By Melinda Young
A new age-friendly initiative is a model focused on providing evidence-based care coordination to older adults and their caregivers. The goal is to train clinics to provide care that addresses what matters most to patients and their families.1
“Age-Friendly Health Systems (AFHS) is a very recent initiative and part of healthcare improvement,” says Sweta Tewary, PhD, MS, MSW, assistant professor at Kiran Patel College of Osteopathic Medicine at Nova Southeastern University in Fort Lauderdale, FL.
Foundations helped fund the research and collaborative work involving improving healthcare. “We’re trying to promote age-friendly health systems in our clinics,” Tewary says. “We’re putting all of our efforts into it.”
AFHS incorporates the elements of the 4M framework, which addresses what matters, medication, mentation, and mobility.1
“To provide better care for older adults, AFHS incorporates all four elements of 4M and helps people age better,” Tewary explains. “AFHS is a movement involving several hundred hospital practices and post-acute long-term care facilities.”
It encourages providers to pay more attention to what patients deem most important in their health, and to look at their cognition and mental health. “What impresses me about this model is it forces the clinician to think of the person as a whole,” Tewary explains. “What used to happen — or is still happening — is when an older person presents himself in front of the clinician, you’re treating the current issue. The 4M model forces you to look at different perspectives.”
For instance, what the patient wants a clinician to discuss is what matters most to them. “Some elements don’t matter to [the patient],” Tewary says. “What matters could be whether they can cook or not, drive or not. That’s what is missed in a primary care visit.”
The age-friendly focus also reminds clinicians to ask patients about their medication, mobility, and mental concerns. “Since we’re so busy taking care of patients, we forget the question on mentation,” Tewary says. “We may ask patients if they have any memory problems, but that’s it. How would [the provider] know if [the patients] really have a memory issue if there’s not testing for any of those memory issues?”
Under the 4M framework for older adults, providers are reminded to perform cognitive assessment to identify the patients’ needs. Providers also focus on advance directives, which is part of identifying what matters to patients.
“We need to find out whether there is documentation of advance directives,” Tewary says.
Documentation is necessary because the 4M areas are billable to payers. “It’s not just a concept from a practice perspective,” Tewary notes. “It’s also a concept from a business perspective.”
By billing for each of these 4M services, providers can lower costs in the overall long-term care of patients. For example, if advance directives are obtained and documented, costs of care can be cut by only administering care the patient both needs and desires.
“It was difficult for us to implement [initially] because we are practicing with a set ideal mindset,” Tewary says. “But over time and with a lot of training and education, it has helped us tremendously from a clinical perspective.”
Clinics can be AFHS-certified, depending on their level of incorporating the concept and 4Ms. “If you are doing the 4Ms, you get level one and two certification,” Tewary says. “If you have level two, you are showing improvement.”
Certification can be challenging. For example, clinics are asked how many patients they saw in the past month where all the 4Ms are incorporated.
Tewary offers these examples of how the 4Ms work in the AFHS framework:
• What matters. This is situation-based and can relate to a patient’s medications, functionality, and support system.
“It goes along with the conversation, talking to patients, and asking questions at the annual visit,” Tewary says. “When you’re asking about care and how well the person is doing, just explore those domains.”
For example, clinicians can discuss advance directives from the point of view of what matters to the patient. They also can align care with each adult, asking patients about their goals and where they are facing issues.
“Sometimes, you have to help them, and sometimes you need to refer,” Tewary says.
• Medication. Assessing patients’ medication adherence and needs comes more naturally to providers. Most probably are already doing this.
“Make sure they’re not taking any unnecessary medications, and be aware of over-the-counter medications they’re taking,” Tewary says. “See if there is an interaction with over-the-counter medications.”
Patients might not tell the provider everything, so some probing is needed (i.e., directly asking about vitamins, supplements, pain relief pills, and other medications). Also, clinicians need to know whether the patient is taking opioids and, if so, for how long.
“Some people take a picture of all the medications they’re taking and bring that in,” Tewary adds. “Medication reconciliation is a part of this, too.”
• Mentation. “In a hospital setting, this can be a routine process,” Tewary says. “In the ambulatory setting, screen for cognitive impairment and document results. Go through valuation and management, and screen for depression.”
If the screenings produce positive results, then clinicians should refer patients for treatment.
• Mobility. Assessing patients for fall risk — particularly in the cases of patients with dementia or neurological challenges — is part of the mobility element.
“The clinician has very little time to sit with the patient and go through the 4Ms. It cannot be an hour-long conversation,” Tewary says. “But they can ask the patient if they’ve fallen in the past two weeks.”
They also can be aware of risks, screen for mobility issues, and document the results. “Ask, ‘Have you fallen? Do you feel awkward while you’re walking?’” Tewary offers. “They’re required to do that screening test.” All of the 4M elements require some screening and discussion. When clinicians cover these bases, they can say they are providing age-friendly care, she adds.
An age-friendly journey is something health systems can work toward, continually assessing through quality improvement (QI) initiatives and chart reviews.
“We did a QI study for 146 patients, and we were able to find that almost [everyone] delivered medication reconciliation,” Tewary says. “For all other [elements], we have done some improvements, but we’re not there yet.”
For about 15 patients, all 4Ms were completed. Other patients revisited the clinic to make sure the other elements were completed appropriately.
“In mentation, we screened only for depression and not for memory loss, and now we are doing dementia screening,” Tewary explains. “Anyone age 65 or older should be screened for dementia.”
This shift in care should occur for all older patients, making sure every element is covered. “We have a virtual reality version [of the program], and it goes through all the 4Ms, what the physician does, and what kind of screening they’re using and assessing for falls risk,” Tewary notes. “There is a YouTube [version] that’s 15 to 20 minutes, and the virtual reality version goes into details.”
Becoming an age-friendly practice and practitioner is challenging, particularly for clinicians who already handle so much documentation. “We just hired a nurse practitioner, and we’re asking her to help us in completing the 4Ms. She’s credentialed to help,” Tewary explains. “Having a social worker or nurse in a clinic can help tremendously because it’s too much of a burden for the physician to make sure all the 4Ms are done and documented — that’s the feedback we’ve received.”
Health systems and ambulatory sites that shift to an AFHS/4Ms model may not see immediate results, but they can expect positive long-term effects. “Long term, there will be a large population entering this whole older adults care domain,” Tewary says. “If we take care of all the 4Ms from the beginning, we’ll have reduced long-term [problems] and fewer revisits to our clinicians.”
The model may lead to fewer hospitalizations, improved patient experience and trust, and a transformation in how older adults experience their medical care.
“They will feel accepted,” Tewary says. “If someone asked you if you fell, and you say you felt shaky, then you’d receive care right there in the clinic. That could prevent a hospitalization.”
If patients are screened for dementia at younger ages, they could receive medication earlier, which improves their care and longer-term experience. “The 4Ms make sure you’re screened so appropriate care is provided to you at an early stage,” Tewary says. “Initially, to be honest, we struggled through it because it’s hard to convince physicians, who already are under a lot of burden, to provide this. But as we force ourselves to look into [the 4Ms], we feel better.”
Eventually, the organization began to see positive results. That encouraged providers and clinicians in their age-friendly efforts. “Any new idea takes time,” Tewary says.
REFERENCE
- Tewary S, Cook N, Pandya N, et al. Using the 4M framework of the Age-Friendly Health System to improve MIPS documentation in primary care clinics: A quality improvement study. Gerontol Geriatr Educ 2022 Sep 5; 1-10.
A new age-friendly initiative is a model focused on providing evidence-based care coordination to older adults and their caregivers. The goal is to train clinics to provide care that addresses what matters most to patients and their families.
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