Age Friendly - Creating Care Champions for Seniors

January-February 2019


This is a story that starts with a daughter — we'll call her Nancy — who has been watching her elderly mother gradually grow unsteady on her feet, occasionally fall, forget things sometimes and sleep poorly. The mother, whom we will call Bernice, has a primary care physician, but she also sees several doctors for specific chronic health conditions. They have given her various prescriptions to take according to a schedule, and Nancy tries to help her mother manage her medications.

Bernice keeps her 12 different bottles of prescription pills in a shoebox. Every time Nancy looks at all those pill bottles, she prays that her mother's primary care physician knows what Bernice is taking and why — and whether there are any side effects, drug interactions or contraindications to worry about. Nancy wonders, does the primary care doctor really know what Bernice needs?

Bernice and Nancy are fictional characters, but this kind of aging parent/worried child health care scenario not only is fact, it occurs more and more frequently across the United States as the number of older adults grows. U.S. Census Bureau data suggest that by 2030, 1 in 5 Americans will be age 65 and older, while the population over age 65 is expected to grow from 49 million in 2016 to 95 million in 2060, a 92.3 percent increase. In that same time period, the number of Americans age 85 and older is expected to grow from 6.4 million in 2016 to 19 million in 2060, a 197.8 percent increase. Also according to the Census Bureau, "By 2035, older adults are expected to outnumber children for the first time in history."1

"As the U.S. population ages and life expectancy increases, the growing number of older adults, particularly those with multiple chronic conditions, poses challenges to the current health care system," observes the Institute for Healthcare Improvement.2

Filling out the picture are the primary care physicians whose elderly adult patients, like Bernice, have complex chronic conditions treated by multiple providers. The situation is worrisome and unsettling for the patient, caretaker and physician alike.

To identify key issues that confront health care for the aging population and to create solutions, the John A. Hartford Foundation and the Institute for Healthcare Improvement, with support of the American Hospital Association and the Catholic Health Association of the United States, convened thought leaders in 2017. The resulting Age-Friendly Health Systems initiative identified four key areas of focus, named the "4Ms":

  • What Matters: Know and align care with each older adult's specific health outcome goals and care preferences including, but not limited to, end-of-life, across all care settings.
  • Medication: If medications are necessary, use age-friendly medications that do not interfere with "What Matters" to the older adult and "Mobility" or "Mentation" across care settings.
  • Mentation: Prevent, identify, treat and manage dementia, depression and delirium across care settings.
  • Mobility: Ensure that older adults move safely every day to maintain function and do "What Matters" to them.

Five large health care systems piloted the initiative. Each tested different ways to use the focus areas and develop interventions that could be adopted and leveraged across the industry. St. Vincent in Indiana, an Ascension ministry, and Providence St. Joseph Health in Oregon were among the participants in this work to improve care of older adults in the outpatient/ambulatory setting. As Catholic health care organizations, St. Vincent and Providence St. Joseph Health are committed to delivering care in the spirit of their mission and core values, as well as ensuring that their associates are equipped to support the patients and families who trust them with their care.

St. Vincent integrated the 4Ms into the care provided at The Center for Healthy Aging, its geriatric specialty clinic in Indianapolis, to provide a consistent approach to the care of the frail elderly who have unique age-related needs. Additionally, to spread the 4M concept further, the St. Vincent Medicare wellness nurses, throughout Indiana embedded in physician offices, use the 4M framework to help them better identify subtle health symptoms that mask larger concerns.

Medicare wellness visits are annual exams utilized to create a personalized prevention plan. By organizing the wellness visits and ensuring appropriate referrals based upon the results, more than 10,000 patients have benefited from the new approach. In 2019, additional provider offices, assisted living and skilled nursing communities associated with St. Vincent will adopt the 4M principles.

Providence St. Joseph Health, in its Portland, Oregon, location, looked at its organization and responded to the call of providers and the community by creating a geriatric mini-fellowship for physicians and providers who have a continuity practice (continuously managing chronic conditions) in primary care. The fellowship is a curriculum of four one-week blocks during the calendar year, using the 4Ms principles as core subject matter.

Seven providers from across the Oregon service area were invited to participate in the fellowship's first year. The goal is to increase the knowledge, skills and competencies of the participating fellows and, in return, the fellows become geriatric clinic "champions" who take their training back to their home clinic and support colleagues when they have questions about the care of the older adult. The champions can offer informed insights about identifying medications that could be contributing to confusion or falls, or ensuring the patient's wishes are documented in a way that allows everyone to support what matters to the patients.

At the home clinic, the champion communicates with pharmacists, nurses, social workers and other colleagues on new work flows to improve care for older adults. This might include ways that front desk staff can identify patients with dementia in the waiting room to provide immediate support to them, or an improved process for a patient who has fallen to have a focused fall evaluation by a clinic nurse.

Performance improvement projects are part of the curriculum and are designed to address ways of incorporating fellowship learnings into practice patterns. Through the fellowship, Providence St. Joseph Health is creating an environment for more than 2,000 patients to be cared for in clinics that understand older adults' unique needs.

One of the physicians participating in the fellowship commented after the session on mentation, "I am more confident in my knowledge and skills. I am more hopeful that I'll be able to offer something to patients and families with dementia and that I'll be able to do that well. I can set up some level of support or future-focused plan of care with other members of the clinic for dementia patients."

Another fellow commented, "I have joy in my practice again."

In 2019, the second fellowship cohort will go through the curriculum, and the senior health team with Providence in Oregon anticipates spreading the fellowship within the broader Providence St. Joseph system in the future.

Now, think back to the story of Nancy and Bernice. In a health system that incorporated innovative approaches to senior care like those of the Age-Friendly Health Systems initiative, Bernice's outcome and experience might be very different. Medicare wellness nurses would ask Bernice every year about her medications, her goals and wishes for her health care and make note of her mobility and any cognitive issues she might be having. Nancy would feel more at ease, knowing her mother's practitioners were providing the focused, tailored care each older adult needs.

Let's not forget Bernice's primary care physician, who could be armed with the kind of insight that helps him especially enjoy caring for his practice's older adult patients. He can be confident he can bring them the solutions and tools he knows will make a positive difference in their lives.

MELANIE HOLT FAUTH is system executive, post acute, care transitions and senior services, St. Vincent, Indianapolis.

RUTH M. JOHANSON is executive director, Senior Health Program, Providence St. Joseph Health Oregon region. She is located in Portland, Oregon.


  1. Jonathan Vespa, David M. Armstrong and Lauren Medina, "Demographic Turning Points for the United States: Population Projections for 2020 to 2060," Current Population Reports P25-1144 (Washington, D.C.: U.S. Census Bureau, 2018) 4. www.census.gov/content/dam/Census/library/publications/2018/demo/P25_1144.pdf.
  2. Institute for Healthcare Improvement, "Age-Friendly Health Systems," Initiatives, www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx.



Age Friendly-Creating Care Champions for Seniors

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