Keeping Our Eyes on the Prize: Embedding Age‐Friendly Care as the Health System Standard for All Older Adults

This is the authors' abstract. We don't add key points for this paper.

Age-Friendly Health Systems (AFHS) represent a movement promoted by the John A. Hartford Foundation, the Institute for Healthcare Improvement (IHI), and the American Hospital Association to improve the quality of care for older adults throughout United States health care systems, with an ultimate goal of systemic and policy changes around how we care for older adults [1]. The movement first focused on organizational-level change and public recognition that older adults were not consistently receiving high quality care based on decades of research defining clinical models that promote best practices to address conditions that contribute to loss of independence, institutionalization, and premature death as we age [2]. AFHS engagement leads health care systems to adopt specific, evidence-based practices that address the essential domains of age-friendly care, known as the 4M's (What Matters, Medication, Mentation, Mobility). Through thoughtfully designed learning networks (collaboratives and action communities) that leverage collective implementation experience, geriatrics expertise, and momentum to improve older adult care, the movement has seen significant scale up with large health care systems, like the Veterans Health Administration (VA), initiating their own action communities. With this significant spread, in addition to the over 300 articles on the AFHS, the movement has gained the attention of policy makers, and other stakeholders, with the FY2025 Age-Friendly Hospital measure adopted by the Centers for Medicare and Medicaid Services [3]. The 4M's were developed as a “sticky” evidence base to ensure recommended changes in practice could be easily understood by stakeholders and were scientifically valid [1]. The initial process measures (documentation of how each “M” is assessed and managed) and outcome measures (30-day readmissions, emergency department visits, patient satisfaction and hospital length of stay) proposed by IHI, while pragmatic, have shown unclear links with quality of care [4]. Additionally, while the evidence base for care practices focused on the individual “M”s is substantial, there is limited evidence supporting the model of assessment and management of all 4Ms as a set. Burke et al. proposed more global measures of age-friendly care that reflect outcomes important to older adults, such as “days at home” and “patient-centeredness” [4]. VA has invested heavily in the AFHS movement, even without large scale evidence of improved outcomes from implementation of the 4M's as a set, nor evidence in all care settings. The article by Bayer et al. adds to the growing body of evidence supporting the use of the 4Ms as a set in the VA inpatient setting. The inpatient VA implementation of age-friendly care in the article by Bayer et al. leveraged a purpose-built electronic medical record (EMR) documentation tool designed to capture age-friendly care. Remarkably, the Bayer et al. evaluation demonstrates that documenting 4M care is associated with better outcomes that are meaningful (decreased 30-day readmissions without a change in mortality rate), even if we cannot fully measure assessment and clinical management attributed to these teams. The VA spent considerable effort to build an EMR-based tool to document age-friendly care, as early VA adopters of age-friendly care identified lack of such EMR documentation was a barrier to measurement of age-friendly adoption and spread [5, 6]. While the nationally deployed VA EMR documentation tool, known as the Age-Friendly 4M template, has allowed settings to better track age-friendly care, the current version of the template requires additional documentation steps and does not yet capture both assessment and management regarding each M. These additional steps outside of typical workflow may account for the relatively small percentage (2,422/55,492 or 4.4%) of hospitalized older Veterans who had all 4M's documented and were eligible for the primary analysis of interest. The current study shows that the current VA purpose-built documentation tool is associated with meaningful patient outcomes; however, may not be optimized for current clinical workflows. Other large health care systems have demonstrated successful purpose-built EMR metrics for both assessment and management of each “M” that extract existing EMR documentation without requiring front line staff to perform additional data input [7, 8]. With additional investment, the VA EMR could be further leveraged to operationalize AFHS documentation across health care settings with greater integration into existing workflows. Additionally, development of an EMR-based resource that extracts and presents 4M's data that is both meaningful for clinical teams at the time of clinical care and for assessing patient outcomes would be the ideal. Implementation of AFHS Initiatives through IHI learning communities in VA has largely occurred in outpatient settings of care that are often led by geriatrician champions or health care providers with geriatrics experience, with 78.9% of participants implementing initiatives in settings such as Geriatrics Patient Aligned Care Teams (Geri-PACT), community living centers (CLCs), and home-based primary care practice groups [5]. Interdisciplinary team partnership is a hallmark of successful AFHS initiatives [2]. Because local spread of age-friendly initiatives into acute care settings may occur through partnership with those who have geriatrics expertise, the sites represented in this manuscript represent “early adopter” inpatient sites within academic affiliated VA (early adopters are typically the first 15%–20% of sites) [9]. These sites likely have access to additional geriatrics expertise compared with early and late majority sites that will accept the innovation in future years. Thus, it is possible that the results obtained in these initial sites could be more robust at future sites as age-friendly initiatives for acute care settings continue to expand beyond early adopter to early majority adopter sites. As a mission-driven organization serving a majority older adult Veteran population, VA is distinct from other US health care systems. Maintaining function, aging in place, and addressing the unique psychosocial needs of older adults and their care givers are foundational to the Veteran-centered model for VA care. As a single-payer system, avoiding institutional care is a high priority for VA, as well as an outcome important to Veterans and their families. The implementation of the AFHS and using the “sticky” framework of the 4M's as a scaffold for organizing and prioritizing complex care for older adults is building momentum within VA and US healthcare, helping to “geriatricize” care in all settings, even those without experts or champions in geriatric care. While meeting Medicare age-friendly hospital metrics may not pertain to reimbursement in the VA system, the VA has internal financial and high reliability organization quality incentives to ensure care for older Veterans is high-value, evidence-based, and Veteran-centric. The Bayer et al. article is another marker along the AFHS journey and encourages continued support for VA EMR operationalization of 4M's care assessment and management as well as research to support the growth of age-friendly care within VA as a leader in the AFHS movement in the United States. Anna K. Mirk and Camille P. Vaughan: preparation of manuscript, drafting for critical revision, and approval of final version of manuscript. This material is the result of work supported with resources and the use of facilities at the Atlanta VA Health Care System. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Department of Veterans Affairs. The authors have nothing to report. The authors declare no conflicts of interest. This publication is linked to a related article by Bayer et al. To view this article, visit https://doi.org/10.1111/jgs.70156.