Age-Friendly Health Systems Initiative Addresses a Care Crisis in the 'Oldest' State

Editor’s note: The John A. Hartford Foundation, the Administration for Community Living and The SCAN Foundation fund the Aging and Disability Business Institute, led by the National Association of Area Agencies on Aging (n4a). The mission of the Aging and Disability Business Institute is to build and strengthen partner­ships between aging and disability community-based organizations (CBO) and the healthcare systemAs partners in the Aging and Disability Business Institute, ASA and n4a are collaborating on a series of six articles and case studies in Aging Today that highlight the Age-Friendly Health Systems initiative.

Maine holds the distinction of being the oldest state in the nation, with a median age of 44.6. There are 252,634 people younger than age 18 in Maine and 266,214 people ages 65 and older, mak­ing up 20 percent of the state’s population. Tammy Vachon, program manager of Geriatrics at MaineHealth, and Katlyn Blackstone, chief program officer for the Southern Maine Agency on Aging (SMAA) are pedaling fast to keep up with the latter cohort’s demands, with an assist from The John A. Hartford Foundation’s Age-Friendly Health Systems (AFHS) initiative.

MaineHealth, a nonprofit group of providers and healthcare organizations, is Maine’s largest healthcare organization. SMAA, begun in 1973, is a nonprofit dedicated to planning and imple­menting social services for adults ages 60 and older. Age-friendly work is not new to either organi­zation, as they have been partnering to help Maine’s older adults for more than 20 years, but the AFHS initiative’s focus on the 4Ms (What Matters; Medication; Mentation; and Mobility) has given a new framework to their collaboration.

The Power of Two

MaineHealth’s AFHS work so far has culminated in an evidence-based delirium prevention pro­gram called the Hospital Elder Life Program (HELP). This inpatient geri­atric service helps to maintain cognitive and physical function in high-risk older adults while they are hospitalized; to maximize their independence at discharge; to assist with transition from hos­pital to home; and to prevent unplanned hospital readmissions. MaineHealth is supported in this effort by SMAA.

“When we asked patients what matters most to them,” says Vachon, “very often it was ‘I don’t want to fall again,’ or ‘I don’t have enough food.’ Whatever it may be, the answer causes a referral to SMAA for an assessment and [sup­portive] resources.” 

When other health systems struggle to collaborate on age-friendly work, it often is because they lack relationships—such as MaineHealth has with SMAA—with CBOs, says Vachon. Critically, MaineHealth knows exactly what SMAA can deliver in the community, and vice versa.  In addition to MaineHealth’s col­laboration with SMAA, it also has rela­tionships with other AAAs, the Alzheim­er’s Association and other CBOs. 

Blackstone agrees: “The history [of collaboration] is so important,” she says. “We at SMAA have a champion in the healthcare system. Where CBOs struggle is in finding someone in that system who will facilitate working together… we have had that for 20 years, with lots of trust built up.” 

Staunch Collaboration Combats the Growing Care Crisis

MaineHealth has approached the AFHS work one program at a time, first with inpatient hospital delirium prevention, second, within their outpatient geriatric center, where they are implement­ing dementia and cognitive screenings, and becoming more efficient at making recommendations to clients for related services. Next up are plans to make the Maine Medical Center’s Cardiac and Trauma units age-friendly, as well as MaineHealth system–owned skilled nur­s­­ing facilities. 

SMAA has strengthened its communications around all-important service referrals, replacing phone and fax use with Internet-accessible community links to the HIPPA-compliant forms pro­viders can employ to make referrals to SMAA’s services. Those services are extensive, from A Mat­ter of

Balance classes and the Money Minders program to instruction in navigating Medicare op­tions and trainings in best practices for nutrition and fitness. SMAA offers Tai Chi and Matter of Balance classes as well as Healthy Steps for Older Adults in rural areas, as four-hour workshops; this makes it more convenient for those who otherwise might have to travel long distances to classes. 

Social workers at the geriatric center ask people what matters during their initial intake (a two-hour process), then document answers at the top of patients’ charts in an electronic health record system called EPIC. These social workers’ resource recommendations form a starting point for SMAA’s involvement, which then begins with a home visit, during which staff often uncover “hidden” issues. 

“Most people are choosing to live out the rest of their lives at home, they are not planning on go­ing to a nursing home,” says Blackstone. That, coupled with a direct care worker shortage for in-home care leaves many older adults without adequate help at home. “It’s a crisis—a growing one—we don’t have the people to provide the services needed, even if the older adults qualify for help.”

Another challenge for SMAA and MaineHealth is the growing number of patients they see who have dementia. Blackstone says that not only are they seeing an increase in dementia incidence as people live longer, but also they are noting the challenges of early onset cases. Thus, interest in the SMAA-run Family Caregiver Support Program has increased. 

SMAA’s community support specialists work with people in the early stages of dementia, to guide them through the system. And Meals on Wheels assessors are in the home as well, check­ing for meal-service eligibility along with any memory concerns.

“MaineHealth has been trying to do a better job of screening and identifying early cognitive impairment and to help providers to make referrals to SMAA,” says Vachon. “We’re actively talk­ing with providers and nurse care managers to train them to see cognitive impairment warning signs and to make appropriate referrals.”

The AFHS Rollout Yields Lessons Learned

The importance of gathering data and learning how to extract and dispense it is one of the biggest lessons that CBOs and health systems involved in the AFHS initiative have learned. “We’ve made very good friends with our IT department,” said Vachon. She recommends that others do the same. 

Once MaineHealth ensured the 4Ms information was being properly entered into the electron­ic health record, Vachon sought help with identifying how to extract that data from the EPIC program. Though physicians are learning to annotate the 4M screening data, difficulties remain with getting that information into a palatable format that could be used for reporting progress to the Institute for Healthcare Improvement, and that would support the creation of further age-friendly programs within the system.

SMAA’s most notable lesson learned involves the need to prioritize which work is most impor­tant, as staff is inundated with clients and lack sufficient federal or state funding to meet people’s needs. “Working with people with dementia takes more time and resources,” says Blackstone. “One of the biggest lessons we learned is that professionals working in the community with de­mentia patients tell us that often they must re-introduce themselves, each and every time they engage with a patient.” 

Blackstone acknowledges another challenge in working with people with dementia: it is hard to know who else is involved with these clients. Sometimes it is law enforcement personnel, general practitioners or caseworkers, but the client could have little to no recollection of them. 

“Our most satisfying outcomes have to do with identifying people in the community who really need our services—who is living alone with dementia, or which family is in crisis, not knowing how to deal with an older adult,” says Blackstone.

Although they don’t yet have data on specific outcomes from AFHS programming, Vachon says, “One hundred percent of patients seen in the Hospital Elder Life Program have all 4Ms addressed.” Anecdotally, Vachon notes that patients seem to enjoy being asked what matters to them, and pro­viders have mentioned an increase in their work satisfaction. 

“Our physicians, once exposed to the 4Ms, are 100 percent on board and love the movement,” says Vachon. “Patients are being heard and listened to, and we’re addressing what’s important [to them]: it’s all about patient care.”