Developing an Aging-Friendly Healthcare System

Abstract

With the rapidly increasing population of older adults, there is a great need to develop Aging-Friendly Healthcare Systems (AFHS) equipped in providing comprehensive healthcare to a complex population across an expansive care continuum. While there are several important components in a successful AFHS, the pinnacle of the AFHS is quality of life for the patients it serves. The John A. Hartford Foundation has launched the 4Ms (What Matters, Mentation, Mobility, and Medication) initiative as a structured approach to assist in the development of AFHS. The AFHS is highly supported by the interdisciplinary team, geriatricians, and primary care physicians, all whom are facing serious workforce shortages, particularly in Missouri. Beginning in 2025, hospitals that participate in Medicare’s Hospital Inpatient Quality Reporting (IQR) Program will be required to report on Aging-Friendly Hospital Measures based on the 4Ms framework or face possible reimbursement penalties.

Introduction

The year 2034 marks the transition point at which there will be more people over 65 years of age than under 18 years of age for the first time in history. ^1,2,3,4 The “graying of America” will be inescapable with one in four older adults being 65 years of age or older, and the population of 85 years or older tripling.⁴ It is foreseeable that there will potentially be more non-working adults than working adults and an astronomical shift in the numbers of older adults with unmet healthcare needs. Historically, healthcare systems were designed around the disease-based acute care model, which aims to treat singular acute disease episodes rather than addressing increasing numbers of chronic comorbidities intersecting with advancing life expectancies across a population.⁵ With the rapidly increasing population of older adults, there is a great need to develop Aging-Friendly Healthcare Systems (AFHS) equipped in providing comprehensive care to a complex population.

What is an Aging-Friendly Healthcare System?

No all-encompassing definition exists on constructing an AFHS, but opinions exist on necessary components (Figure 1). Components of a robust AFHS include quality of life, successful transitions of care, reduction in hospitalizations, promotion of aging in place, identifying and supporting end-of-life care preferences, maximizing functional and cognitive abilities, and the creation of individualized treatment plans. While all of these components are equally important for care delivery, the pinnacle of the AFHS is quality of life for the patients it serves. These AFHS components should be implemented in all locations of care delivery for older adults across the system, including the outpatient clinic, the hospital, and post-acute and long-term care facilities. Because healthcare for older adults occurs across the geriatric care continuum, the AFHS requires infrastructure in place to facilitate smooth transitions of care across the continuum. The implementation of successful transitions of care is critical to improving measurable outcomes such as morbidity, mortality, hospital/facility length of stay, and hospital/facility readmissions rates as well as reducing overall healthcare costs.⁶ Financially, establishing an AFHS makes dollars and sense, as demonstrated in a study of two large health systems which found an increased monetary return on investment through improvement on federal survey quality scores and decreased hospital length of stay, admission frequency, and admission severity.⁷ In this study, the AFHS demonstrated lower costs, primarily through the reduction in delirium which is a common complication in older adults in the inpatient hospital setting resulting in costly delays and barriers to care.⁷ It also generated an extra revenue of $3.6 million dollars annually from Medicare Annual Wellness Visits (MAWV) via a focus on screening and prevention and generation of downstream referrals.^{7, 8}

Figure 1.

Key components of an Aging- Friendly Healthcare System

Accounting for Disparities

The AFHS must account for healthcare disparities and high levels of disability in the aging population. Health spans do not always match age spans resulting in a large proportion of older adults living with poor health and missed opportunities to improve health span by staying socially, mentally, or physically active.^9,10 Older adult single households 65 years and older increased from 9.4% in 2010 to 11.1% in 2020 and the poverty rate in this demographic increased by 0.3%.^11,12 The prevalence of those with the necessary financial resources to improve health, such as adequate social security and pensions, has decreased over time and is projected to continue to worsen.¹³ Older adults often have high levels of disability with 39% of those over 65 having an ambulatory difficulty, 29% being hearing impaired, 21% being visually impaired, and 28% having cognitive impairment.¹⁴ Additionally, more than one out of three older adults have one functional limitation, and nearly two out of three have problems ambulating or using stairs.⁹ A large proportion of older adults (31.3%) have impairment in activities of instrumental daily living (IADLS), which are necessary to enable one to live safely alone and include the ability to manage money, medications, making telephone calls, preparing meals, shopping for groceries, and/or using a map when driving.¹⁵ The AFHS requires resources and a support infrastructure in place to accommodate the common place functional, physical, and cognitive limitations in the population it is serving.

Who Should Lead the AFHS Initiative?

Geriatricians who specialize in the healthcare of older adults are uniquely poised to push aging-friendly initiatives and are experts in managing geriatric syndromes, facilitating transitions of care, differentiating pathologic versus physiologic aging, polypharmacy reduction, helping patients and families set realistic end-of-life care goals, managing multimorbidity, and having personal experience with each of the interdisciplinary team member roles.¹⁶ According to the American Geriatric Society, in 2021, there were 7,454 board certified geriatricians nationwide, yet a predicted 30,000 geriatricians will be needed to serve the older adult population by 2030.^17,18 In 2022, Missouri only had 111 board certified geriatricians with the Missouri geriatric doctor to patient ratio being 19% lower compared to other states.^17,19 Too few geriatricians are present to change the healthcare system culture into a more aging-friendly mindset. Medical schools lack required geriatric rotations with only 10% requiring a geriatric rotation as of 2021, which is down from 23% in 2005, and internal medicine training programs no longer requiring geriatric medicine exposure as part of their curriculum.²⁰ Given that only 43% of geriatric medicine fellowship spots are filled each year, which is the lowest of all fellowship specialties, most of the work and policy change will need to be implemented by primary care providers and other members of the interdisciplinary team.²¹ The goal, therefore, is for geriatricians to educate and train the workforce and interdisciplinary team on best management principles for healthcare delivery in older adults.

In an aging-friendly healthcare system, adequate numbers of primary care providers, which include physicians and advanced practice providers (APPs), are needed across all socioeconomic levels. This may be challenging given the predicted shortage of 20,000–40,000 primary care physicians to adequately cover the population by the year 2036.²² The Missouri primary care physician shortage is sobering with 32% of physicians now at retirement age. The state is hypothesized to be short by more than 3,000 physicians by 2030, ranking in the bottom half of all states for total numbers of active primary care physicians.¹⁹ One hundred and eleven counties out of a total of 114 Missouri counties are designated as “Health Professional Shortage Areas,” defined by the Health Resources and Services Administration as a specific geographic area or population group lacking adequate numbers of mental health, primary care, or dental healthcare providers to adequately serve the population.²³ Because much of the implementation of an AFHS is done by the primary care workforce, the shortage of primary care healthcare providers in Missouri will be an essential challenge for the state to tackle.

Importance of Interdisciplinary Team

Healthcare delivery in an AFHS is highly dependent on the interdisciplinary team (IDT) which is essential in providing comprehensive care to older adults and includes nurses, physical therapists, occupational therapists, speech therapists, social workers, dieticians, and behavioral health specialists—many of which are facing serious workforce shortages (Figure 2).²⁴ The interdisciplinary team has always been central in the field of geriatrics and has more recently been implemented in other specialties. The premise of the team approach allows each team member to contribute individual expertise through the lens of diverse specialties. With the expertise of multiple disciplines, care delivery can be comprehensive, additive, and encompassing of the physical, mental, and psychosocial needs of the individual which lies at the very heart of the AFHS. In addition to the interdisciplinary team, care delivery for older adults is also often implemented by family and caregivers. Recommendations to include family caregivers as part of the interdisciplinary team are important because caregivers are often patient advocates and aware of their loved ones’ healthcare preferences and goals.⁹ Of the family caregivers surveyed, 88% described wanting more support sharing the care burden, increased guidance and education, and additional financial resources in which to utilize to care for their loved one.⁹ The AFHS will ideally work through the interdisciplinary team to support patients and their caregivers and utilize a team-based approach in healthcare delivery.

Figure 2.

Members of the Interdisciplinary Team

4Ms Framework of an Aging-Friendly Health System

What is the 4Ms Framework of an Aging-Friendly Health System? In 2016, the John A. Hartford Foundation, a private philanthropic group dedicated to improving the healthcare of older adults, launched the 4Ms initiative in collaboration with the Institute for Healthcare Improvement.²⁵ The 4Ms include What Matters, which places emphasis on aligning care delivery with one’s personal healthcare goals and preferences; Mobility, which focuses on maintaining physical function so that one can maintain independence; Mentation, which includes identifying and managing dementia, depression and delirium; and Medications, which should be routinely assessed for risk versus benefit and which should not interfere with the other Ms (Figure 3).²⁵

Figure 3.

4Ms Framework of an Aging-Friendly Healthcare System.²⁵

The 4Ms can be implemented across the care continuum by assessing for each of the Ms, and acting on them by aligning care plans with What Matters most.²⁵ Structuring an AFHS around the 4Ms framework is achievable and facilitates improved outcomes during all levels of care delivery and points of transitions of care. Prioritizing individualized healthcare plans by What Matters is person-centered and leads to improved physical and psychological responses and increased treatment compliance.²⁶

What do older adults want? Older adults value listening skills in their healthcare provider as highly as knowledge and competence—each at 67%, and nearly half of older adults want their provider to collaborate with them as partners.⁹ Not surprisingly, 94% of older adults feel it is more important to maintain quality of life than quantity of life.⁹ Demographic factors such as socioeconomic class, race, and ethnicity influence how older adults feel their healthcare provider interactions could be more age friendly. For example, more African American older adults wish for discussions on What Matters and decreasing polypharmacy (i.e., the 4M focused on Medication) as compared to other race/ethnic groups.⁹ A recent study revealed that 90% of clinicians agree older adults require a different approach to care than younger patients, yet only 50% of clinicians feel that they “always” take patient age into consideration when determining care. ²⁷ Only one in five providers are routinely addressing all four 4M categories with only about 50% asking about What Matters regarding well-being.⁹ The majority of older adults (77%) also prefer to age in place rather than be moved from their home to a care facility such as an assisted living or nursing home, indicating infrastructure in an AFHS is needed to support this preference whenever possible.^1,28 After surveying a large health system, only half of family members thought a care facility was the safest place for their loved one with more than 60% citing fear of poor quality of care and loss of dignity with institutionalization.⁹ To promote successful aging in place, which is What Matters to many older adults, a focus on maximizing functional and cognitive abilities so that one can age in place should be prioritized.

Patient-Centered Care

Another important component of What Matters is patient-centered care.²⁵ Many best practice guidelines and research studies do not include older adult populations in the supporting evidence leading to ambiguous recommendations and difficulty applying study findings to older, frailer and sicker populations. The creation of individualized treatment plans is essential because much heterogeneity exists in the older adult population and there are limited evidence-based guidelines including those over 75 years of age. One 90-year-old may be robust, active, and living in the community while another 65-year-old may be wheelchair bound, frail, and living in a nursing home. The preventative healthcare goals of the two individuals are likely to be completely different requiring an individualized treatment plan accounting for the unique bio-psycho-social and physical needs of each. Advanced care planning, or end of life care, is an essential part of What Matters and guides treatment plans for older adults.⁹ Yet, only 13% of older adults have discussed end of life wishes with their primary care provider with one in three older adults in the United States having completed an advance directive.^9,29 Missouri data gathered from more than 11,000 older adults demonstrated 56% of people aged 65–74 reported completing advanced directives and 84% of those aged 85 and older reported completing advanced directives.³⁰ However, despite a positive cultural shift in the past several years that prioritizes end of life care goals, only one in eight adults receive care in their last months of life that is consistent with their wishes.³¹ An AFHS must prioritize addressing end of life care preferences which align with the pinnacle component of “What Matters” and promotion of quality of life, which is central to a successful AFHS.

Medication

The epidemic of exceedingly long and increasingly inappropriate medication lists can diminish quality of life in older adults and through side effects and drug-drug interactions, adversely affect What Matters, Mentation, and Mobility. Prescribing cascades, where one medication is started to fix side effects from another medication is an important reason why Medication is included in the 4Ms framework. The CDC’s National Ambulatory Medical Care Survey from 2009–2016 analyzed two billion healthcare visits of adults 65 years and older and found 36.8% were prescribed ≥ 5 meds and of those, 70% had one potentially inappropriate medication.³² One study found that when using the Beers Criteria and STOP-START Toolkit, the percentage of potentially inappropriate medication prevalence by setting was 19.1% at primary care visits, 29.7% in the nursing homes, and 44.6% in the hospitals setting.³³ Medications can be addressed by performing a thorough medication reconciliation, deprescribing, ordering a pharmacy consult when pharmacy services are available, and avoiding high risk medications such as benzodiazepines, opioids, highly anticholinergic medications, sedatives, muscle relaxants, tricyclic antidepressants, and antipsychotics.²⁵ However, just 70% of providers ask about medications, limiting the management of polypharmacy and potentially inappropriate medications.⁹

Mentation

Mentation, another component of the 4Ms framework, can be addressed by screening for dementia, depression, and delirium. Data gathered from over 11,000 older adults in Missouri revealed that nearly 42% screened positive for dementia in the oldest age group (85 years of age and above).³⁰ Dementia, particularly that caused by Alzheimer’s Disease, is one of the most feared health conditions by older adults with 69% citing that losing the ability to think clearly is the biggest worry of living a long life, yet only 40% of older adults report having a cognitive evaluation.⁹ Screening for mentation/cognitive impairment should occur in both inpatient and outpatient healthcare settings and can be accomplished by any member of the interdisciplinary team. There are many validated screening tools, but the authors of this article recommend using the Saint Louis University Mental Status Examination (SLUMS) or Rapid Cognitive Screen (RCS).^34,35 Both are non-copyrighted, brief to administer, and have been validated internationally and across the geriatric care continuum. The SLUMS screening tool is particularly useful in that the score is adjusted for education level, making it more applicable in populations with lower education levels. In certain care settings, ensuring being orally hydrated, reoriented, having adaptation equipment on (i.e. hearing aides, glasses) and preventing sleep interruptions can improve acute mentation deficits and should be incorporated into best care practices.²⁵ Given the high prevalence of cognitive impairment in the aging population, the AFHS should routinely screen for cognition deficits and work to provide older adults and families with resources to preserve cognition and promote the best Mentation possible.

Mobility

The 4Ms framework component of Mobility can be addressed in the outpatient setting by performing gait evaluations, referring to physical/occupation therapy to improve deficits, screening for falls and fear of falls, and encouraging ambulation.²⁵ In the inpatient setting, getting patients out of bed for meals, ordering physical and occupational therapy, avoiding chemical and physical restraints, and removing catheters or other tethering devices may improve and/or maintain previous levels of mobility.²⁵ Older adults have a much higher risk of becoming immobile during prolonged hospital stays, which often results in institutionalization and inhibits quality of life and one’s ability to successfully age in place. System-wide implementation of the 4Ms, including Mobility assessments in all care settings, drives quality and safety, coordinates healthcare efforts across the care continuum, and improves outcomes during transitions in care.²⁶

Aging-Friendly Hospitals

Few hospitals truly meet the needs of older adults but evidenced-based aging-friendly approaches to better care in hospitalized older adults is emerging. Historically, hospitals were designed to provide rapid diagnoses and treatments of single episodes of acute illnesses. Older adults are more susceptible to hospital-associated complications such as falls, delirium, pressure ulcers, and functional decline which can prolong stays, increase readmissions, make higher costs and result in nursing home placement at discharge.³⁶ The framework for an aging-friendly hospital includes leadership/organization support, guiding principles, patient and family-centered care practices, staff competence in geriatrics, interdisciplinary team resources/support, and an adapted physical environment (Figure 4).³⁷ Leadership and organizational support is the highest priority and sets the stage for allocation of resources, development of aging-friendly policies and procedures, and adaptation of the physical space and healthcare team care delivery processes which are sensitive to the needs of older adults.³⁸ The guiding principles should be founded on evidence and best practices which account for the physiology and pathology of aging and encourages care delivery which promotes continuity through transitions of care and fosters the goal of maintaining physical and cognitive function throughout the hospital stay. Patient and family-centered practices ideally are devoid of ageism and respect the individualized bio-psycho-social care needs of older adults and their caregivers, maximizing patient/family satisfaction in the care received. Staff competence in geriatrics is achieved by continuous training and emphasis on managing common geriatric conditions such as falls, dementia, delirium, and incontinence. Interdisciplinary support highlights the important role of each member of the healthcare team and allocates additional financial resources to accomplish best practices even if they don’t always appear to result in financial gain (i.e. allowing physical therapy to work with the older adult for longer sessions in the hospital to decrease functional decline even when health insurance may not reimburse fully for additional time). An adapted physical environment in the hospital promotes safety, independence and reduces functional decline and minimizes the vulnerabilities of often severely frail older adults. Examples of environmental adaptations include hallways with railings to promote ambulation, contrasting paint tones for the visually impaired, large clocks and calendars for orientation, bright lighting—ideally natural light to reduce delirium, common areas for families and visitors, chairs in rooms so patients can get out of bed for meals and throughout the day, elevated toilet seats and grab bars in bathrooms, walk-in showers for bathing ease, geri-chairs and accessible ambulatory devices to promote movement, availability of pocket talkers/hearing devices for those who don’t have their hearing aids, and otoscopes for ear evaluations.³⁹

Figure 4.

Framework for Development of an Aging- Friendly Hospital.³⁷

Acute Care for the Elderly

Another important element of the Aging-Friendly Hospital is the availability of an Acute Care for the Elderly (ACE) unit/team.³⁹ The ACE unit/team philosophy was first developed around 1990 and is structured around a care model that focuses on the “big picture” and accounts for life expectancy, quality of life, and comorbidities while acute medical interventions are carried out.⁴⁰ It can be implemented as a physical place in the hospital (i.e. a geriatric floor/unit) or as a healthcare team that delivers care based upon this model. The ACE unit/team is driven by established guidelines and protocols based on published evidence for patient-centered care delivery in the geriatric population.⁴¹ It recognizes the prevalence of geriatric syndromes, consistently screens all patients and utilizes evidence-based strategies to reduce the incidence of inpatient falls, delirium, length of stay, pressure ulcers and physical and cognitive decline.³⁹

During each hospital stay, the ACE unit/team engages in dedicated discussions on patients’ healthcare preferences and end of life care goals. A dedicated delirium unit may be part of the ACE unit/team and typically consists of a multi-bed room with specially trained staff who provide more individualized care and added assistance with activities of daily living.⁴² The staff should be trained in managing behaviors associated with dementia and delirium utilizing primarily non-pharmacologic strategies.⁴³ Delirium rooms tend to have a higher staff to patient ratio, but without such a structured multi-bed room the patients would likely require one to one bedside sitters, making a delirium room more economically beneficial. Both ACE units/teams and delirium rooms are highly supported by the interdisciplinary team. True patient-centered care dictates no physical restraint utilization and low chemical restraint utilization and to achieve this goal, added support from staff and the interdisciplinary healthcare team is essential.⁴⁴ Early mobilization, attention to visual and hearing aids, attention to and assistance with nutritional intake and maintenance of sleep/wake cycle are all focuses of the delirium room and good principles of managing/preventing delirium.⁴⁵ The prevention and quick management of delirium is economical for a healthcare system, as delirium is an independent predictor of adverse hospital outcomes such as morbidity, mortality, length of stay, nursing home placement, functional decline and higher costs.

Beginning in 2025, hospitals that participate in Medicare’s Hospital Inpatient Quality Reporting (IQR) Program will be required to report on Aging-Friendly Hospital Measures (Table 1) based on the 4Ms framework.⁴⁶ These measures apply to the care of adults over 65 years of age in the inpatient setting, emergency department, and other hospital departments. Hospitals must have policies and procedures that 1) elicit patient health care goals; 2) responsibly manage medications; 3) implement frailty screening and interventions (includes cognition and mobility); 4) assess social vulnerability (i.e. social isolation, caregiver stress, elder abuse); and 5) establish Age-Friendly Care Leadership.⁴⁶ The five domains focus on 10 requirements, and failure to comply with these requirements can result in reimbursement penalties.⁴⁶

Table 1.

CMS Aging-Friendly Hospital Measures

Domain	Requirements
Eliciting Patient Healthcare Goals	Use protocols to obtain and document treatment goals, living wills, healthcare proxies, and advance care planning
Responsible Medication Management	Use evidence-based guidelines to review and reduce potentially inappropriate medications (PIMs)
Frailty Screening and Intervention	Use validated instruments to screen mentation, mobility, and malnutrition Care plan positive screens to minimize risk of delirium, promote early mobility, and develop nutrition plans Collect and demographically stratify data on fall rates, pressure ulcers, and 30-day readmission rates Use protocols to reduce delirium by shortening length of stay in the emergency department for admissions and discharges
Social Vulnerability	Screen on admission and discharge for social isolation, economic insecurity, limited access to healthcare, caregiver stress, and elder abuse Care plan positive social vulnerability screens for interventions, referrals, and resources
Age-Friendly Care Leadership	Designate a champion and/or interprofessional committee to oversee, educate, report, and prioritize efforts on age friendly care initiatives Use demographically stratified and compiled Age-Friendly Hospital Measures to drive quality improvement cycles

Conclusion

With the increasing aging population, an essential focus is the development of Aging-Friendly Healthcare Systems that can meet the unique healthcare needs of this complex population. The pinnacle of an AFHS is focus on What Matters, and quality of life and this should be the driving force for policy and procedure development. The 4Ms framework (i.e., What Matters, Mentation, Medication, and Mobility) developed by the John Harford Foundation offers a structured approach to prioritizing the components of an AFHS. Some questions to consider include asking if your healthcare system is ready to encounter the increasing older adult population? What elements are in place and what is still needed? How can the healthcare culture be changed into one which is more aging-friendly?