December 2019, Volume XXXIII, No 9

Senior Care

Age-friendly health systems

Providing care that matters

here are currently 700,000 to 800,000 people over the age of 65 in Minnesota. In 20 years, that number will grow to 1.3 million. With that figure on the rise, we need to make it a priority to know how to care for those individuals. The last 30 years of geriatric research has elucidated treatments and approaches to care for older adults that result in better health care outcomes, yet they have not all been implemented.

At the University of Minnesota, we are working to close that implementation gap and improve the health care and health of older adults across the state. We recently received the support of a five-year, $3.74 million Geriatrics Workforce Enhancement Program (GWEP) award from the U.S. Health Resources and Services Administration (HRSA) to help in these efforts. The resulting Minnesota Northstar GWEP project calls for partnership with the HRSA-funded National Center for Interprofessional Education and Practice, which will perform all of the evaluations.

There is a gap between what matters to our patients and the care they are receiving.

In addition to our GWEP interprofessional team, consisting of University of Minnesota experts from the Medical School, College of Pharmacy, School of Nursing, School of Public Health, School of Dentistry, and Department of Rehabilitation, as well as the Community–University Health Care Center (CUHCC), we have partnered with seven community organizations that represent a wide swath of services and outreach to older adults across Minnesota.

The four “Ms”

A major initiative of the HRSA GWEP program is the promotion of what are known as the Age-Friendly Health Systems. The Institute for Healthcare Improvement (IHI) reviewed all of the literature in geriatrics over the past 30 years and identified 11 interventions that have been shown to improve health in older adults. They categorized them into four groups and created the 4 M’s of Age-Friendly Health Systems: What Matters, Mentation, Mobility, and Medications. These 4 M’s indicate effective interventions for successful Age-Friendly Health Systems:

  1. What matters to the patient needs to influence the care provided. As physicians, we need to focus on goal-oriented care. However, there is a gap between what matters to our patients and the care they are receiving. There are patients who receive care that they don’t want and others who want care but don’t receive it. An all-too common scenario is an older adult becoming ill and receiving unwanted, technologically intensive procedures, resulting in further morbidity and functional decline. These situations could be obviated if older adults were first asked what they want out of health care. Elucidating goals and care preferences is particularly important for patients in the last stages of their lives.
  2. Mentation addresses problems such as dementia, delirium, and depression, and the importance of preventing, identifying, treating, and managing those diseases. One prominent example of the importance of addressing mentation concerns delirium in hospitalized older adults. Delirium is not just observed in the patient down the hall who is “out of their head” and screaming. Those patients represent a minority of hospitalized patients who are delirious. For most, the delirium is subtle and isn’t something a casual observer can easily identify. Unrecognized delirium is a risk factor for terrible outcomes such as institutionalization, severe complications, readmission to the hospital, and even death. Several evidence-based interventions for detecting and treating delirium have been developed but are not always being implemented.
  3. Mobility highlights the importance of attending to topics such as physical mobility, the importance of exercise, and the risk of falls. It is important to screen for mobility limitations to ensure patient safety and maintain physical functioning. We know that gait speed, or how fast somebody walks, is a good marker of their health, and that slowed gait speed is a marker of frailty and the likelihood to become hospitalized or have functional decline. While it is not routine practice in caring for older adults, screening for slow gait speed could identify older adults at risk and prompt therapies to mitigate associated hazards.
  4. Medications need to be age-appropriate and carefully prescribed to older adults. Older adults are often prescribed multiple medications, some of which aren’t always necessary, placing them at an increased risk to suffer harm from their medications. Periodically performing a standard medication-reconciliation and deprescribing harmful or unnecessary medications would help to lower the risk of adverse drug events.

Specific projects

Over the next five years of the Minnesota Northstar GWEP, we will work to improve the health care and health of older adults across the state through addressing the implementation gaps and promoting Age-Friendly Health Systems, educating both the formal and informal health care workforce and providing support to patients, their families, their caregivers, and their direct care workers. Our projects include:

  • Creating a geriatrics education and training (GET) repository. The online clearing house repository will serve as a resource for state-of-the-art, up-to-date educational materials that health care learners can undertake, course directors at the University can use, and people outside the University can access. We have also set up an interesting set of experiences that will offer unique and exciting learning opportunities, such as a case competition where students work in teams to devise a plan that addresses a complex case in geriatrics.
  • Transforming all of the residency training clinics in the University of Minnesota Medical School’s Department of Family Medicine and Community Health into Age-Friendly Health Systems. This will include eight of the 11 Family Medicine training clinics in the state, the Community–University Health Care Center in south Minneapolis, and all 60-plus clinics in the primary care service line at M Health Fairview. Our goal is to alter the processes of care at all the clinics to systematically address the 4 M’s: changing workflows, modifying the electronic medical record, altering how older patients are roomed, and collecting appropriate data on every patient for the implementation gaps previously described.
  • Performing outreach activities in every one of the 87 counties in the state. Joe Gaugler, PhD, professor and Robert L. Kane Endowed Chair in Long-Term Care and Aging at the  School of Public Health, is leading the implementation of a series of outreach and support activities for families, patients, caregivers, and care workers serving the elderly in Minnesota. One activity is the Caring for a Person With Memory Loss program, which provides practical information and group support to families dealing with Alzheimer’s disease and other dementias. We will also reach the public through Minnesota Public Radio and the Medical School’s Hippocrates Cafe, a melding of spoken word, art, and music intended to enlighten and educate the public on a particular health care topic.
  • Promoting the Dementia Friends program, an educational and attitude-orienting experience where participants learn to value the strengths that people dealing with dementia have to offer. It facilitates more respectful and humane treatment and fosters inclusion of them in society.

Older adults are often prescribed multiple medications, some of which aren’t always necessary.

Measuring success

A large part of the project is evaluation. We will measure how many health care learners we are reaching with our educational interventions and how confident they feel caring for and approaching elderly problems. We will also measure how many patients, families, caregivers, and direct care workers we reach with our outreach programs. Finally, we will measure specific health outcomes in the patients served in the transformed Age-Friendly primary care clinics, including the eight family medicine clinics, CUHCC, and across the primary service line at M Health Fairview.

Closing thoughts

The MN Northstar GWEP is a breakthrough at the University. As one of 63 GWEP sites across the country, we are the only one in Minnesota. As the older adult population will continue to increase in the state, there is a great need to educate our workforce on the best ways to take care of them, and the MN Northstar GWEP is helping us do that.

James T. Pacala, MD, MS, is a professor and head of the Department of Family Medicine and Community Health at the University of Minnesota Medical School. He is also a family medicine physician who cares for geriatric patients at M Health Fairview Clinic–Smiley’s. 

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James T. Pacala, MD, MS, is a professor and head of the Department of Family Medicine and Community Health at the University of Minnesota Medical School. He is also a family medicine physician who cares for geriatric patients at M Health Fairview Clinic–Smiley’s.