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Background Older adults with chronic or acute cognitive impairment, such as dementia or delirium, who are hospitalized face unique barriers to person-centered care and a higher risk for negative outcomes stemming from hospitalizations. There is a need for co-designed interventions adapted for these patients to the hospital setting to improve care and outcomes. Patient life storytelling interventions have demonstrated promise in enhancing person-centered care by improving patient–care team relationships and providing information to enable care tailored to individual needs and values. Objective This study aims to engage patients, care partners, and clinical stakeholders in a co-design process to adapt an existing life storytelling model for use with older adults with dementia and at risk of delirium in the acute care hospital setting. Methods We recruited patients with dementia or at risk of delirium who were hospitalized, their care partners, clinicians, and informaticists. A 3-stage co-design process that used a mixed methods data collection approach including in-depth interviews and surveys was completed. We used content analysis to analyze qualitative data and descriptive statistics to summarize quantitative data. Results In total, 27 stakeholder informants (ie, patients, care partners, and interdisciplinary care team [IDT] members) participated. Stakeholders were unanimously interested in using patient life stories as a tool for hospital care through electronic health record (EHR) integration. Stakeholders shared potential topics for life stories to cover, including social support, information on patients’ key life events, and favorite activities. Participants provided insights into the logistics of integrating life stories into acute care, including interview arrangement, story-sharing methods, and barriers and facilitators. IDT members shared preferences on EHR integration, resulting in 3 co-designed mock-ups of EHR integration options. Stakeholders shared ways to optimize future acceptability and uptake, including engaging with the care team and promoting awareness of life stories, ensuring suitability to the acute environment (eg, distilling information in an easily digestible way), and addressing concerns for patient capacity and privacy (eg, engaging care partners when appropriate). Thoughts on potential impacts of life stories were also elicited, including improving patient- and care partner–IDT member relationships; humanizing patients; increasing clinical team, patient, and caregiver satisfaction; and enabling more specific, tailored care for patients with dementia and at risk of delirium. Conclusions This study resulted in a co-designed life storytelling intervention for patients with dementia and at risk for delirium in an acute care hospital setting. Stakeholders provided valuable information to ensure future intervention acceptability and uptake, including potential benefits, facilitators, and challenges in the acute care setting.
Abstract Background Redesigning the healthcare system to consistently provide effective and tailored care to older adults is needed. The 4Ms (What Matters, Mobility, Medication, and Mentation) offer a framework to guide health systems' efforts to deliver Age‐Friendly care. We use an implementation science framework to characterize and assess real‐world implementation experiences with the 4Ms across varied health systems. Methods With expert input, we selected three health systems that were early adopters of the 4Ms and engaged in different implementation support models through the Institute for Healthcare Improvement. We conducted 29 semi‐structured interviews with diverse stakeholders from each site. Stakeholders ranged from hospital leadership to frontline clinicians. Interviews covered each site's approach to and experiences with implementation, including facilitators and barriers. Interviews were recorded, transcribed, and deductively coded using the Consolidated Framework for Implementation Research. We characterized each site's implementation decisions and then inductively identified overarching themes and subthemes with supporting quotes. Results Health systems varied in their implementation approach, including the implementation order of each of the 4Ms. We identified three overarching themes: (1) the 4Ms offered a compelling conceptual framework for advancing Age‐Friendly care, but implementation was complex and fragmented; (2) complete and sustained implementation of the 4Ms required multidisciplinary and multilevel leadership and engagement; (3) strategies that facilitate implementation success and support frontline culture change included top‐down communication and infrastructure alongside hands‐on clinical education and support. Common barriers are siloed implementation efforts across settings that impeded synergies and scaling; disengaged physicians; and difficulty implementing What Matters in a meaningful way. Conclusions Similar to other implementation studies, we identified multifactorial domains impacting 4Ms implementation. To achieve Age‐Friendly transformation, health systems must plan for and attend to multiple phases of implementation while ensuring that the work coheres under a unified vision that spans disciplines and settings.
As part of an institutional quality improvement (QI) initiative for the 2018-2019 academic year, orthopedic residents at our tertiary center were incentivized to bring over 75% of hip fracture patients with American Society of Anesthesiologists (ASA) Class 2 or less to surgery in under 24 hours, compared to the baseline rate of 55.9%. The time between admission and surgery for hip fracture patients with ASA class 2 or less was prospectively recorded. At the end of the study period, a retrospective comparison was performed between patients treated before and after the resident QI initiative. The percentage of patients who underwent surgery within 24 hours of admission increased significantly in the Study Cohort compared to the Baseline Cohort (78.6% vs. 55.9%, p = .037). Length of stay was shorter in the Study Cohort compared to the Baseline Cohort (3 days vs. 4 days, p = .01), whereas readmissions (3.6% vs. 4.4%, p = .85) and discharges to skilled nursing facilities (60.7% vs. 57.4%, p = .76) were comparable between both cohorts. A goal-directed, resident-led QI initiative was associated with a significantly increased percentage of hip fragility fracture patients who underwent surgery in less than 24 hours.
BACKGROUND Many health systems are establishing geriatrics‐orthopedics (Geri‐Ortho) comanagement programs; however, there is paucity of published information on existing programs' variations in clinical operations, structure, and reported implementation challenges and perceived successes. OBJECTIVE Our objective was to obtain detailed information about the variety of existing Geri‐Ortho comanagement programs in the United States. DESIGN/PARTICPANTS We conducted a cross‐sectional survey of 44 existing Geri‐Ortho comanagement programs, with 23 (52%) of programs responding. MEASUREMENT Quantitative questions were used to assess operational, staffing, and financial structures; and qualitative questions were used to identify reported challenges and perceived successes of implementation. RESULTS Programs self‐identified as urban (n = 23), academic (n = 20), or nonprofit (n = 22) and as having a level I trauma center (n = 17). Most programs (n = 18) were funded fully by the institution. Fourteen programs used geriatricians, and nine used medicine/hospitalists as the supporting clinical service, whereas approximately half (n = 11) used these services in a true comanagement model. Six universal themes were identified as necessary for program implementation. The most commonly described successes perceived by all respondents were improvements in clinical outcomes and better interdisciplinary relationships. Reported challenges included difficulty in interdisciplinary geriatrics education, difficulty in adherence to protocols, and lack of funding for staffing. CONCLUSIONS There are diverse types of Geri‐Ortho comanagement programs in the United States, although universal elements exist. Many had similar challenges in implementation, and further studies are needed to determine which implementation elements are critical to clinical and financial outcomes. J Am Geriatr Soc 68:1714‐1719, 2020.
The clinical benefits of Acute Care for Elders (ACE) units have been established for over 25 years. However, how widely disseminated ACE units are in the United States and the degree of fidelity to the key elements of this model of care are unknown. Our objective was to identify all existing ACE units in the United States and to obtain detailed information about variations in implementation.The strategy to identify current ACE units began with online searches and snowball sampling using contacts from professional societies and workgroups. Next, a request for information regarding the existence of ACE units was sent to the remaining US hospitals listed in a national hospital database. An online survey was sent to identified ACE unit contacts to capture information on implementation characteristics and the five key elements of ACE units.There were 3692 hospitals in the database with responses from 2055 (56%) hospitals reporting the presence or absence of an ACE unit. We identified 68 hospitals (3.3%) with an existing or previous ACE unit. Of these 68 hospitals, 50 (74%) completed the survey and reported that 43 ACE units were currently open and 7 had been closed. Of the 43 currently open ACE units, most are affiliated with an academic hospital and there is variable implementation of each of the five key ACE elements (from 69% to 98%).Among the 50 hospitals to complete the survey, 43 current ACE units were identified, with variable fidelity to the key elements. Estimates of prevalence of ACE units and fidelity to key elements are limited by nonresponses to the national survey request by nearly half of hospitals.
Abstract Background To support implementation of the 4Ms framework and more rigorous evidence of 4Ms impact, we translated Institute for Healthcare Improvement's (IHI's) recommended 4Ms routine care practices into electronic health record‐based, encounter‐level adherence measures and then implemented measures at a large academic medical center. Methods We started with the 19 care practices in IHI's 4Ms implementation guide and developed encounter‐level adherence measures using structured EHR data. We also developed overall 4Ms‐level and M‐level composite measures. Next, we operationalized measures at UCSF Health—an academic medical center that has implemented the 4Ms using the IHI guide. We identified UCSF Health patients who should have received 4Ms care during their inpatient admission (19,335 individuals 65 years and older with an admission between January 1, 2019 and December 31, 2021), then implemented the individual measures and composite measures (all at the encounter level) using Epic EHR data. We focused on 4Ms inpatient care processes, but similar approaches can be followed for ambulatory, post‐acute, and other settings. Results We developed 18 EHR‐based measures that captured all IHI care practices, 16 of which could be implemented using UCSF Health EHR data. For example, the EHR‐based measure for the Medication care practice “deprescribe high risk medications” was measured using EHR data as “Patient had no previously existing prescriptions for high‐risk medications OR patient had ≥1 previously existing prescriptions for high‐risk medications deprescribed during the encounter,” and 29.5% of UCSF Health encounters met this measure. For composite measures, on average, UCSF Health encounters had 61.1% adherence to the 4Ms (SD = 14.4%), with the lowest average adherence to What Matters (50.9%; SD = 44.3%) and the highest for Mentation (68.4%; SD = 13.4%). Conclusions It is feasible to construct encounter‐level measures of 4Ms adherence using EHR data and derive insights to guide ongoing implementation efforts. Future efforts should refine measures based on assessments of reliability and validity.
