Supporting Family Caregivers in the 4Ms of an Age-Friendly Health System, published in collaboration with the AARP Public Policy Institute as part of the ongoing Supporting Family Caregivers: No Longer Home Alone series. The 4Ms of an Age-Friendly Health System (What Matters, Medication, Mentation, and Mobility) is an evidence-based framework for assessing and acting on critical issues in the care of older adults across settings and transitions of care. Engaging the health care team, including older adults and their family caregivers, with the 4Ms framework can help to ensure that every older adult gets the best care possible, is not harmed by health care, and is satisfied with the care they receive. The articles in this series present considerations for implementing the 4Ms framework in the inpatient hospital setting and incorporating family caregivers in doing so. Resources for both nurses and family caregivers, including a series of accompanying videos developed by AARP and the Rush Center for Excellence in Aging and funded by The John A. Hartford Foundation, are also provided. Nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet—Information for Family Caregivers—and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses. Cite this article as: Zonsius, M.C., et al. Optimizing Older Adults' Medication Use. Am J Nurs 2022; 122(3): 38-43.

Recognizing and Acting on Mentation Concerns Caregivers are key partners in addressing depression, dementia, and delirium in older adults.

This article is the fourth in a series, Supporting Family Caregivers in the 4Ms of an Age-Friendly Health System, published in collaboration with the AARP Public Policy Institute as part of the ongoing Supporting Family Caregivers: No Longer Home Alone series. The 4Ms of an Age-Friendly Health System (What Matters, Medication, Mentation, and Mobility) is an evidence-based framework for assessing and acting on critical issues in the care of older adults across settings and transitions of care. Engaging the health care team, including older adults and their family caregivers, with the 4Ms framework can help to ensure that every older adult gets the best care possible, is not harmed by health care, and is satisfied with the care they receive. The articles in this series present considerations for implementing the 4Ms framework in the inpatient hospital setting and incorporating family caregivers in doing so. Resources for both nurses and family caregivers, including a series of accompanying videos developed by AARP and the Rush Center for Excellence in Aging and funded by The John A. Hartford Foundation, are also provided. Nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet—Information for Family Caregivers—and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses. Cite this article as: Mack, L., et al. Recognizing and Acting on Mentation Concerns. Am J Nurs 2022; 122(5): 50-55

The effect of the right care, right place, right time (R3) initiative on Medicare health service use among older affordable housing residents.

To determine the effect of an affordable housing-based supportive services intervention, which partnered with health and community service providers, on Medicare health service use among residents. Analyses used aggregated fee-for-service Medicare claims data from 2017 to 2020 for beneficiaries living in 34 buildings in eastern Massachusetts. Using a quasi-experimental design, a "difference-in-differences" framework was employed to isolate changes in outcomes, focusing on changes in pre- and post-intervention health service use across two stages of the intervention. Phase 1 encompassed the initial implementation period, and Phase 2 introduced a strategy to target residents at high risk of poor health outcomes. Key health service outcomes included hospitalizations, 30-day hospital readmission, and emergency department use. Medicare claims data for 10,412 individuals were obtained from a Quality Improvement Organization and aggregated at the building level. Analyses for Phase 1 found that hospital admission rates, emergency department admissions and payments, and hospital readmission rates grew more slowly for intervention sites than comparison sites. These findings were strengthened after the introduction of risk-targeting in Phase 2. Compared to selected control buildings, residents in intervention buildings experienced significantly lower rates of increases in inpatient hospitalization rates (-16% vs. +6%), hospital admission days (-25% vs. +29%), average hospital days (-12% vs. +14%), hospital admission payments (-22% vs. +33%), and 30-day hospital readmission rates (-22% vs. +54%). When accounting for the older age of the intervention residents, the size of the decline recorded in emergency department admissions was 6.7% greater for the intervention sites than the decline in comparison sites. A wellness-focused supportive services intervention was effective in reducing select health service use. The introduction of risk-targeting further strengthened this effect. Age-friendly health systems would benefit from enhanced partnerships with affordable housing sites to improve care and reduce service use for older residents.

Age-friendly care in the Veterans Health Administration: Past, present, and future.

The Veterans Health Administration (VHA) has long recognized the need for age-friendly care. VHA leadership anticipated the impact of aging World War II veterans on VA healthcare systems and in 1975 developed Geriatric Research, Education, and Clinical Centers (GRECCs) to meet this need. GRECCs catalyzed a series of innovations in geriatric models of care that span the continuum of care, most of which endure. These innovative care models also contributed to the evidence base supporting the present-day Age-Friendly Health Systems movement, with which VHA is inherently aligned. As both a provider of and payor for care, VHA is strongly incentivized to promote coordination across the continuum of care, with resultant cost savings. VHA is also a major contributor to developing the workforce that is essential for the provision of age-friendly care. As VHA continues to develop and refine innovative geriatric models of care, policymakers and non-VHA health care systems should look to VHA programs as exemplars for the development and implementation of age-friendly care.

Achievement of age-friendly health systems committed to care excellence designation in a convenient care health care system.

To describe the implementation of the age-friendly health systems (AFHS) 4Ms Framework, an evidence-based framework to assess and act on "What Matters, Medication, Mentation and Mobility to deliver Age-Friendly health care for patients 65 and older", to achieve the Institute for Health care Improvement (IHI) Committed to Care Excellence recognition in a convenient care health system and test two novel implementation strategies. The study was conducted in over 1100 convenient care clinics in 35 states and DC. MinuteClinics are located in community-based retail pharmacies in rural, suburban, and urban areas and staffed with approximately 3300 nurse practitioners and physician associates. In Year 1, the project used a quality improvement design, and in Year 2, a quasi-experimental implementation research design to pilot two strategies at the provider level (Virtual Clinic and Plan-Do-Study-Act (PDSA)). Statistical process control charts were used to assess changes in 4Ms documentation over time. Mixed-effects Poisson regression was used to assess the effectiveness of the pilot studies. The electronic health record (EHR) was enhanced to capture documentation of the AFHS 4Ms assessments and actions. A learning platform was created to teach and evaluate provider 4Ms competency, and the two data sources were merged into a registry. A formative evaluation was conducted using Tableau and reporting dashboards. After 18 months and the implementation of 20 strategies to improve the uptake of the 4Ms, MinuteClinic achieved the IHI Committed to Care Excellence recognition. A significant increase over time in the reliable delivery of all 4Ms and each M component individually was found. For the research, there were significant improvements in the mean number of Ms delivered per visit (M-Score) in the Virtual Clinic (Incident Rate Ratio [IRR]: 2.47, p= 0.001) and PDSA (IRR: 3.08, p= 0.002) strategy intervention groups when compared to controls. Application of quality improvement and implementation methodologies contributed to the success of implementing age-friendly 4Ms evidence-based practice.

An age-friendly population health dashboard geolocating by clinical and social determinant needs.

An age-friendly population health dashboard geolocating by clinical and social determinant needs.