By Grace Vitaglione
North Carolina’s population of adults 65 and older is expected to grow by about 50 percent in the next couple decades — from 1.8 million in 2023 to 2.7 million in 2040, according to state data.
As these residents age, they’ll have greater need for care.
That reality helped drive creation of a new federal rule from the Centers for Medicare and Medicaid Services stipulating that hospitals, beginning in 2025, will have to report whether they have “age-friendly” protocols.
The age-friendly measure is based in part on a framework devised by the nonprofit Institute for Healthcare Improvement, an organization that’s focused on making health care safer and more efficient. Their “4Ms” framework includes making changes around “What Matters, Medication, Mentation and Mobility.”
Implementing these age-friendly services means a sharper focus on factors that can affect a patient’s healing process. Those include working with patients around their health care goals and how they manage medications, screening these patients’ level of frailty and assessing how vulnerable they are to isolation and exploitation.
And hospitals will have to demonstrate that they have age-friendly leadership.
Adoption of these principles means that most hospitals may have to tweak some of their practices. Some of North Carolina’s hospital systems have already made changes, and hospital representatives say they’re working on how to implement changes to comply with the new rule.
Why “age-friendly” services?
Making hospitals more age-friendly could be a “game-changer” for improving services to older patients, according to Jennifer Szakaly, founder and CEO of a Charlotte-based care manager services organization for older adults called Caregiving Corner.
Hospitals are already a stressful place for many people, and they can be worse for an older adult with cognitive challenges, Szakaly said.
Medications and fall prevention are two areas where things often go wrong in a hospital setting for older patients. If a patient falls and the hospital treats the injury but fails to address the reason the patient fell, they’ll likely fall again, Szakaly said. Doctors may also prescribe medications based on the patient’s health record without knowing whether the patient is correctly taking the medications recorded there.
The CMS measure could help address some of these issues. Many hospitals in North Carolina said they already incorporate age-friendly services, but representatives said the measure will provide more support for those services and hopefully lead to expansion.
“There’s no overstating how big this could be for older adults,” Szakaly said.
The first M: “What Matters”
Independence is a priority for many older people, and to return home, they will often have to manage medications or treatments as part of their healing journey.
For an older adult who uses a walker, falling and breaking their wrist isn’t just an inconvenience, said Eric LeFebvre, a WakeMed emergency department physician and geriatric emergency medicine liaison. It may mean they can no longer move around to make meals or go to the bathroom.
At Cone Health, the transitions team talks with patients about where they would like to go upon discharge, such as back home or to a skilled nursing facility, and whether that will be possible, said Rebecca Zickler, executive director of the transitions of care team at Cone Health.
Cone Health has specialty discharge planners who focus on women’s services or high-need patients such as trauma cases, she said. They’re familiar with those systems and can take the time needed to properly plan the discharge, she said.
Duke Health is improving how providers talk with patients about their health care goals and document the interaction, according to Heidi White, a doctor in the geriatrics division of the Department of Medicine at Duke.
The second M: “Medication”
Older adults are often on more medications and are more prone to medication side effects, LeFebvre said. They also tend to have complex psychosocial needs.
“Older adults have more challenging physiology. It takes less to knock them off kilter,” he said.
Older patients are also at risk of taking medications incorrectly. They may not fill a prescription because it costs too much, they may not be able to get to the pharmacy, and they may take multiple medications — which can be complicated and sometimes can conflict with one another.
At WakeMed emergency departments, the electronic health records for older adults include instructions on dosing medications appropriate to their age for different situations such as agitation or pain control, LeFebvre said.
The electronic health record at Duke University Health System pre-fills prescriptions at age-friendly dosages for people over 65 and will offer alternatives to medications that may not react well for older patients, White said.
At UNC Hospitals Hillsborough Campus, a geriatric specific pharmacist goes through older patients’ medications, and providers talk about the medications with patients before they leave, according to Kittra Felton, inpatient geriatrics services manager.
The third M: “Mentation”
Older adults in hospitals are also at a higher risk for delirium or acute confusion, LeFebvre said. Even just not having your glasses or hearing aids at the hospital can make the situation more difficult.
Some hospitals screen to see if a patient is at risk of delirium. The Duke University Health System uses the Nursing Delirium Screen Scale on general medicine floors and the Confusion Assessment Method for the Intensive Care Unit in intensive care units, according to Kimberly Smashe, manager of Geriatrics and Care Transitions at the Duke Population Health Management Office.
UNC Health’s Felton remembered a patient who needed a posey bed, a type of bed surrounded by mesh walls, because the patient’s delirium was so acute that he couldn’t stay in bed. That was significant for Felton as a caregiver, as the patient had been caring for himself before becoming delirious in the hospital.
Using chemical and physical restraints on older patients can contribute to delirium, so reducing their use is important, she said. Prevention through screening and communication helps to reduce the need for restraints.
LeFebvre said at WakeMed emergency departments they try to prevent medication-induced delirium in part by providing local anesthetic hip nerve blocks to patients with hip fractures. That can reduce the patients’ length of stay in the hospital, mortality and rates of pneumonia, along with less delirium.
The fourth M: “Mobility”
The most common reason Szakaly’s clients go to the hospital is falls, she said. There are often underlying factors, such as dehydration or a urinary tract infection, which can create confusion. Those infections may go untreated and result in a cycle of readmission, she said.
Some hospitals try to figure out the reason behind those falls with a fall assessment. Zickler of Cone Health said patients who are readmitted undergo additional screening to figure out why they didn’t get the care they needed the first time.
Mobility is an important part of making sure older patients are not debilitated when they’re discharged, she said.
Stephanie Bohling, director of nursing at UNC Hospitals Hillsborough Campus, said that every morning, providers raise the shades, turn on the lights and get patients out of bed.
Working with patients on mobility can be “an uphill battle,” said Duke Health’s Smashe. Patients may think they need to rest in bed while in the hospital, but that can actually be detrimental to their health.
Why leadership needs to be age-friendly
Health systems such as Cone Health and Novant Health are creating steering committees to direct age-friendly services to fulfill the new CMS requirements.
Duke Regional Hospital has a steering committee for age-friendly services that works with different units to apply the 4Ms framework in a manner tailored to that unit, White said.
The Duke University Health System also recently convened an age-friendly executive steering committee, and the system is creating committees at each of their hospital facilities, according to Smashe.
The plan is to extend that model to the ambulatory sites as well.
Szakaly said she’s worried that hospitals will try to incorporate all of the new services without any new resources. Discharge planners, she said, are already overwhelmed.
UNC Health’s Lynch said that age-friendly services need to be incorporated into regular workflows. He said they’ve been working on disseminating these types of protocols for over a decade.
Making a facility age-friendly can’t fall to just one discipline, he said. The work takes an interdisciplinary team, with therapists, doctors and nurses alike.
White at Duke said it’s important to try to incorporate the principles of care so it’s as easy as possible for providers.
“I call it stealth geriatrics. It’s like you’re practicing geriatrics without maybe even realizing that you are,” she said.
The idea isn’t to add extra burden to health care providers, but build the services into current systems, said Rani Snyder, vice president of Program at The John A. Hartford Foundation.
The foundation has funded initiatives at the Institute for Healthcare Improvement, American College of Surgeons and American College of Emergency Physicians to create programs and standards for geriatric care that hospitals can use.
The measure complements existing patient safety reporting, Snyder said. But the foundation’s work is not done —the hope is that the measure will eventually lead to hospitals being paid more for better performance, she said.
In the meantime, she said the public being able to see reports and competition with other hospitals will hopefully be a motivation to incorporate these services.
The measure applies to hospitals participating in Medicare’s Hospital Inpatient Quality Reporting Program. And the public will be able to see how hospitals report on the age-friendly measure through the CMS Care Compare site.
“This is like a foot in the door, which is why we’re so excited that CMS is finally doing this,” she said.
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