Selecting implementation strategies to drive Age-Friendly Health System Adoption

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

BACKGROUND

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, the effect of Age-Friendly recognition on patient outcomes is largely unknown. We sought to identify this effect in the Veterans Health Administration (VHA)-one of the largest Age-Friendly integrated health systems in the United States.

METHODS

There were 50 VA medical centers (VAMCs) recognized as Age-Friendly by December 2021. We used a time-event difference-in-difference analysis to identify the association of a VAMC's recognition as Age-Friendly on the change in facility-free days (days outside the hospital or nursing home) among Veterans treated at that facility. We also evaluated this association in three subgroups: Veterans at particularly high risk of nursing home entry, Veterans who lived within 10 miles of a medical center, and facilities that had reached Level 2 Age-Friendly recognition. We also evaluated individual components of the endpoint in terms of change in hospital and nursing home days separately.

RESULTS

We found Age-Friendly recognition was associated with small statistically significant improvements in facility-free days (0.2% on a base of 97% facility-free days on average per year, or an additional 0.73 days per year on a base of 354 days). There were no differences in any subgroup, or any individual component of the endpoint across all groups.

CONCLUSIONS

At the individual level, an increase of 0.2% in facility-free days is a weak effect. However, sites were early in implementation, and facility-free days may not be a responsive outcome measure. However, across an entire population, small changes in facility-free days may accrue large cost savings. Future evaluations should consider a broader variety of process and outcome measures.

Developing electronic health record-based measures of the 4Ms to support implementation and evidence generation for Age-Friendly Health Systems

BACKGROUND

To support implementation of the 4Ms framework and more rigorous evidence of 4Ms impact, we translated Institute for Healthcare Improvement's (IHI's) recommended 4Ms routine care practices into electronic health record-based, encounter-level adherence measures and then implemented measures at a large academic medical center.

METHODS

We started with the 19 care practices in IHI's 4Ms implementation guide and developed encounter-level adherence measures using structured EHR data. We also developed overall 4Ms-level and M-level composite measures. Next, we operationalized measures at UCSF Health-an academic medical center that has implemented the 4Ms using the IHI guide. We identified UCSF Health patients who should have received 4Ms care during their inpatient admission (19,335 individuals 65 years and older with an admission between January 1, 2019 and December 31, 2021), then implemented the individual measures and composite measures (all at the encounter level) using Epic EHR data. We focused on 4Ms inpatient care processes, but similar approaches can be followed for ambulatory, post-acute, and other settings.

RESULTS

We developed 18 EHR-based measures that captured all IHI care practices, 16 of which could be implemented using UCSF Health EHR data. For example, the EHR-based measure for the Medication care practice "deprescribe high risk medications" was measured using EHR data as "Patient had no previously existing prescriptions for high-risk medications OR patient had ≥1 previously existing prescriptions for high-risk medications deprescribed during the encounter," and 29.5% of UCSF Health encounters met this measure. For composite measures, on average, UCSF Health encounters had 61.1% adherence to the 4Ms (SD = 14.4%), with the lowest average adherence to What Matters (50.9%; SD = 44.3%) and the highest for Mentation (68.4%; SD = 13.4%).

CONCLUSIONS

It is feasible to construct encounter-level measures of 4Ms adherence using EHR data and derive insights to guide ongoing implementation efforts. Future efforts should refine measures based on assessments of reliability and validity.

Central Nervous System-Active Prescriptions in Older Veterans: Trends in Prevalence, Prescribers, and High-risk Populations

BACKGROUND

Little is known about the prevalence or chronicity of prescriptions of central nervous system-active (CNS-active) medications in older Veterans.

OBJECTIVE

We sought to describe (1) the prevalence and trends in prescription of CNS-active medications in older Veterans over time; (2) variation in prescriptions across high-risk groups; and (3) where the prescription originated (VA or Medicare Part D).

DESIGN

Retrospective cohort study from 2015 to 2019.

PARTICIPANTS

Veterans age ≥ 65 enrolled in the Medicare and the VA residing in Veterans Integrated Service Network 4 (incorporating Pennsylvania and parts of surrounding states).

MAIN MEASURES

Drug classes included antipsychotics, gabapentinoids, muscle relaxants, opioids, sedative-hypnotics, and anticholinergics. We described prescribing patterns overall and in three subgroups: Veterans with a diagnosis of dementia, Veterans with high predicted utilization, and frail Veterans. We calculated both prevalence (any fill) and percent of days covered (chronicity) for each drug class, and CNS-active polypharmacy (≥ 2 CNS-active medications) rates in each year in these groups.

KEY RESULTS

The sample included 460,142 Veterans and 1,862,544 person-years. While opioid and sedative-hypnotic prevalence decreased, gabapentinoids exhibited the largest increase in both prevalence and percent of days covered. Each subgroup exhibited different patterns of prescribing, but all had double the rates of CNS-active polypharmacy compared to the overall study population. Opioid and sedative-hypnotic prevalence was higher in Medicare Part D prescriptions, but the percent of days covered of nearly all drug classes was higher in VA prescriptions.

CONCLUSIONS

The concurrent increase of gabapentinoid prescribing paralleling a decrease in opioid and sedative-hypnotics is a new phenomenon that merits further evaluation of patient safety outcomes. In addition, we found substantial potential opportunities for deprescribing CNS-active medications in high-risk groups. Finally, the increased chronicity of VA prescriptions versus Medicare Part D is novel and should be further evaluated in terms of its mechanism and impact on Medicare-VA dual users.

One Step at a Time: Improving Gait Speed Measurement in a Geriatric Medicine Clinic

(1) Background: Mobility assessment is a key component of the assessment of an older adult as a part of the Age-Friendly Health System (AFHS) "geriatric 4Ms" framework. Several validated tools for assessing mobility and estimating fall risk in older adults are available. However, they are often under-utilized in daily practice even in specialty geriatric medicine care settings. We aimed to increase formal mobility assessment with brief gait speed measurement in a geriatric medicine outpatient clinic using phased change interventions. (2) Methods: This quality improvement (QI) initiative was conducted in a single outpatient geriatric medicine clinic. All clinic attendees who could complete a gait speed measurement were eligible for inclusion. The outcome measure was the completion of a 4 m gait speed. Several change interventions were implemented on a phased basis using the Model for Improvement methodology during the period from December 2018 to March 2020. Statistical process control charts were used to record gait speed measurements and detect non-random shifts. (3) Results: During this QI initiative, 80 patients were seen, accounting for 142 clinic visits. In response to change interventions, gait speed measurement at clinic visits increased from a median of 25% of visits to 67% by March 2020. (4) Conclusions: Adopting an AFHS care model is an urgent and challenging task to improve the quality of care for older adults. This initiative details how to effectively incorporate a brief, validated assessment of mobility using gait speed measurement into every geriatric medicine outpatient visit and progresses implementation of the AFHS "geriatric 4Ms". Mobility assessment can aid in identifying older adults at increased fall risk.

Study protocol: Type III hybrid effectiveness-implementation study implementing Age-Friendly evidence-based practices in the VA to improve outcomes in older adults

BACKGROUND

Unmet care needs among older adults accelerate cognitive and functional decline and increase medical harms, leading to poorer quality of life, more frequent hospitalizations, and premature nursing home admission. The Department of Veterans Affairs (VA) is invested in becoming an "Age-Friendly Health System" to better address four tenets associated with reduced harm and improved outcomes among the 4 million Veterans aged 65 and over receiving VA care. These four tenets focus on "4Ms" that are fundamental to the care of older adults, including (1) what Matters (ensuring that care is consistent with each person's goals and preferences); (2) Medications (only using necessary medications and ensuring that they do not interfere with what matters, mobility, or mentation); (3) Mentation (preventing, identifying, treating, and managing dementia, depression, and delirium); and (4) Mobility (promoting safe movement to maintain function and independence). The Safer Aging through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative (QUERI) seeks to implement four evidence-based practices (EBPs) that have shown efficacy in addressing these core tenets of an "Age-Friendly Health System," leading to reduced harm and improved outcomes in older adults.

METHODS

We will implement four EBPs in 9 VA medical centers and associated outpatient clinics using a type III hybrid effectiveness-implementation stepped-wedge trial design. We selected four EBPs that align with Age-Friendly Health System principles: Surgical Pause, EMPOWER (Eliminating Medications Through Patient Ownership of End Results), TAP (Tailored Activities Program), and CAPABLE (Community Aging in Place - Advancing Better Living for Elders). Guided by the Pragmatic Robust Implementation and Sustainability Model (PRISM), we are comparing implementation as usual vs. active facilitation. Reach is our primary implementation outcome, while "facility-free days" is our primary effectiveness outcome across evidence-based practice interventions.

DISCUSSION

To our knowledge, this is the first large-scale randomized effort to implement "Age-Friendly" aligned evidence-based practices. Understanding the barriers and facilitators to implementing these evidence-based practices is essential to successfully help shift current healthcare systems to become Age-Friendly. Effective implementation of this project will improve the care and outcomes of older Veterans and help them age safely within their communities.

TRIAL REGISTRATION

Registered 05 May 2021, at ISRCTN #60,657,985.

REPORTING GUIDELINES

Standards for Reporting Implementation Studies (see attached).

Implementing CAPABLE With Care Partners Through an Area Agency on Aging: Identifying Barriers and Facilitators Using the Consolidated Framework for Implementation Research

BACKGROUND AND OBJECTIVES

Community Aging in Place, Advancing Better Living for Elders (CAPABLE) is an evidence-based intervention to promote aging in place. Although CAPABLE has been implemented in more than 40 community sites, wide variation in implementation exists. Guided by the Consolidated Framework for Implementation Research (CFIR), this study sought to determine key barriers and facilitators that may influence CAPABLE implementation with older adult and care partner dyads through an area agency on aging (AAA).

RESEARCH DESIGN AND METHODS

A formative evaluation was completed using qualitative data from the pilot of a Hybrid Trial Type 1 study implementing CAPABLE in an AAA. Multiple sources of data were collected, including 2 focus groups, field notes, a tracking log, and meetings with CAPABLE interventionists. Data were analyzed using a framework method and validated through a negative case analysis approach in NVivo 12 Pro.

RESULTS

Fourteen dyads enrolled in the pilot and 6 completed the CAPABLE intervention. Key themes aligned with 10 constructs from 5 domains of the CFIR. Facilitators included adaptability of the intervention, cost, networks and communication, and knowledge and belief of individuals. Barriers included intervention complexity, client needs and resources, and executing the planned process.

DISCUSSION AND IMPLICATIONS

Results enhance understanding of contextual factors that can influence the implementation of CAPABLE with care partners. Strategies to overcome barriers include simplifying recruitment materials and targeting older adults with recent onset of disability. The CFIR is a valuable resource for planning and evaluation of the implementation of evidence-based interventions to promote aging in place.

Telehealth for geriatric post-emergency department visits to promote age-friendly care

OBJECTIVE

To describe a feasibility pilot study for older adults that addresses the digital divide, unmet health care needs, and the 4Ms of Age-Friendly Health Systems via the emergency department (ED) follow-up home visits supported by telehealth.

DATA SOURCES AND STUDY SETTING

Data sources were a pre-implementation site survey and pilot phase individual-level patient data from six US Department of Veterans Affairs (VA) EDs.

STUDY DESIGN

A pre-implementation survey assessed existing geriatric ED processes. In the pilot called SCOUTS (Supporting Community Outpatient, Urgent care & Telehealth Services), sites identified high-risk patients during an ED visit. After ED discharge, Intermediate Care Technicians (ICTs, former military medics), performed follow-up telephone, or home visits. During the follow-up visit, ICTs identified "what matters," performed geriatric screens aligned with Age-Friendly Health Systems, observed home safety risks, assisted with video telehealth check-ins with ED providers, and provided care coordination. SCOUTS visit data were recorded in the patient's electronic medical record using a standardized template.

DATA COLLECTION/EXTRACTION METHODS

Sites were surveyed via electronic form. Administrative pilot data extracted from VA Corporate Data Warehouse, May-October 2021.

PRINCIPLE FINDINGS

Site surveys showed none of the EDs had a formalized way of identifying the 4 M "what matters." During the pilot, ICT performed 56 telephone and 247 home visits. All home visits included a telehealth visit with an ED provider (n = 244) or geriatrician (n = 3). ICTs identified 44 modifiable home fall risks and 99 unmet care needs, recommended 80 pieces of medical equipment, placed 36 specialty care consults, and connected 180 patients to a Patient Aligned Care Team member for follow-up.

CONCLUSIONS

A post-ED follow-up program in which former military medics perform geriatric screens and care coordination is feasible. Combining telehealth and home visits allows providers to address what matters and unmet care needs.

The Program of All-Inclusive Care for the Elderly: An Update after 25 Years of Permanent Provider Status

PACE is the gold standard for community-based integrated care. Over the 25 years as permanent provider status by Centers for Medicare and Medicaid Services, it has evolved in design and grown in numbers served. We review the evidence base, history, and future direction of PACE.