report by david kidd · • dr kathleen brasher for her ongoing considered and thorough support,...
TRANSCRIPT
Report by
David Kidd B.Pod., MPH, MHM, CHIA
2018 The Sir William Kilpatrick Churchill Fellowship
To improve the quality of care of older people in our health system.
Awarded by The Winston Churchill Memorial Trust I understand that the Churchill Trust may publish this report, either in hard copy or on the internet or both, and consent to such publication. I indemnify the Churchill Trust against any loss, costs or damage it may suffer arising out of any claim or proceedings made against the Trust in respect of or arising out of the publication of any Report submitted to the Trust and which the Trust places on the website for access over the internet. I warrant that my Final report is original and does not infringe the copyright of any person, or contain anything which is, or the incorporation of which into the Final Report is actionable for defamation, a breach of any privacy law or obligation, breach of confidence, contempt of court, passing off or contravention of any other private right or of any law. Signed: Date: 16 August 2019
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Acknowledgments
I would like to acknowledge the following:
• The Winston Churchill Memorial Trust and the late Sir William Kilpatrick for giving
me the support and opportunity to pursue this life shifting exploration.
• My wonderful family, Alison Fitzgerald and Ella Kidd for their support,
understanding and enthusiastic encouragement before during and after my
Fellowship.
• Dr Kathleen Brasher for her ongoing considered and thorough support,
connection, networks, encouragement, clarity and assistance throughout the
conceptual development, application process and throughout my Fellowship
exploration and enabling my Fellowship to come to fruition.
• Margaret Bennett and the Northeast Health Wangaratta Board of Directors for
their support and encouragement of my pursuing the opportunity of my
Fellowship.
• Stacey Manfield and Eleanor Capel at Northeast Health Wangaratta for acting in
my role during my fellowship to allow my complete concentration on the
exploration and experience.
• Dr Catherine Crock, medical pioneer, producer of music and theatrics,
humanitarian, mother and advocate for change for her endless giving and
assistance in helping me frame my Churchill Fellowship experience.
• Alana Officer, Senior Health Advisor - Ageing and Life Course at the World Health
Organisation for her support and connections to enable my Fellowship to come to
fruition.
• Terry Fulmer, President and CEO of the John A Hartford Foundation for her
support and connections that opened the door for my Fellowship to occur across
the USA unhindered.
• Leslie Pelton, Senior Director – Age Friendly Health Systems at the Institute of
Healthcare Improvement (IHI) for allowing me to enter the world of Age Friendly
Health Systems across the USA and connecting me with the pioneer health
systems, IHI and the Age Friendly Health Systems Team.
• Alice Bonner, Senior Advisor, Aging & Innovation at IHI for providing me with
honour of meeting such wonderful innovators across Boston in Age Friendly
Communities, seniors support, wellbeing, housing, research and employment.
• IHI Emeritus Don Berwick, former CEO; Maureen Bisognano, former CEO; Don
Goldmann, Chief Medical and Scientific Officer and Karen Baldoza, IHI Executive
Director and Kedar Mate, Chief Innovation and Education Officer for their insights
and gifts and lessons in leadership, improvement science and implementation
science.
• Amy Berman, Senior Project Officer and Rani Snyder, Vice President at John A
Hartford Foundation for their insights and provisions of opportunities on my
Fellowship.
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• Lil Banchero – Institute for Healthy Aging, Anne Arundel Medical Centre and her
team for her unreserved passion and unhindered sharing of all things Age Friendly
Health Systems.
• Linda Murphy, Pat and Diane Healey, Jenny Albright, Suzanne Engle and Denise
Staschke - Center for Healthy Aging, Ascension St Vincent health System for their
sharing, Indi 550 experience, local produce experience and geriatrician leadership
insights beyond my expectations.
• Ruth Johanson, Collen Casey and Marian Hodges - St Joseph/Providence Health &
Services for their allowing of me to enter their Geriatric Mini Fellowship as an
observer.
• Carrie Rubenstein and Iyabo Tinubu-Karch – Swedish Health for their openness,
giving and sharing.
• Shant Bairian and Karineh Moradian - Kaiser Permanente - Woodland Hills for
allowing me to enter their program and learn unhindered and exposing me to a
legendary LA Double Double.
• Chad E Boult – St Alphonsus/ Trinity Health System for sharing his legendary
leadership in geriatric care insights and a view into the future of geriatric health
care.
• All the special people that made my Fellowship, exploration and adventure across
the USA such a learning, growing and life changing experience:
o IHI: KellyAnne Johnson,Kimberly Mitchell, Derek Feeley (IHI Chief Executive
Officer), Jesse McCall, Allison Luke, Cory Sevin, Catherine Mather, Soma
Stout, Kelly McCutcheon Adams, the 100 Million Healthier Lives project
team, The Conversation Project team.
o Mary Tinetti, MD – Yale School of Medicine, Section Chief, Geriatrics
o Executive Office of Elder Affairs Acting Secretary Robin Lipson and her
team Amanda Bernardo, Pam MacLeod James Fuccione, Lynn Vidler,
Devon Garon, Carole Malone, Annette Peele and Emmett Schmarsow.
o Mike Festa - State Director, American Association of Retired Persons,
Massachusetts State Office.
o Boston Medical Center Board of Visitors
o Amy Schectman - President & CEO - 2Life – Housing and Health Care
Brighton.
o Larry Tye - Health Coverage Fellowship Session with Alice Bonner, Len
Fishman & Dr. Dorene Rentz.
o HEARTH – Elder Homeless Program.
o Joseph Coughlin - AgeLAb,, Massachusetts Institute of Technology: Age
Lab.
o Tim Driver - retirementjobs.com.
o Emily Shea - Commissioner of the Age Strong Commission.
o Ruth Moy & Team - Chinese Golden Age Center.
o Susan Edgeman-Levitan - Executive Director MGH of the John D. Stoeckle
Center for Primary Care.
o Paul Levy – Advisor and Professor.
o Carolyn Stem – New York Academy of Medicine.
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Introduction
With the proportion of the population
ageing increasing across our
communities, services and infrastructure
are needing to adjust to address the
needs and wants of this growing
demographic. As we live longer, health
services are seeing increasing numbers
of older people with an increasing
number of chronic and complex
conditions.
Being in hospital is generally not a
positive experience for older people with
the potential of leaving hospital more
disabled than when they arrived. As a
health service leader who strives to
establish the best care possible for the
community, I wished to explore a new
way of thinking and framing of care for
older people in and out of our health
system.
I am currently the Executive Director of
Community Health, Partnerships and
Well Ageing at Northeast Health
Wangaratta. I have a diverse background
with an undergraduate degree in
Podiatry, Masters in Public Health and
Masters in Health Service Management,
with experience in community
development from bushfire and drought
recovery to working with men who use
domestic violence.
I am a key driver of the Well Ageing
Vision & Engagement (WAVE) initiative in
Wangaratta, the outcomes of which have
stimulated age friendly research,
community information, education and
support in government, health and
community sectors across northeast
Victoria.
Contact details
David Kidd
Email: [email protected]
Phone: (+61) 0429 803 354
Twitter: @davidkiddtweets
Keywords
Age Friendly Health Systems
Acute Care for the Elderly
Quality Improvement
Improvement science
General Practice
Older people
Age Friendly
Health care
4Ms
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Table of Contents
Acknowledgement Page 2
Key words Page 4
Contact details Page 4
Introduction Page 4
Table of Contents Page 5
Executive Summary Page 7
Highlights Page 7
Major learnings Page 8
Conclusion and Recommendations Page 8
Itinerary Page 9
Aim Page 13
Context Page 13
Boston, Massachusetts Page 16
Institute of Health Care Improvement Page 16
Improvement leadership Page 17
Senior view of Boston Page 20
Massachusetts Councils on Ageing,
Small and Rural Conference 2019 Page 20
Executive Office of Elder Affairs for the
Commonwealth of Massachusetts Page 21
Age Friendly Massachusetts Page 22
AARP Page 23
Age Friendly Boston Page 24
2Life Communities Page 25
Retirement Jobs Page 26
Masachussets Institute of
Technology – AgeLab Page 27
Health Coverage Fellowship Page 30
New York City Page 32
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Age Friendly Health System Page 34
Age Friendly Health System Pioneer sites Page 41
Anne Arundel Health System. Annapolis, Maryland Page 42
Ascension, St. Vincent Health System. Indianapolis, Indiana Page 46
Providence Health and Services, St. Joseph Health
System Portland, Oregon Page 49
Trinity Health, St. Alphonsus Health System. Boise Idaho Page 53
Kaiser Permanente Page 55
Conclusion Page 60
Recommendations Page 62
Dissemination Page 63
Appendices
Appendix 1 Masachussets Institute of Technology
AgeLab Research areas Page 64
Appendix 2 Ascension, St. Vincent Health System.
Indianapolis, Center for Healthy Aging
Geriatric Assessment Clinic overview Page 68
Appendix 3 IHI Age Friendly Health System Action
Community Wave 2 - Boston Gathering Page 71
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Executive Summary
The 2018 Sir William Kilpatrick Churchill
Fellowship to improve the quality of care
of older people in our health system.
This project is a journey of two distinct
parts. One is the exploration of some
distinct issues that relate to older people
in Boston, USA and an exploration the
leadership, partnerships, thinking,
systems and services that can support
older people to thrive. The second is an
exploration of healthcare quality
improvement and the success factors of
implementation and scaling of a health
improvement framework – Age Friendly
Health Systems.
The intended audience for this report are
the policy makers, health service leaders
and health professionals that are in the
business of care for older people. Local
government and broader services and
individuals who are in the business of
making our communities more age ready
and age friendly. Individuals and groups
who see the strength of older people as
resources and assets to develop
individuals and communities to live
longer and better.
Highlights
• Immersion at the Institute of Healthcare Improvement and being exposed to the inner workings of health improvement initiatives like the Conversation project, 100 Million Lives project, The Playbook and of course, the Age Friendly Health Systems framework.
• Meeting and learning from IHI Emeritus and former Institute of Healthcare Improvement CEO, Don Berwick; former Institute of Healthcare Improvement CEO, Maureen Bisognano; Chief Medical and Scientific Officer Don Goldmann, and Institute of Healthcare Improvement Executive Director Karen Baldoza and Institute of Healthcare Improvement Chief Innovation and Education Officer, Kedar Mate.
• Exploring the broader issues and thought leadership relating to ageing and older people in Boston, as a guest of Alice Bonner, who revealed to me the power of informal relationships in leadership.
• Meeting the amazing Lil Banchero who changed the way I think health care for older people should be.
• Meeting the passionate geriatricians Drs Diane and Pat Healy in Indianapolis
• Being a guest of Linda Murphy and her husband to a practice session at the Indianapolis 500.
• Mountain biking in Oregon, bushwalking in Idaho and running in Boston
• Heading to Seattle and meeting Carrie Rubenstein and being experiencing the drive and passion of an individual in a large health system.
• Being able to attend the second wave Action Community in Boston, just prior to my departure home.
• Having a Double Double at In’n’Out on my last day in the USA. A cultural experience
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Major learnings
Leadership is crucial in the implementation of change, transformation and improvement.
Partnerships raise leadership to new heights.
Partnerships come in three forms:
• Strategic partnerships – alignment for mutual and future gain.
• Formal partnerships – agreed combined or integrated action to achieve a desired mutual outcome.
• Informal partnerships – personal relationship based alignment and connection based on mutual values and genuine care for one another. This I witnessed being as the strongest and most influential determinant of outcomes.
Values based leadership provides the greatest vision, engagement and personal
fulfilment.
Engagement of people and staff based on values creates dynamic environments for
growth, care and outcomes.
Conclusion and Recommendations
The aim of my Churchill Fellowship was to explore how to improve the quality of care of
older people in our health system. To do this I ventured to the United States (US) to
explore a framework of care for older people that is evidenced based, causes no harm
and aligns with What Matters to the older adult and their family caregivers. Through my
exploration of this framework, I learned the essentials from imminent leaders, thinkers
and authors of improvement science, implementation science, scaling and sustainability.
Combined with lessons in leadership and partnerships, I now have established networks,
resources and experience to share and support the improvement of care of older people
in our health system.
I have made eight recommendations as an outcome of my Churchill Fellowship:
1. Reframe ageing 2. Self-actualisation of older people 3. Utilise the strength in the community 4. Promote the Age Friendly Health System framework 5. Implement the Age Friendly Health System framework 6. Develop and promote values based leadership 7. Engagement in the advancement of care for older people. 8. Build trust and relationships
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Itinerary
Date Location Organisation Meetings
April 23, 2019 Boston,
Massachusetts
Institute of
Healthcare
Improvement
• Leslie Pelton, Director of
Innovation
• KellyAnne Johnson, Senior
Project
• Kimberly Mitchell, Project
Manager
• Derek Feeley, Chief
Executive Officer
• Middle East and Asia Pacific
Team
• Kedar Mate, Chief
Innovation and Education
Officer
•
April 24, 2019 Sturbridge,
Massachusetts
Small & Rural Conference: Massachusetts Council on
Aging
April 25, 2019 Boston,
Massachusetts
Executive Office of
Elder Affairs,
Commonwealth of
Massachusetts
• Home Care Discussion –
Lynn Vidler & Devon Garon
• Community Programs –
Asst. Sec. Carole Malone,
Annette Peele, and Emmett
Schmarsow
• Leadership and Age-
Friendly Network – Acting
Secretary Robin Lipson,
Amanda Bernardo, Pam
MacLeod, and James
Fuccione
American
Association of
Retired Persons
(AARP),
Massachusetts State
Office
• Mike Festa, State Director
2Life – Housing and
Health Care • Amy Schectman, President
& CEO
Boston Medical
Center Board of
Visitors
Attended the Board of Visitors,
Injury Prevention presentations
April 28, 2019 Boston,
Massachusetts
Health Coverage
Fellowship Session
• Visit to HEARTH – Elder
Homeless Program
• Health Coverage Fellowship
presentations by Alice
Bonner, Len Fishman & Dr.
Dorene Rentz.
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April 29, 2019 Boston,
Massachusetts
Massachusetts
Institute of
Technology: AgeLab
• Joseph Coughlin MD,
Director and team
Retirementjobs • Tim Driver, CEO
City of Boston • Emily Shea, Commissioner
of the Age Strong
Commission
Institute of
Healthcare
Improvement
• Karen Baldoza, Executive
Director
Chinese Golden Age
Center
• Ruth Moy – CEO and Team
April 30, 2019 Boston,
Massachusetts
Institute of
Healthcare
Improvement
• Playbook Team
o Catherine Mather,
Director
• Emergency Department
Avoidance
o Cory Sevin, Senior
Director
• 100 Million Healthier Lives
Aging Hub
o Soma Stout, Vice
President
• IHI Emeritus
o Don Berwick,
former CEO
o Maureen
Bisognano, former
CEO
o Don Goldmann,
former Chief
Medical Officer
May 1, 2019 Boston,
Massachusetts
Institute of
Healthcare
Improvement
• The Conversation Project
o Kate DeBartolo,
Senior Project
Director
o Naomi Fedna,
Project Coordinator
Massachusetts
General Hospital
• Susan Edgeman-Levitan,
Executive Director of John
D. Stoeckle Center for
Primary Care Innovation
May 2, 2019 Boston,
Massachusetts
Institute of
Healthcare
Improvement
• Age Friendly Health
Systems
o KellyAnne Johnson,
Senior Project
Manager
• The Conversation Project
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o Kelly McCutcheon
Adams, Senior
Director
• Paul Levy, Advisor and
Professor
May 6, 2019 New York City,
New York
John A Hartford
Foundation
• Terry Fulmer – President &
CEO
• Rani Snyder – Vice
President
• Jane Carmody – Project
Officer
• Marcus Escobedo, Vice
President, Communications
and Senior Program Officer
Communications
May 7, 2019 New York City,
New York
The New York
Academy of
Medicine
• Carolyn Stem
• Diane Kolack
May 9-10, 2019 Annapolis,
Maryland
Anne Arundel Health
System
• Lil Banchero, Senior
Director
• Pharmacy Department
• Barbara Jacobs , Director of
Nursing
• Andrew McGlone MD,
General Practitioner
• Rae Leonard, Domestic
Violence Coordinator
May 13, 2019 Washington,
District of
Columbia
• Emmarie , Journalist –
Kaiser Health Report
May 15-17, 2019 Indianapolis,
Indiana
Ascension Health
System -
St. Vincent Hospital
• Diane Healy
• Denise
• Dr Shumacher
• Suzanne Engle, Director of
Coordinated Care
• Judy , Navigator/Care
Coordinator
• Dr Mason Goodman
• Dr Wagner ,
Neuropsychologist
•
May 20 -22, 2019 Portland,
Oregon
Providence Portland
Medical Centre
• Marian Hodges
• Collen Casey
• Attended Geri Mini
Fellowship – Mobility
sessions 1-3
May 23-24, 2019 Seattle, Swedish Health • Carrie Rubenstein, Director
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Washington • Iyobo
May 29-30, 2019 Boise,
Idaho
Trinity Health – Saint
Alphonsus Health
System
• Chad Boult
June 3, 2019 Woodland
Hills,
California
Kaiser Permanente –
Woodland Hills
• Shant Bairian
•
June 4-5, 2019 Boston,
Massachusetts
Institute of
Healthcare
Improvement
Attended the Age Friendly
Health System – 2nd Wave
Action Community gathering
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The Sir William Kilpatrick Churchill Fellowship to improve the quality of
care of older people in our health system.
Aim
To improve the quality of care of older people in our health system.
Ageing is an inevitable process. You live,
you age. Every day the challenges, joy
and adventures of life bear witness to us
ageing. The changes that occur to us as
we age are neither linear nor consistent.
Age is therefore only a loose association
to one’s physical or social wellbeing. It is
both a physical occurrence and a social
construct and there is no place where
this intersects more strongly that in our
health services. Whether they be the
primary care settings of general practice
and the allied health services or the
emergency department and acute
hospital care.
Considering the increasing level of
ageing across Australia and the world,
being appropriately ready and
supportive of approaches that enrich
ageing, need to be the norm. Therefore
reframing ageing away from its negative
connotations to that of opportunity and
potential of longevity needs to occur.
The USA is a snapshot of a multitude of
these innovations and expansions in
thinking, infrastructure and social
movements to support population
longevity.
I have a deep interest in the vision of
well ageing, enabling greater levels of
older people’s contribution in our
communities and improvement in the
quality of care of older people in our
health system, I wished to explore the
variety of activities and achievements
across the USA. In particular, I was
1 https://www.who.int/news-room/fact-sheets/detail/ageing-and-health 2 Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-Associated Disability: “She Was
interested in exploring a framework for
care of older people in hospital and
primary care settings, known as Age
Friendly Health Systems, in addition to
how communities and their assets,
namely services and infrastructure,
supported older people to thrive. As
such my Churchill Fellowship exploration
across the USA was one of two parts,
interconnected by older people’s health
and wellbeing.
Context
Across the world, the number of persons
aged 60 years will nearly double by
20501 and this will be reflected also in
Australia over the coming decades.
According to the Australian Institute of
Health and Welfare 20% of those aged
65 and over experienced disability in the
form of a severe or profound core
activity limitation3.
Older Australians see their general
practitioner more than twice as many
times than those under 65 years3.Being
in hospital is generally not a positive
experience for older people. Up to third
of older people leave the hospital more
disabled than when they arrived, even if
they recover from the illness or injury
they were originally hospitalised for2.
Add in dementia and older people are at
higher risk from death in hospital,
nursing home admission, long lengths of
stay, as well as intermediate outcomes
such as delirium, falls, dehydration,
Probably Able to Ambulate, but I’m Not Sure”. JAMA. 2011;306(16):1782–1793. https://doi.org/10.1001/jama.2011.1556
14
reduction in nutritional status, decline in
physical and cognitive function and new
infections in hospital3.
With twenty years of experience in
health care, I have been seeing this shift
first hand. This caused me to investigate
better ways as I considered that this
cannot be new ground. I looked across
Australia and found limited
documentation of frameworks for the
care of older people that have been
implemented and were effective.
In the local government area of
Wangaratta, Victoria, the health service
at which I work, asked the community
what would make Wangaratta the place
to “age well”. What they said was not
related specifically to health or health
care. The community said they wanted
access to information and they wanted
access to education and learning
opportunities about ageing well.
From this grew the Well Ageing Vision
and Engagement (WAVE) initiative4,
which established a volunteer driven
Well Ageing Info Hub and Well Ageing
Info Sessions providing information and
insights into areas like preparing for
retirement, how to read your utility bills
or advance care planning.
The WAVE initiative came to the
attention of the Victorian health
department who brought ageing expert,
Dr Kathleen Brasher, to support age
friendly initiatives across northeast
Victoria. Highlighting my concerns re our
health systems approach to the ageing
population, Dr Brasher introduced be to
Alana Officer, Senior Health Adviser,
Ageing and Life Course at the World
3 Fogg, C, Griffiths, P, Meredith, P, Bridges, J. Hospital outcomes of older people with cognitive impairment: An integrative review. International Journal of Geriatric Psychiatry. 2018; 33: 1177– 1197. https://doi.org/10.1002/gps.4919
Health Organisation (WHO), who
introduced me to Dr Terry Fulmer, CEO
and President of The John A Hartford
Foundation, a private, nonpartisan, US
philanthropy dedicated to improving the
care of older adults.
Dr Terry Fulmer had initiated a
framework to enable health systems to
support the complex needs of older
people and reduce the disproportionate
amount of harm while in the care of the
health system.
Extending on the WHO’s Age Friendly
Communities in 2017, The John A.
Hartford Foundation and the Institute for
Healthcare Improvement (IHI), in
partnership with the American Hospital
Association (AHA) and the Catholic
Health Association of the United States
(CHA), set a bold vision to build a social
movement so that all care with older
adults is age-friendly care, which:
• Follows an essential set of evidence-
based practices;
• Causes no harm; and
4 Well Ageing Vision and Engagement initiative. Northeast Health Wangaratta. https://www.northeasthealth.org.au/wave/
David Kidd at the Well Ageing Info Hub
15
• Aligns with What Matters to the older
adult and their family caregivers5.
Dr Fulmer, I was soon to learn, is an
impressive leader. Passionate, insightful
and extremely giving in her knowledge
and aspiration to improve the care of
older people. So, before I even
embarked on my US exploration, I
became fascinated in the influence of
leadership in health transformation
Following the virtual introductions and
further correspondence with Dr Fulmer,
my journey began to explore the Age
Friendly Health System framework in
action and bring the learnings back to
Australia through my Sir William
Kilpatrick Churchill Fellowship to
improve the quality of care of older
people in our health system.
5 Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults. April 2019. Institute of Health Care Improvement. Accessed at http://www.ihi.org/Engage/Initiatives/Age-
Friendly-Health-Systems/Documents/IHIAgeFriendlyHealthSystems_GuidetoUsing4MsCare.pdf
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The Journey
Boston, Massachusetts
23rd April – 2nd May 2019
Institute of Healthcare Improvement
I arrived in Boston early on the “red eye” from Los Angeles. I was promptly identifying
myself at the desk of the Institute of Healthcare Improvement (IHI), in State Street,
Boston. This would be my base for the next week and half. The building foyer was a
renovated period building with a cavernous glass ceiling that housed the original
architecture.
Knowing IHI as a world leader in healthcare quality improvement and admiring from afar
the work they, being at IHI was very significant to me. Once in the IHI offices, Allison Luke,
Age Friendly Health Systems Project Coordinator, meet me and provided me with my
itinerary and my adventures truly began. Fifteen minutes after my arrival, I entered my
first meeting welcoming me to IHI with Leslie Pelton, Director of Innovation, KellyAnne
Johnson, Senior Project Manager and Kimberly Mitchell, Project Manager. Here I was
introduced to the Age Friendly Health Systems model and the key drivers of the
framework development.
Following this I met IHI’s CEO, Derek Feeley. As previous Chief Executive of the National
Health Service of Scotland, Derek Feeley, joined IHI in 2013 to lead IHI’s growing
international work and further drive leadership in key areas of program growth. My
discussion with Derek Feeley explored leadership and the fundamentals of IHI’s
philosophy of healthcare improvement. Derek Feeley noted that he had been accused at
the NHS of developing the system as a business. He went on to note, that yes he did run it
like a private company, as he felt the Service should be accountable to its shareholders
the Government and community, and responsible for its outcomes and financial viability
as a service provider.
IHI was officially founded in 1991, but commenced in the late 1980s as part of the
National Demonstration Project on Quality Improvement in Health Care, Dr. Don Berwick
and a group of visionary individuals set about redesigning health care into a system
without errors, waste, delay, and unsustainable costs. Since then, IHI has grown from an
initial collection of grant-supported programs to a self-sustaining organisation with
worldwide influence6.
IHI now partners with Safer Care Victoria (SCV) with a staff member located in the SCV
office in Melbourne. The visit to IHI was an exploration into the world of improvement on
a scale like no other. The thinking, culture and output of IHI is clear, defined and
systematised.
While at IHI, I spent some time with five leaders in improvement and implementation
science. I was honoured to meet with former CEO and IHI Emeritus Don Berwick; former
CEO, Maureen Bisognano; Chief Medical and Scientific Officer, Dr Don Goldmann; IHI
Executive Director, Karen Baldoza and Chief Innovation and Education Officer Dr Kedar
6 Institute of Healthcare Improvement history – accessed at http://www.ihi.org/about/pages/history.aspx on 30/06/2019
17
Rogers Diffusion of Innovation model
Mate. Here, I will share the most valuable lessons in the science and art of quality
improvement form these eminent leaders in healthcare quality improvement.
The IHI philosophy of improvement is built on three key areas of improvement science;
• The work of W Edwards Deming (the essential implementation of the Plan, Do,
Study, Act (PDSA) cycle),
• Rogers Diffusion of Innovation and
• Kotter model of change.
The Age Friendly Health
System is an example of the
use of these key elements of
improvement.
The use of the diffusion model was key to implement the framework with a small group of innovators to test the framework, modify it and then scale it up to a larger group of early adopters who would further test and redesign the framework.
Improvement leadership In meeting with Dr Goldman, I asked why quality improvement is feared in the day to day working of the health system. This is something that can be transformed, he noted, by doing rigorous quality improvement research as a part of the routine work by appealing
Don Berwick, David Kidd and Maureen Bisognano at IHI, Boston
18
to people’s curiosity and make the data collection part of what they do anyway. Consequently, as Maureen Bisognano reiterated, curiosity questioning (CQ) needs to be developed as a new leadership skill to support enquiry on the floor, in interviews for new staff and around the board table. Partnerships were highlighted as a core improvement leadership competency. Importantly, this allows the key driver to give up control, as no one person can implement improvement solely on their own. The leader therefore needs to therefore create an environment to enable people to do their best work in their key role. To keep human behaviour in balance.
To do this, trust is crucial. As the key driver, trusting the people to do their best work while listening, understanding and provoking.
Karen Baldova, pointed out that the fundamental principles of improvement science are the systems, concepts, methods and tools. The elements of which include: • Understanding Deming’s lens of profound knowledge • Understanding Systems thinking • Understanding variation • Understanding how we learn • Understanding Theorist knowledge • Understanding Psychology of human behaviour
Frameworks are helpful in quality improvement, however, improvement is very much an art and a science. How these are finessed enables the art and the science to work together embedding it in real work. Quality improvement therefore needs curiosity, partnerships, systems, concepts, methods and tools. Figuring out how to bring the right elements of this together, to achieve what you are looking for, there must be an outcome. Date collection Dr Goldman noted, if you have to hire somebody to help do it or collect data, your systems are likely not designed for improvement. If you have the right system, the data would flow out of the daily work. So, if you spend more than 10% of your time collecting and analysing data, it is a waste of time not spent on actually making things better. At this point the project has become about the data rather than the outcome that is trying to be achieved. Conversely, we need to be aware of implementing tactics becoming the primary exploit and forgetting the measurement. This is not reflective practice and as such will not lead to improvement.
If the project you are thinking of doing means you have to hire somebody to
help do it or collect data – your systems are not designed for improvement. Dr Don Goldman
IHI
19
Karen noted to be careful not to over plan and hence never get started on the testing and implementing. Do not postpone the action until you have the perfect data. Use whatever data you have available. Don’t wait for IT to get the data to you, meanwhile people are dying. Ask the people on the ground what they know or see. It may well be the information that trumps the data. Dr Goldman made it very clear that,”if the quality improvement study is so designed that you can’t learn anything from it, then it is not ethical”. Quality can be for free but it needs to be of value. So, we need to ask does what you are doing bring value? Does it bring care up to the existing standard? This can be done by knowing a patient’s satisfaction in their care is high, but asking them whether there was anything that got them angry, can add value by singling out a process, action or experience that needs attention. In the health system today, Karen Baldova explained, the reporting of errors is a measure of performance, not improvement. We need to ensure that the focus is on understanding variation in the measures to create improvement. The key elements to understanding this are:
• What is the question we are trying to answer?
• What is the data that is going to help us answer this? o Understanding whether this is normal variation, whether it is acceptable or
not acceptable or is this something special. o How do we get it in control? Control being getting it consistent. This is
where and control chart is useful. This is where the process does the talking. Leaders are responsible for the process. They are responsible for making it possible for people to do what is being asking them to do. Leaders therefore need to understand the data and act accordingly. Accepting whether something is good enough and acknowledging when something is not good enough and then to stop is essential. There is no reason to be wasting the time and energy analysing when the outcomes will not be achieved, Karen reinforced. Scaling an improvement Scaling is the hard part of any quality improvement. Karen Baldova highlighted the importance of implementation capability, the knowledge and skills and the alignment from leaders to know what is important to do, as essential.
Age Friendly Health System framework is a good example of implementing a quality improvement at an acute ward level and then scaling up to implementing as an organisation and national scale. They are the same elements of improvement and scale, just bigger and more complex as it grows.
When scaling, the emphasis however shifts from quality improvement to quality control and sustainability. They are all related but different systems. Sustainability is to determine what is the key metric we have to continue to look at over time? It is not the family of measuring being done at the improvement phase. Planning for sustainable quality improvement Collaborative learning and learning systems need to be in place in improvement science. Therefore organisations that create the learning environment to increase what is already
20
happening and bring people together to learn from one another around the concepts, methods and tools, increase the power rate of adoption. Karen reinforced the psychology of people is important. The language used, the way things are done needs to be modified to be appreciative of the individual and cultural understanding mechanisms. Some people love jargon and jargonsistic structures. Others need the straight language and structures. The aim is to make improvement natural for people as we are ultimately working with people. There is no end point for improvement. It is a continuous journey.
Senior view of Boston
On my first day at IHI I met, a humble and powerful leader, who would teach me lessons
in leadership every day I was in Boston and ever since. Dr Alice Bonner is Senior Advisor,
Ageing and innovation at IHI. She is also the Director of Strategic Partnerships at the
Center for Innovative Care in Aging, a collaboration between the Johns Hopkins
Bloomberg School of Public Health and the Institute for Healthcare Improvement.
Through my week and half with Dr Bonner and the people she was able to introduce me
to, my learning about how to enable older people to thrive were significant.
Before IHI, Dr Bonner was Secretary of the Executive Office of Elder Affairs for the
Commonwealth of Massachusetts. Whilst Secretary, Dr Bonner oversaw the significant
shift in Massachusetts fulfilling, the Governor of Massachusetts, Governor Charlie Baker’s
vision to make Massachusetts the most age-friendly state7.
The following is an overview of the enormous information, passion and innovation I was
exposed to
Massachusetts Councils on Ageing, Small and Rural Conference 2019
I was fortunate to attend the Massachusetts Councils on Ageing, Small and Rural
Conference 2019 in Sturbridge, Massachusetts as a guest of Dr Bonners. This conference
7 Baker, Charlie, 2019. "AARP The Journal 2019: Guiding Massachusetts Toward an Age-Friendly Future." AARP International: The Journal, vol.12: 44-45. https://doi.org/10.26419/int.00036.013
“We need to think differently about aging in
Massachusetts. This isn’t just about
acknowledging a shift in demographics; it’s
about being intentional in our planning to
ensure that those who grew up here, raised
families and built communities, can continue
to contribute their energy experience and
talents where they live and make
Massachusetts the most age-friendly state”
Governor Charlie Baker,
2018 State of the Commonwealth Address
21
provide me with insights into how the Councils on Ageing play a strong conduit for
implementation of Massachusetts’s ageing directions and in so doing support their
communities.
The Massachusetts Councils on Aging and Senior Centers (MCOA) are the 350 municipal
agencies that provide local outreach, social and health services, advocacy, information
and referral for older adults, their families and caregivers in the state of Massachusetts.
They serve as a link to and support for elders.
Acting Secretary of the Executive Office of Elder Affairs of the Massachusetts
Government, Robin Lipson opened the conference reinforcing that the state of
Massachusetts thinks of ageing as a priority and what it means to age is Massachusetts.
Robin Lipson highlighted the support of the Massachusetts Governor, Charles D. Baker,
who placed ageing on the state agenda in 2018 by noting; “We need to think differently
about aging in Massachusetts”. This has aligned Massachusetts to ReiMAgine8 it’s vision
of ageing in Massachusetts to “a movement, not a moment”.
The conference covered sessions on LGBTIQ programs at senior sessions, developing
dementia friendly communities and how to analyse data utilising the Massachusetts
Healthy Ageing Report and how to use it to help plan locally.
At the conference I met with James Fuccione, Senior Director, Massachusetts Health
Aging Collaborative, who highlighted (MCOA) as the driver of age friendly communities
across Massachusetts. These communities are addressing health systems, transport,
regional planning and even an age friendly university. Innovative programs have been
established such as Seniors Skip day, where 100 children “skip” school and support
seniors in daily activities, Community Compacts, Village to Village9 and supporting the
development Age Friendly Communities.
Whilst at the conference, I was fortunate to be on the agenda in a break out workshop
where I was able to present the work done in the Rural City of Wangaratta through the
Well Ageing Vision and Engagement initiative and Age Friendly Northeast Victoria.
Executive Office of Elder Affairs for the Commonwealth of Massachusetts
On ANZAC Day, I was a guest at the Executive Office of Elder Affairs for the
Commonwealth of Massachusetts. The Executive Office of Elder Affairs are the driving
force behind Massachusetts’ ReiMAgine Ageing agenda. Throughout the morning we
explored Dementia friendly Massachusetts and age friendly and how the Office is
coordinating technology development to assist care givers with assistive tech and
addressing ageing in Massachusetts.
The Executive Office also provide Home Care service including haircare at home,
transport, housing, community engagement and access to food. These services are
8 Commonwealth of Massachusetts. 2019. ReiMAgine Ageing – Planning together to create an age friendly future for Massachusetts. https://www.aarp.org/content/dam/aarp/livable-communities/livable-documents/documents-2018/action-plans/massachusetts-state-action-plan-2019.pdf 9 Village to Village Network. Accessed at https://www.vtvnetwork.org/content.aspx?page_id=22&club_id=691012&module_id=248578
22
provided under the Older Americans Act of 196510 which states the rights of older
Americans to access the basics to remain independent.
In addition to these services the Executive Office provide access to Aging Services Access
Points (ASAP), where a flat monthly fee enables access to personal care, meal prep,
dementia coaching, day programs (with the inclusion of access to a nurse). As is common
in the US, ASAP's are private non-profit agencies funded by the Government.
Age Friendly Massachusetts
As there are similar developments occurring in the north east Victoria, it was of great
interest to me to explore and learn about the motivations and processes that have
brought about Age Friendly Communities across Boston, Massachusetts and New York.
Massachusetts is proudly the second Age friendly state in the US AARP’s network of age-
friendly states. Governor Baker was keen to make Massachusetts the state to grow up
and grow old.
The Councils on Ageing played a key role in the move toward being Age Friendly with
their access to older people across the State and supporting local interest. Leadership
development continues to be provided with communities to strengthen the community’s
leaders.
10 AARP Public Policy Institute. 2014. The Older Americans Act. https://www.aarp.org/content/dam/aarp/research/public_policy_institute/health/2014/the-older-americans-act-AARP-ppi-health.pdf
Acting Secretary of the Executive Office of Elder Affairs of the Massachusetts Government, Robin Lipson (centre) and her team.
23
In 2019, the State
of Massachusetts
became a member
of the second Age
friendly state in the
US AARP’s network
of age-friendly
states. The vision
continues to now
become Dementia
Friendly.
AARP
After my morning at the Executive Office, it was a
smooth transition into meeting Mike Festa, State
Director of AARP. Mike Festa shared with me the
incredible entity that is AARP, it’s membership and
services it provides.
Mike Festa, also a former Secretary of Elder Affairs and
ex Massachusetts House of Representatives member,
had a real presence and exuded passion for his role
and older people across the State. He shared that a
key area of AARP activity was to support carers. Care
givers account for up to 40 % of AARPs 840,000
members across Massachusetts, who bring some
USD$12bil in savings to the care system. This is
expected to increase as funding is shifted out of
nursing homes into the community to give the care
recipient more choice. As a consequence, AARP is
keeping a close eye on carers the ones with awareness
and the early warning alert for their care recipients.
AARP’s strength is in its
membership size and the
consequent political
impact. Added to this is
AARP’s policy
development,
contribution to research
to support older people
and myriad of products
including insurance, grants
for housing, tackling food
insecurity and health
insecurity.
Source: Baker, Charlie, 2019. "AARP The Journal 2019: Guiding Massachusetts Toward an Age-Friendly Future." AARP International: The Journal, vol.12: 44-45.
AARP
Formerly the American
Association of Retired
Persons, AARP is a US based
interest group whose stated
mission is "to empower
people to choose how they
live as they age". According
to the organization, it had
more than 38 million
members as of 2018. AARP is
a nonprofit, nonpartisan
organization that empowers
people to choose how they
live as they age.
Mike Festa, AARP Massachusetts State Director
24
Partnering with the WHO, AARP leads the implementation of Age Friendly Communities
and Cities across the US.
This visit made me reflect on how we can better utilising an existing organisation to
greater support the care givers in our communities.
Age Friendly Boston
The following week, I met
with Emily Shea,
Commissioner of the Age
Strong Commission of the City
of Boston. In 2018, the
Commission on Affairs of the
Elderly changed its name to
Age Strong Commission. This
change was to reflect the new
thinking that has come through becoming the second US age-friendly city11. The Age
Strong Commission is Boston’s area agency on Ageing and Boston’s Council on Ageing,
making Boston inclusive, accessible and positive for people to age well.
It took five years to become an Age Friendly member. In May of 2017, the city released
the Age-Friendly Boston Action Plan aimed to address how Bostonians are ageing now
and their hopes for the future.
After two years the achievement were significant. I was provided with the soon to be
released Age-Friendly Boston Achievements Year Two report. This document contained
significant reporting of actions across the City. Significant highlights included Memory
Cafés, City of Boston’s second Civic Academy (six-week course emphasising advocacy skill
development), “Connect the Knocks” (door knocked 1,500 households to share resources
on economic security and how to prevent social isolation), an outreach strategy for
sharing tax-relief opportunities with older adults and “What Unites Us” cooking classes
(celebrating the immigrant experience and healthy aging through culture and food).
A significant shift to inclusive ageing
language. Reframing ageing with Age
strong, highlights that words matter in
making a powerful affirmation to
embrace ageing.
Following this meeting it was clear the Mayor Walsh, and that of Governor Baker were to
enable their vision across the State and City had in an integrated and unhindered way.
The Age Friendly Action Plan remains the city’s blueprint to achieve this to make Boston
the place to live and age in.
11 https://www.boston.gov/sites/default/files/document-file-07-2019/age-friendly_year_2_report_0.pdf
“We are committed to making Boston the
best place to live and age well”. Martin J Walsh
Mayor of Boston
January 2019
25
2Life Communities
One thing that I came across in my exploration across the US was the significance of
retirement and the impact it has on the financial situation of many Americans. Not having
a superannuation system many lower income Americans transition into a significant
reduction of income in retirement. With 33% of those currently working in the US likely to
rely solely on Social Security for all of their retirement income, housing affordability
becomes a major issue and significant determinant of one’s health outcomes. With social
security paying around USD$12,000 per year, there is no State in the US where the
average monthly Social Security payment can pay the rent of a one-bedroom apartment.
Since 2000, the number of Massachusetts residents living in neighbourhoods where
poverty rates surpass 40 percent has more than doubled to nearly 165,0012. Add
additional burdens of pre-existing illness or a life-long struggle with mental illness and
homelessness becomes a closer reality than expected. This is the reality for 1,200
homeless adults in the Boston area over the age of 50 and this is expected to increase by
33% between 2010 and 2020 and more than double by 205013. Homelessness accelerates
the ageing process and reduces life expectancy to 55y ears, some thirty years lower than
the general population.
As a social determinant of health14, to explore the plight of older people and housing, I
visited 2Life Communities, one organisation truly making an impact to support those who
would otherwise be homeless. 2Life Communities is an affordable housing organisation in
Brighton, just outside Boston. There I met Amy Schectman, the organisation’s President &
CEO. Meeting Amy Schectman confirmed her profile on the 2Life Communities website
was extremely accurate15. Having worked for over 35 years in the public and nonprofit
sectors to advance affordable housing and social justice, Amy Schectman is a master at
establishing strategic partnerships and is a thought leader in holistic approaches to
housing for older people. Amy Schectman serves on Governor Charlie Baker’s Council to
Address Aging in Massachusetts, serves on several not for profit boards, has been invited
to The White House four times and has hosted U.S. Congressmen, U.S. Senate staff, and
state legislators.
I received an insight into leadership and the power of partnerships through my time with Amy Schectman. Massachusetts has the nation’s second largest shortfall between income and basic living expenses, meaning many older adults can’t afford housing. Some are forced to skimp on essentials like medicine and food, just to pay the rent.
During a tour of the of the Brighton campus, I was greeted by many Chinese and Russian Jewish residents, who emigrated to the US in the 1960’s and 1970’s and have become homeless since stopping work. The passion and joy shown by these residents upon Amy Schectman’s arrival was touching. What has been created with 2Life Communities is an organisation that provides more than 1,500 people with affordable house, safety and
12 Ben Forman Alan Mallach. 2019. Building Communities of Promise and Possibility. State and Local Blueprints for Comprehensive Neighborhood Stabilization. 13 The U.S. Department of Housing and Urban Development (HUD). Homelessness data exchange. https://hudhdx.info/Default.aspx 14 Wilkinson, R. and Marmot, M. (ed). 2003. Social determinants of health: the solid facts. 2nd edition. World Health Organisation. http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf 15 2Life Communities website. https://www.2lifecommunities.org/
26
comfort. Amy Schectman’s team are as passionate about her and their work as the residents.
As an organisation, 2Life Communities has support from City, State, and Federal Government to subsidise 93 percent of their apartments. With the median annual household income for those in 2Life Communities being $10,100, this is significant.
As a master of partnerships, Amy Schectman has established partnerships with major corporations, foundations, generous individuals, primary schools and universities, hospitals and health insurers and local businesses. The contribution may be through volunteering, sharing their expertise or making financial contributions. There was even a low cost convenience store, run by a local business, that only stocks healthy foods at cost price.
I was overwhelmed by Amy Schectman’s personability and leadership and her string conviction to “ageing in community”. As I waited for my ride back to Boston, my thoughts were reinforced by the enthusiasm of the young doorman. He was adored by the residents and he passionately told me about all the great things that 2lIfe Communities does.
Retirement Jobs
As evidenced at 2Life Communities, older people in the US can find it difficult to make
ends meet on social security if they have not saved enough over their lives. To combat
this some older people are required to or desire to remain in the workforce. Tim Driver is
the CEO of an employment agency, Retirement Jobs, provides employment placement for
older people across America16. Tim and I had lunch and chatted about his venture and
what it means for older people to remain employed.
Retirement Jobs targets jobs for older people. Tim Driver started the company because
the number of retirees was increasing and they were retiring with greater skills and
capabilities than ever before. In a reduced labour market, the availability of retirees is
able to full gaps in the workforce, especially as now the concept of retiring is changing.
Older people, Tim explains to me, bring to their role a three times reduction in turn over,
they are more dependable, have increased work ethics and have increased flexibility in
schedules and pay. Age friendly employment is beneficial as it adds purpose and
credibility of workers, addresses ageism in the community, caters to a person’s desire to
or not to retire, addresses employment issues of turnover and enables staff longevity and
increased customer satisfaction
There is a shift in the labour market with younger generations expecting a higher level of
remuneration with less skills, so it had made sense in many circumstances to employ and
older person. It has shifted the thinking as there is now such a strong shift in the
development in age friendly thinking and services like Tim Driver’s provide a platform for
older people to continue and thrive in the workforce.
16 Retirement Jobs. https://www.agefriendly.com/
27
This discussion reinforced my thinking about the potential of this market in Australia.
Many community and regional development programs focus on bringing younger people
to the region to provide skills and create demand, when an existing workforce may well
be already there. Jobs create income which creates economic activity, older people may
be the new economy opportunity.
Massachusetts Institute of Technology - AgeLab
An absolute highlight of my time
in Boston was meeting Dr
Joseph Coughlin and his team. A
researcher, teacher, speaker
and advisor, Dr Coughlin’s work
explores how global
demographics, technology and
changing generational
behaviours are transforming
business and society. He teaches
in MIT’s Department of Urban
Studies & Planning and the
Sloan School’s Advanced
Management Program. He is a
Senior Contributor to Forbes magazine, Dr Coughlin is also the author of the book, “The
Longevity Economy: Unlocking the World’s Fastest Growing, Most Misunderstood
Market”17.
The MIT AgeLab was created in 1999 to invent new ideas and creatively translate
technologies into practical solutions that improve people's health and enable them to “do
things” throughout the lifespan. Equal to the need for ideas and new technologies is the
belief that innovations in how products are designed, services are delivered or policies
are implemented are of critical importance to our quality of life tomorrow18.
Dr Coughlin shared with me some of his thinking on what is and what could be in the
world if we looked at ageing, or as he preferred to call it, longevity, as the opportunity
and for communities to get age ready, rather than age friendly. Dr Coughlin believes age
friendly reflects what should already be in place anyway for all ages.
But, oldness is a social construct at odds with reality. It stifles business thinking, it limits
opportunities and thinking. Older age has us withdrawing, pulling back, living on the
financially limit. “Seismic shift”, “age wave”, “perfect storm”, these re not books of
optimism, but a coming calamity.
Old age and retirement are mere stories. There is no objective law of physics that says 65
years of age is retirement or that you must slow down. We made that up. There is no
objective reality in the images, the stories, the myths or the rituals that structure what we
think that old age is supposed to be.
17 Coughlin, J., F.. 2017 The Longevity Economy: Unlocking the World's Fastest-Growing, Most Misunderstood Market. PublicAffairs. https://longevityeconomy.com/ 18 http://agelab.mit.edu/
28
Dr Coughlin highlights that society loses its creativity when you hit retirement age – there
are no more rituals, no more events, no more birthday cards. It is a strong indication that
we have no idea what to do with older age. Therefore, it is a problem, rather than looking
at it as one third of your adult life and what you can make of it. We are swayed by all the
parents, peers, advisors, employers, books and movies telling us what to do, what to buy,
how to live all your life. Then you get to 65 years of age and it is all walking beaches and
seating at cafes.
Retirement equates to one third of one’s adult life - 8,000 days 0-21 years of age, plus
8,000 days to midlife (where there are structures and institutions – guide posts of life
achievements – study, family, work development), plus 8,000 days from midlife to
retirement. Then retirement is 8,000 days. One third of your adult life, assuming you life
the average lifespan.
An AgeLab study asked people what “life after work” meant to them19. Older people
reported that they had no idea how much time there would be. In Naples Florida, the
highest density of retired CEOs in the US, two thirds of the older population were
unhappy. One person stated that when they were a CEO, the world came to them – they
needed their permission, they wanted their opinion, the information flowed in. Now, a
business magazine is the only briefing material they get, it’s months old in a glossy
19 Lee, C. & Coughlin, J.F. 2018. "Describing Life After Career: Demographic Differences in the Language and Imagery of Retirement," Journal of Financial Planning 31(8): 36–47 https://www.onefpa.org/journal/Pages/AUG18-Describing-Life-After-Career-Demographic-Differences-in-the-Language-and-Imagery-of-Retirement.aspx
Dr Joseph Coughlin and his MIT AgeLab team
29
magazine. Their partners noted that their cycle of life was now play golf, have lunch, then
go back to the club for dinner,…. Every single day.
Younger men reported death came after work and older age. Young women used words
like successful, accomplish, achievement. Older men said golf, beaches and spending time
with their spouse. Older women didn’t mention their spouse. They stated time for me,
given there is time for me.
Over the total words in the modern vocabulary – 29 words explained 60% of responses.
This concise vocabulary articulates the vagueness of what retirement looks like.
The future is female – the real innovators are the care givers, often younger, often
female, addressing ageing at a young age as care givers – adult daughters, spouses,
daughter’s in law. They are neglected. Innovators will no longer be seen as a disruptor in
sneakers writing code. The greatest number of new business developers in the US today
are older females.
Real innovators are hacking
problems. Making sure mum is
taking her medication. Making
dad can stay in his own house,
but engage with life. These are
the people that know ageing far
better than researchers,
clinicians or engineers.
MIT AgeLab is exploring the integrated way to live in old age or with greater longevity. As
opposed to just how to take your medication and drive safe.
How you define the problem determines the obtainable, desirable and affordable
solutions. So, if we describe older age as providing for their pensions, we immediately
frame the thinking. Conversely, asking, how many are innovators, how many can do what
they used to do? How many can volunteer with verve? How do we create a whole new
housing system by stealth that is attractive to young people as matter of convenience but
provides care when older? Young people buy it because it is cool, older people buy it
because it provides care. Across this we reframe how we think of older people.
Dr Coughlin explained if you develop something specifically for older people - Young
people won’t touch it and older people won’t touch it.
The AgeLab started looking at mobility for older people. It found that transportation helps
hold life together. If you don’t get there, it is not happening. Technology is a great
support, but it cannot provide the presence. Dr Coughlin notes that there needs to do
good research in these areas, but what was missing was how the consumer interacts with
them. Integration is key. People only look at transportation as getting to a destination,
solving a task, not a life.
When I ask Dr Coughlin, where to from here, he noted that looking forward society needs
to use this unprecedented shift of people with different education, income and political
demand, to reshape society in such a way that it improves life from zero to one hundred.
Rather than saying we need to improve life for people 65 and over. It can be used as a
trigger event to change what we perceive to be quality of life. Which means rethinking
“Birthdays don’t kill, health conditions do.” Dr Joseph Coughlin,
AgeLab
Massachusetts Institute of Technology
30
housing and education across the life span not just into your twenties. If we do it now, we
can look a society from 0-100, not 25yrs of people off the grid at young age and 25 years
of people off the grid at older age. Meaning there is only 50% of your life where you are
allegedly productive, engaged and supported.
The age of university participants is getting older. The degree currently held is no longer
important to older people. They are thinking about what additional degree or certificate
would be fulfilling. Enabling people to learn how they learn for a lifetime makes education
obtainable. Being mindful of the physical worker who at 50 years old is physically done,
but is searching for opportunities to find fulfilment. It’s not about more people needed in
the workforce for example, what’s needed are more skills.
From here we need to change the narrative to older people being articulate and
courageous. We need to rewrite the social contract for government, institutions, families
and individuals. Realise that there are new expectations and new opportunities.
We need to live longer, better. To do so this there needs to be a shift in perspective,
leadership beyond the election cycle, provide the products people want and good story
telling.
Health Coverage Fellowship
Lastly in Boston I was invited to participate in a different side of health for older people,
the Boston Health Coverage Fellowship. This is a fellowship for journalists, which helps
the media do a better job reporting on critical issues like public health, mental health and
high-tech medicine. Launched in 2001 and supported by a series of foundations, the
fellowship trains a dozen medical journalists a year from newspapers, radio stations, and
TV outlets nationwide.
Larry Tye is a New York Times bestselling author whose most recent book is a biography
of Robert F. Kennedy, the former attorney general, U.S. senator and presidential
candidate along with numerous other books on the public relations pioneer Edward L.
Bernays, the Jewish renewal underway from Boston to Buenos Aires, the birth to today’s
African-American middle class and the nearly-real life story of Superman, the most
enduring American hero of the last century.
Over the day I spent with the Health Coverage Fellowship, three presentations were
made by three very distinguished authorities on the health of older people;
Dr Len Fishman, a nationally recognised leader in the field of aging policy and the director
of the Gerontology Institute at UMass Boston’s John W. McCormack Graduate School of
Policy and Global Studies.
Dr Alice Bonner, Older Persons advisor at IHI and the Director of Strategic Partnerships for
the Center for Innovative Care in Aging, a collaboration between the Johns Hopkins
Bloomberg School of Public Health and the Institute for Healthcare Improvement.
31
Dorene M. Rentz, Associate Professor of Neurology at Harvard Medical School with dual
appointments in the Departments of Neurology at Brigham and Women’s Hospital and
Massachusetts General Hospital, Boston, Massachusetts.
The presentation explored the issues relating to dementia and the cost to society, carers
and families. The audience was made of print, TV and online journalists from across the
US from organisations including CNN, the Boston Globe, Kaiser Health Report and NPR.
The fellowship was a great experience to understand the level of insight journalist have
around health, provided insights in how to engage journalists and the current dilemma of
fact checking in a rapid news environment.
Dr Len Fishman presenting to the Boston Health Coverage
32
The Journey
New York City
6th May – 7th May 2019
Visiting New York is always an absolute adventure. Made up of the five boroughs, New
York City is a city of diversity and like other major centres has an increasingly ageing
population. In 2007, the New York City Council partnered with the New York Academy of
Medicine (NYAM) to create a blueprint for New York City to become a model age-friendly
city. In 2008, the NYAM, in conjunction with the Bloomberg Administration released a
report, “Toward an Age-Friendly New York City,” which outlined the major themes that
emerged from a yearlong assessment and conversation with New York’s older residents20.
I met with Project Assistant, Age-friendly NYC, Center for Health Policy and Programs,
Carolyn Stem and Policy Associate, Advancing Prevention Project, Diane Kolack at the
NYAM. I was pre warned about the NYAM and was expressly advised to have a tour of the
old book library. Established in 1847, The New York Academy of Medicine is dedicated to
ensuring everyone has the opportunity to live a healthy life. Through their research,
policy and program initiatives, the NYAM aims to provide the evidence base to address
the structural and cultural barriers to good health and drive progress toward health
equity.
With New York City being home to 1.3 million older New Yorkers, a number expected to
increase by close by 50 % by 2030, NYAM seemed to be ideally positioned to create the
research, partnerships and lead to make New York City age friendly. Since becoming the
US’s first age friendly city in 2012, Age-Friendly New York City was since awarded the
“Best Existing Age-Friendly Initiative in the World” by the International Federation on
Aging in 2013. In addition, NYAM now provides strategic assistance to more than 50 cities
worldwide seeking to replicate the Age-Friendly NYC model.
20 https://nyam.org/age-friendly-nyc/about/history/
"As we continue to support community development efforts that deliver health and
wellness opportunities for residents, we are honored to be recognized by two of the
world's most prestigious organizations, AARP and the World Health Organization,
for establishing New York as the first age-friendly state in the nation."
Andrew M. Cuomo
Governor New York
December 2017
33
In 2017, the drive continued beyond New York City with Governor Cuomo’s
announcement in his 2017 State of the State address, to make more liveable communities
for people of all ages and enable more New Yorkers to age comfortably in their homes21.
In December 2017, Governor Cuomo
announced that New York has been
designated the first age-friendly state in
the nation.
The drive to achieve such high
aspirations for the largest city in the US,
Age-friendly New York City successfully
implemented solutions to prevent the
social isolation of older adults in the
City. The introduction of policy changes
and programs and infrastructure to
support older people changed the face
of the City. Arts were targeted are a
community building tool through an
Arts and Culture plan and increased
seniors programs and infrastructure
along the Museum mile (5th Avenue
adjacent to Central Park). Added to this,
social connection programs created
better neighbourhoods and successful
solutions to prevent social isolation of older adults.
The clear planning and spread of partners across New York City, along with a top
down/bottom up approach has seen a strong emphasis on the voice of the community
through to the drive and support of Governor Cuomo.
The breadth of the plan was immense with strategies that even saw a 16% reduction in
senior fatalities due to infrastructure changes such as increasing traffic islands and
extending "walk" signal time at pedestrian crossings.
The utilisation of
technology as a tool
to connect and
enhance the older
people’s lives was
encouraged. The
latest initiative is
Image NYC
21 Cuomo, A., 2017. M. New York State: Ever Upward. 2017 State of the State https://www.governor.ny.gov/sites/governor.ny.gov/files/atoms/files/2017StateoftheStateBook.pdf
34
map.org22. This interactive Map of Aging provides interpretive awareness of community
data. The aim was to increase equity and access to services to support ageing in place and
providing access to information about what older people may want and need in their
neighbourhood or in the borough next door. Phase 2 of the Image NYC map is to map
access points for Medicare and Medicaid services.
OATS Older Adults Tech Services harnesses the power of technology to change the way
people age by using older people to teach older people how to use technology age23.
It was interesting to discuss the details
of what NYAM had achieved. But the
deeper knowledge of how it happened
was drawn out when Carolyn Stem
and Diane Kolack explained simply
that it came about by champions at
high levels, the passion of Governor
Cuomo, the visionary that was Mayor
Bloomberg and partners across
communities, the Department of State
and Department of Health.
These champions and leadership were
able to address the challenges of the
diversity of communities, source funding and build and support leadership at community
level. Challenges still remain in addressing homebound older people, employment of
older people and infrastructure and cost of housing into the future.
22 Image NYC map.org http://www.imagenycmap.org/ 23 Older Adults Tech Services https://oats.org/
35
The Journey
Age Friendly Health Systems across the USA Boston Annapolis Indianapolis Boise Portland Woodland Hills Introduction Age Friendly Health Systems framework was an initiative developed initially by Dr Terry Fulmer, President and CEO or the John A Hartford Foundation. I met with Dr Terry Fulmer and her team at in New York and discussed the evolution of the framework and the immerse amount of work across multiple organisations to establish the framework. Dr Fulmer had developed numerous models of care, the most wide spread was the Nurses Improving Care for Healthsystem Elders (NICHE). NICHE is a nursing education and consultation program designed to improve geriatric care in 710 health organisations across the 5 countries24. The models Dr Fulmer has developed had similar principles but with different localities and demographics. Dr Fulmer wished to development a broader framework across broader heath systems and the Age Friendly Health System framework was born. In 2017, Dr Fulmer strategically determined the key organisations to bring on board to assist in the development of the framework. These organisations included the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA). The John A. Hartford Foundation also brought along the Institute of Healthcare Improvement (IHI), a Boston based health improvement organisation known for system change and quality improvement and set the aim of 20% of US hospitals and health systems (1000 hospitals and 1000 general practices) will be Age-Friendly Health Systems by December 31, 2020. The Age Friendly Health System framework was established to build a social movement so that all care of older adults is age-friendly care:
• Guided by an essential set of evidence-based practices;
• Causes no harms; and
• Is consistent with What Matters to the older adult and their family. The development of the framework The IHI set about to establish the framework:
• 150 articles were reviewed of care for older people.
• 17 models of older persons care were determined through extensive research
• Creators of models, health systems and the associations were invited to contribute, critique and evolve the model.
24 Nurses Improving Care for Healthsystem Elders (NICHE). https://nicheprogram.org/
36
• 90 elements were established, which were reduced down to nine principles by industry experts, an esteemed group of Faculty members (see Appendix 1.).
• Redundant concepts were removed and 13 discrete features were determined.
• Faculty deliberation led to the selection of the “vital few”: the 4Ms of What Matter, Medication, Mentation and Mobility.
As there is a very strong medical community that drives and manage health care systems across the US, addressing the medical needs was seen as essential to the models success25.
The Age Friendly Health System Team
25 Personal interview – Rani Snyder, Vice President – John A Hartford Foundation – 7/5/2019
37
Success features of the Age Friendly Health System framework
The IHI leaders driving the implementation of the Age Friendly Health System (AFHS)
framework are Dr Kader Mate and Leslie Pelton. Along with the AFHS team they have
established multiple documents that provide step by step awareness and implementation
guidance of the framework. Dr Kader Mate and Leslie Pelton lead me through the
implementation of the framework that any health service could master.
The framework features four key elements as the primary “content” theory or
intervention set - the 4Ms. The implementation of the framework in the US utilised an
“execution” theory of its implementation which included resource development, the use
of Action Communities and state-based facilitation. IHI’s role was to set out the approach
to executing the framework at scale. IHI remained as a neutral, non-subject matter
expert, as they were not wedded to the full breadth of geriatric interventions. IHI
contributed further by defining the scalable framework, designing of the testing
framework, integrating the improvement science, designing and driving the national
scale-up capitalising on the deep trust and credibility IHI have with health systems. IHI
also developed leaders to inform policy with 4Ms, development of tools to support a
team and health system’s testing and describing and counting of 4Ms.
The added advantage of the framework is that the cost of implementation is fairly
negligible. Almost no systems are adding personnel to carry out the 4Ms and the AFHS
implementation. It is more about redirecting existing personnel to think and act
differently. IHI incurs costs to coordinate and execute the initiative and provides all the
written resource free of charge on their website.
The 4Ms as a framework has been
acceptable and engaging to health systems
from the start. The key resource for this is
“The Guide to Using the 4Ms” 26, which
describes the recipe for reliable
implementation of the 4Ms as a set:
1. Get ready to assess and act on the 4Ms
2. Define what it means to provide care consistent with the 4Ms
3. Design/adapt your workflow to deliver care consistent with the 4Ms, including how you will document the 4Ms
4. Provide care consistent with the 4Ms
26 Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults. April 2019. Institute of Healthcare Improvement. http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Documents/IHIAgeFriendlyHealthSystems_GuidetoUsing4MsCare.pdf
38
5. Study your performance – how reliable is your care? What impact does your care have?
6. Improve and sustain care consistent with the 4Ms
IHI set about developing the 4Ms of the AFHS as a framework, rather than a model, to be
clear there is room for local adaptation, skilling local health systems to run their own local
version of the framework. This is evidenced by the implementation testing at the five
pioneer sites. The variation across the five is tremendous and it came down to two
distinct variables:
1. Leadership – Did the leader have the will and ability to execute on the ideas in the
4Ms framework? Could they engage necessary stakeholders such as front line
staff, IT or the Executive leadership?
2. Whether the Age-Friendly Health System framework was mapped to a strategic
priority – Do the 4Ms advance what already matters to the health system? It died
if it was something new to the organisation and this happened.
Interestingly, the outcomes were also impacted but these two variables.
As could be expected, IHI have supported the
measurement of the impacts and outcomes
as well. The outcomes of the framework are
multiple and measures are provided in
measurement guides provided by IHI.
Measurement of the Framework
The measures outlined in the Measurement Guide help the health service with studying their performance such as how reliable is their care? What impact does your care have?27
Action Communities
To scale the framework, IHI established what they call an Action Community. These are the next waves of framework implementation following the pioneer site. The Age Friendly Health Systems Action Community Measure Guide was hot off the press when I visited IHI. This resources provides the outcome and process measures for improvement and their operational definitions when implementing the AFHS framework.
The Action Community enables the ability of new organisations to the framework to share their outcomes to develop together. It is also encouraged that each Action Community team test and study results from a small number of conversations with older adults or their caregivers as valuable qualitative data for learning.
27 Age Friendly Health Systems Action Community Measure Guide. April 2019. Institute of Healthcare Improvement.
39
I met with the IHI AFHS Senior Project Manager, KellyAnne Johnston to learn more about
the Action Communities.
The Action Communities are aimed at scaling the AFHS to enable the achievement of the
aim of 20% of US hospitals and health systems being Age-Friendly Health Systems by
December 31, 2020. The second wave Action Community of some 160 sites was
underway during my visit. During the last two days of my Fellowship I was invited to
attend a two day in person gathering of this second wave in Boston.
The second wave followed IHI principles of
test and retest with the design and
development of the framework being
amended as a result of the feedback from the
first wave Action Community and now being
implemented by second wave Action
Communities.
The second wave Action Community
implementation saw an improved change
package focusing on the psychology of
change as a result of initial implementation
feedback and a new resource focusing on
how to address what matter - when it can be
asked, how it asked. With this came a focus
on the organisation’s own narrative and
story.
The third wave Action Community, is due to commence in September 2019. Keeping with
the science of improvement and the diffusion of innovation, the following waves will
attempt to bridge the gap to engage the late adopters. As a consequence the spread and
scale is now being taken over by the American Healthcare Association to capitalise on
AHA’s trust and “market” penetration.
Business Case for becoming an Age-Friendly Health System The Business Case for becoming an Age-Friendly Health System report document was released in April 2019 developed by IHI and Victor Tabbush, Adjunct Professor Emeritus, UCLA Anderson School of Management. The business case report sets out the six steps to establishing the business case for becoming an Age-Friendly Health System and its financial returns: 1) Adopt a perspective; 2) Determine additional costs; 3) Estimate financial benefits; 4) Estimate the return on investment (ROI); 5) Compare the ROI to a hurdle rate; 6) Conduct sensitivity analysis.28
28 The Business Case for Becoming an Age-Friendly Health System report – Institute for Healthcare Improvement, April 2019 – accessed at http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Documents/IHI_Business_Case_for_Becoming_Age_Friendly_Health_System.pdf - 30/06/2019.
40
The business case modeller is developed specifically for determining the financially returns of an Age-Friendly Health System based on the US health service remuneration funding models. Communications Plan Finally, whilst in New York at the John A Hartford Foundation, I met with Marcus Escobedo, Vice President and Senior Program Officer Communications. Marcus and I discussed over lunch the details of the communications around the AFHS model. Marcus noted the details of the communications plan which was targeted in the first instance to help the target audience of health care teams to be able to describe the concept and value to the organisation. From this they could address what is important to them and to build on the strengths and change the narrative with their organisation such as shifting from focusing on falls to focusing on mobility. The change that is the AFHS framework, being supported in action by the communications in language and resources. I naively asked the communications expert why a communications plan was needed. Marcus laughed and responded to my nativity with comforting clarity. Because communications establishes credibility, he noted. However, he then added, to do so on such a scale, one needs to have heavy weight partners. That is where IHI, AHA, Catholic Health Association of the United States, one of the biggest health care providers in the US, come in. Marcus went on to explain the technical aspects of the AFHS communications plan of the key communications tool to build and disseminate the model. These included the writing of papers, creating peer review commentary or editorials which are strongly favoured and using other outlets including use of the partners, blogging, general media, conferences, local activity in local media, health specific media and publications such as Kaiser Health News, media partnerships for advertising and associations and advocacy groups. From this my thoughts immediately went to the dissemination of my Churchill Fellowship learning and how I best plan these. From here Marcus explained the campaign design. To do this John A Hartford Foundation used an advertising agency to support the information roll out as they had the capability to design a campaign and provide follow up theming and market research. This enabled rapid turnaround timeframes and a theming of all AFHS material and resources in use today.
41
Age Friendly Health Systems Pioneer Sites
In 2017, to test and establish the Age Friendly Health Systems framework of care, five
innovator US health system pioneers partnered with IHI to test, refine and scale up the
Age Friendly Health Systems Framework.
The five pioneer health systems were:
1. Anne Arundel Medical Center - Annapolis, Maryland.
2. Ascension, St. Vincent Health System - Indiana, Indianapolis.
3. Providence Health and Services, St. Joseph Health System - Portland, Oregon.
4. Trinity Health, St. Alphonsus Health System - Boise, Idaho.
5. Kaiser Permanente - Woodland Hill, California
Five pioneer Age Friendly Health Systems
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Anne Arundel Health System
Annapolis, Maryland
8th – 10th May 2019
Overview
Anne Arundel Medical Centre (AAMC) was the first Age Friendly Health System pioneer
site I visited. It was an exemplar in the implementation of the Age Friendly Heath System
framework and passionate providers of care for older people.
Located in the Maryland’s state capital and naval academy town (think An Officer and a
Gentleman) of Annapolis, AAMC is a major health care provider in eastern Maryland.
The other major centres nearby include Baltimore and Washington DC, both around 45
minutes away. AMMC is a 340 bed hospital and multiple provider primary care health
system. The concentration of my visit was the AAMC Acute Care for the Elderly (ACE)
Unit, a 30 bed medical ward concentrating on the care of people over 65 years of age.
The AAMC ACE unit is led by Lil Banchero, the Senior Nursing Director for the Institute for
Healthy Ageing & Senior Director for the Acute Care for the Elderly Unit and openly
supported by president and chief executive officer, Victoria W. Bayless and Vice
President, Nursing and Chief Nursing Officer, Barbara Jacobs. The introduction of the
AFHS framework came with Executive leadership support, noting that the AFHS
framework “is the right thing to do and it is what we should be doing!”
Lil Banchero has been able to capitalise on this lead, assisted by Deborah Cockerel,
Clinical Director of the ACE Unit and Denette Redley, Clinical Educator, to establish a
passionate care team, build upon the previous work based around the NICHE (Nurses
Improving Care for Healthsystem Elders) program and coordinate the implementation of
the AFHS framework.
43
In 2016, IHI and John A Hartford Foundation sought out AAMC to assist in the
development and testing of the AFHS framework. As a result, AAMC became one of the
five AFHS pioneer sites.
The frameworks implementation was carefully crafted by Lil Banchero, supported by IHI.
Organisation leadership valued the framework which supported it embedding as normal
practice. Lastly, the framework aligned with the organisation’s vision of Living Healthier
Together and mission, to enhance the health of the people we serve.
Patient bedside communication board with “What Matters” at the centre
Lil Banchero and the AAMC ACE Unit team
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Anne Arundel Health System
Annapolis, Maryland
8th – 10th May 2019
Implementation factors
Primary implementation in Acute Care for Elderly (ACE) unit/ward
Priority elements
1. What matters to the patient, what the patient wants to achieve by being in the ACE unit (What Matters)
2. Pharmacy reconciliation (Medication) 3. Hydration (Mentation) 4. Mobility (Mobility)
• Greatest impact - asking the question What Matters
• Staff engagement - all the staff were asked what to do and they have continued to drive the change.
• The staff training around the AFHS framework, focused the specialised care that is geriatric care.
• Every two weeks something different was planned for implementation. It was tested and assessed what worked. Then work on the next things while further developing the first thing following the PDSA cycle for each change.
• Key Mentation goal was delirium. Targeted patient hydration. The unit tried different cups and measured the amount of water consumption. It was found that more water was drunk with a cup with a lid and straw. So, the unit ordered cups with a lid and straws for all patients. The cost is more, but as a result hydration of patients increased by 73%.
• What matters to the patient is the centre of the patient’s bedside communication boards.
• Patient care was everyone’s role, from the nurses to the cleaners.
• AAMC ACE unit is the only unit in the hospital that is screening for delirium. Followed recent work by Donna Fick’s work29 from the Pennsylvania State University College of Nursing on dementia and delirium – positive impact by not missing, mislabeling or mistakenly attributing delirium to the underlying dementia or “sundowning”. As delirium can occur four to five times more often in a person with dementia and can subsequently increase hospital stays, increase cognitive decline and rehospitalisation, addressing it as part of the 4M framework upon admission can improve a patient’s health outcomes.
• Falls reduction by increasing mobility.Use of the Johns Hopkins Activity and Mobility Promotion model30. This identifies how much mobility the patients is to perform each day. The higher the level of mobility, the greater the range of staff who can support the patient. Such as a level eight mobility task can be supported by all staff.
29 Fick, D. M., Hodo, D. M., Lawrence, F., & Inouye, S. K. (2007). Recognizing delirium superimposed on dementia: assessing nurses' knowledge using case vignettes. Journal of gerontological nursing, 33(2), 40–49. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2247368/ 30 The Johns Hopkins AMP Program https://www.hopkinsmedicine.org/physical_medicine_rehabilitation/education_training/amp/index.html
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Despite the demographic being older and more frail than any other unit in the hospital (average age of 82 year old), no falls with injury in over four years and no falls in the four month prior my visit. Across the hospital the rate averages 18 falls a month for a 340 bed hospital. This was achieved by no additional staff and no extra expertise needed.
• Daily exercise sessions are also run where patients participate in a 40-minute group session. These sessions are part therapy and part socialising.
• Electronic medical record (EMR) Incorporating “what matters” into the centre of the electronic medical record, translates what is now on the patient’s bedside whiteboard.
• Beers Criteria was introduced into the electronic medical record31.
• 4Ms in shift reports and to guide patient handovers between shifts.
• Team rounding to drive this mindset change. During team meetings, physicians, nurses and care managers discuss how to prioritise each patient’s preferences and needs. What matters to the patient is discussed as part of planning their care.
Success factors
• The AFHS framework and IHI support – user friendly, well researched, allowed overview of the patient’s needs and addressed all complex issues.
• Use the PDSA cycle for each change
• Executive leadership support, ward level leadership support and staff support of the framework.
• Passionate ward leadership that engaged staff in the vision. Lil Banchero has been able to harness the passion people had and focused on the people passionate about the work. Through this at every meeting and opportunity the vision was reinforced.
• Measure the progress against the 4Ms, a scorecard is displayed which includes falls numbers, the percentage of patients mobilised, the percentage patients reported on and the number of staff incidents. Watch measures were created that measured the patient’s length of stay and patient’s 30 day readmission rates.
Barriers
• Data collection - insufficient data mining and data analysis occurred at the start of the initiative. This meant that there was limited
baseline data to measure the overall improvement of care on the ward.
• No geriatrician on the ward.
• Capturing the hearts and the minds of the doctors and the majority of medical are not geriatric minded.
Unintended Success
• AMMC ACE unit has the highest staff satisfaction across AAMC, the best patient satisfaction results. While I was visiting AAMC, I had the
pleasure of joining the staff at the health system’s International Nurse Day celebration dinner and the staff were clearly cohesive,
passionate and love what they do. The only staff not attending the dinner were working in the unit.
31 American Geriatrics Society Updated Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. 2019. https://geriatricscareonline.org/ProductAbstract/american-geriatrics-society-updated-beers-criteria-for-potentially-inappropriate-medication-use-in-older-adults/CL001
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Ascension St Vincent’s Health System
Indianapolis, Indiana
15th -17 May 2019
Overview
Next stop the largest motor sport event in the USA, the Indianapolis 500. I had the good
fortune to head to Indianapolis a week before this major event to visit St. Vincent’s
Medical Centre and explore their implementation of the AFHS framework. And I attended
a practice session of the Indianapolis 500, which was washed out by rain and the stands
had to be evacuated due to lighting and I witnessed the start of a tornado – an eventful
afternoon.
St. Vincent is a member of Ascension, the largest Catholic, mission-driven, not-for-profit
health care system in the United States. Their vision is to care for the mind, body and
spirit of their community. St Vincent’s health system has over 16,000 staff and 3,000
medical staff across 24 sites in Indiana.
While at St Vincent’s, I spent two days embedded with their geriatric team and the Center
for Healthy Aging, which was made up of geriatric medicine physicians, geriatric
psychologists, nurse practitioners, registered nurses and social workers. The St. Vincent
geriatric team is a very experienced multidisciplinary patient centred team who focus on
the diagnosis and treatment of senior health concerns, especially medical symptoms that
are disguised as an “aging” complaint.
I spend time with geriatricians Dr Diane Healy and Dr Pat Healy, Director of Care
Coordination, Suzanne Engle and the manager of the Center for Healthy Aging, Jennifer
Allbright. Supported by the AFHS project lead, consultant Linda Murphy, this core team
became key leaders in the introduction and implementation of the AFHS 4M framework.
St Vincent’s have been able to implement a small yet effective approach to the AFHS
framework. Implementation in the Center for Healthy Aging is positive and the primary
care Fellowship is developing. General practice uptake of the framework is limited to one
practice and it is very early days. Once again Executive leadership was a strength and their
willingness to address the ageing population’s need despite the cost – at this point in
time. In addition, the clear leadership and guidance provided by the project lead, Linda
Murphy. The passion of the geriatrician leadership was obvious and the relationship that
they held with their staff was positive and rewarding.
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Ascension St Vincent
Indianapolis, Indiana
16th May – 18th May 2019
Implementation factors
• Focus on Primary Care (general practice).
• Integration of the AFHS framework into the electronic medical record. This allowed the Medicare annual wellness assessment to be completed around the 4Ms framework.
• Strong geriatric assessment model of care that addressed issues and communicated with patients around the 4Ms. The individual and their family, or carer, would then attend the clinic for a geriatric assessment which runs over three consultations over three weeks.
• 4Ms Primary Care Fellowship at the Johnson Nichols Primary Care Clinic in Spencer, some 95 kilometres out of Indianapolis. St Vincent’s developed professional development program for primary care practice staff. Attended by a nurse practitioner, two practice nurses and four practice administrative staff. The sessions included:
o Session 1 – What Matters o Session 2 – Medication o Session 3 – Mobility o Session 4 – What Matters o Session 5 – Funding o Session 6 – QI project
• Medication reconciliation, use of the BEERS criteria and teaching general practitioners to calculate creatinine clearance calculations, the rate at which waste, measured by creatinine, is cleared from the blood by the kidneys was presented as a means to understand medication clearance rates in an older people.
• No diagnosis of a person’s cognitive status is made without a full Neuropsychologist assessment. I met with Neuropsychologist, Dr Patrick Wagner, who reinforced to me too many people are misdiagnosed for dementia. No cognitive diagnosis is valid unless a repeatable battery of assessments is performed using neuro cognitive assessment standard and composite scores. Too much depression and anxiety is confused and misdiagnosed as dementia. The new current language of major neuro cognitive disorder is now replacing the use of the term dementia, due to the potential overuse and misdiagnosis.
Success factors
• Supportive Executive leadership
• Structured implementation process implemented by an AFHS champion
• Geriatric assessment costs more than the potential Medicare or insurance repayments. Senior Executive support is willing to address the ageing population’s need over the viability of the model – at this point in time.
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• Use of innovator primary care clinic to roll out and test 4Ms Primary Care Fellowship.
• Passionate geriatric leadership, operational leader and Executive leadership.
• Inclusion of practice staff in Fellowship - Fellowship session on medication discussed de-prescribing inappropriate medications. It was noted by the practice’s administrative staff that they assumed that once you were prescribed a medication, you stayed on it. This was a powerful message for the administrative staff as patients would often share with them their concern when a doctor de-prescribes a medication. As a result of this session, administrative staff were empowered to support the Doctor’s de-prescribing by reassuring patients it was a positive action.
Barriers
• General practitioner (primary care provide) engagement
Unintended Success
• Increased patient engagement, improved staff satisfaction, increased health service remuneration and increased patient and families’ understanding of their care.
Dr Diane Healy and Dr Pat Healy.
Just prior to my departure from Indianapolis, I had the pleasure of sitting down for an
insightful discussion with geriatricians, Dr Diane Healy and Dr Pat Healy at a Starbucks
across the street. Drs Diane and Pat Healy met me on their day off to share their passion
for the Center and their roles. In our discussion they noted that the current success in
health ageing provided by medicine has created extra burden on individuals and the
system due to people having multiple conditions at once. With specialists in the US
accounting for 80% of the medical workforce, there are very few looking at the general
health care of people. The US system is now so underprepared for the change in
population demographics, the introduction of the AFHS framework could now enable
general practitioners to be in the driver’s seat of older persons care. However, they
urged, this requires a change in
mindset and a degree of urgency.
Drs Diane and Pat Healy, now
work part time to maintain the
lifestyle balance and their passion
for their roles as geriatricians.
They love the AFHS framework
because “it is what we as
geriatricians have been doing for
thirty years, but now makes it
digestible and therefore a great
way to structure assessments,
communication and engagement
with patients”.
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Providence Health & Services
Portland Oregon
20th – 24th May 2019 I was now on the west coast of the US, in Portland, Oregon. I was here to visit the Providence St. Joseph Health. Providence St. Joseph is part of Providence Health & Services, a non-profit Catholic health care system operating multiple hospitals across five states. In Oregon, they operate some eight hospitals, 90 general practice clinics and a health insurance plan.
I was honoured to be invited by Providence St. Joseph Health Oregon region executive director of the Senior Health Program, Ruth Johanson, to observe the Providence Health & Services Geriatric Mini Fellowship in action. The Geriatric Mini Fellowship is a four week fellowship provided to selected general practitioners. Providence Health & Services senior leadership allows for the participating fellows to be offline out of their clinics for four one week blocks. The offline time is fully paid and not penalised as part of the Providence productivity model. Once graduated, the fellows get two hours per week administrative time from Providence to work on a project or initiatives related to improving the care for seniors. The aim is to increase the knowledge, self-efficacy, skills and competencies of participating fellows and in return for them to become geriatric “clinic champions”.
The clear vison of the Senior Program to use this fellowship as a unique, effective and comprehensively strategic way of implementing AFHS into general practices across Providence’s catchment, was brilliant to see. The use of implementation science, change management and strategic communication with senior leadership has provided great opportunity. The passion and leadership of the small team of the Senior Program at Providence is admirable. The program has used its strengths in clinical knowledge, research and group facilitation to provide a remarkably professional and structured program that touched the hearts of the fellows, open their thinking and reinforced their ability to make significant difference in people’s lives.
Marian Hodges, MD, MPH and Colleen Casey, PhD, ANP are the Course Co-directors with David Kidd.
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Providence Mini Fellowship in action
Falls in focus – GPs patient’s falls incidence and outcomes
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Providence Health & Services
Portland Oregon
20th – 24th May 2019
Implementation factors
Geriatric Mini Fellowship for Primary Care (general practitioners) from across the Providence Oregon catchment.
o 2018 – Seven general practitioners o 2019 – Six general practitioners and three nurse
practitioners across three geographical medical directorate areas of Oregon.
• Fellowship implementation – waiting list of general practitioners GPs wanting to do the program. 2019 and 2020 fully committed at end of 2018.
• Fellows selected by regional medical directors
• Fellowship noticed when Over the four weeks, this practitioner reengaged with the professions. The fellows reported that the fellowship re-engaged them with why they went into medicine in the first place.
• Four week release of the fellows
• Each week, of the four week fellowship, focuses on one of the 4Ms each week.
• Fellowship covers the foundations of the care of seniors plus overview of how you approach an older adult, what’s normal ageing, normal ageing physiology. Last day of week one is on driving – could be mobility or what matters.
• Mobility work developed around recognised standards.
• During the week the fellows were trained in assessments across mobility, which included fall risk screens, awareness of falls risk areas such as vision, medication, orthostasis (drop in blood pressure when standing up), vestibular (inner ear) issues, gait and footwear.
• Expanding the geriatric expertise within each clinic among all providers. A weekly performance improvement assignment is developed by the participating fellow, to identify ways to incorporate the fellowship learnings into their own practice patterns.
• Sharing stories with the regional directors has been very powerful. The regional directors have requested more fellowships. Group size is desired to remain at eight or less to maintain positive group dynamics.
• Very careful with observers in the room as it changes the group dynamic after establishing group trust.
• Used the fellow’s clinics as a pilot sites for a falls study run by Dr Casey. 120 patients – graduated fellows understood and easily adopted the study concepts.
• The Senior Program team is the only geriatric service within Providence. Senior Program made up of pharmacist,
52
physiotherapists, nurse practitioner and analytics. Partners include social work and nurses.
Success factors
• All fellow’s practice staff attend one day of each week’s sessions.
• Mini fellowship AFHS implementation strategy - The fellows are the mechanism to scale AFHS across the system.
• The fellowship emphasises the use of data to support change. Through the use of the right metrics you can prove the worth of the work.
• Fellows learn about system level change that helps them identify facilitators and barriers to clinic change and choose and implement operational strategies to improve their care of patients using the 4Ms.
• Using Kotter’s model of change - the strategy is to provide a consultative service to build the will and identify early adopters and the skills needed to train up staff.
• It is all about relationships. Developing relationships and identifying the threads of a collaboration are key Senior Program activities.
• The Senior Program team and partners believe in the work and are therefore able to catalyse other teams.
• The fellows believe in the framework and go on to advance the work while improving the care for seniors.
Barriers
• Providence Senior Program is a small program, so has limited access and influence in the acute setting. Only 4.5 effective full time (EFT) staff levels. Can only do so much due to workforce limitations.
• Lack the funds to expand.
• Future is not bright re bringing on new geriatricians and nurse practitioners into the system as they are the least paid medical profession.
Unintended Success
• Creation of the fellowship as a product for dissemination model of the 4Ms – potential opportunity within Providence and across the country.
• Outside of the expected improvements in the quality of care, reduced burn out and an increase in patient donations to the health system foundation were unexpected.
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Trinity Health System – St Alphonsus
Regional Medical Center
Boise, Idaho
29th – 30th May 2019
A one hour flight inland from Portland brought me
to Boise, Idaho. Famous for potatoes, Idaho is a
mix of alpine Rockies and prairie land. Bordered
by iconic states like Wyoming and Montana, Idaho
has some 1.7 million people. The capital of the
state is Boise, with 730,000 people.
I was here to explore the AFHS roll out at St
Alphonsus Regional Medical Center, part of the
Trinity Health System, a not-for-profit Catholic
health system operating 93 hospitals in 22 states.
St Alphonsus is an acute, level II
emergency/trauma centre and primary care system with a focus on cardiac, maternity,
orthopaedic and emergency care.
There I met with Director of
Medical Services – Geriatrics,
Chad Boult, MD, who led me
through the AFHS
implementation at St
Aplhonsus. Dr Boult has
extensive experience in
developing and testing new
models of comprehensive
health care for persons with
chronic conditions, has
published two books and more than 100 articles in biomedical scientific journals.
The framework implementation appears to have been less successful at St Alphonsus.
This was put down to several factors, namely limited support from senior management,
the role of care of older people did not fit the current organisational business model and
lastly, there was no clear data collected during the project and as a result they were
unable to prove positive progress.
An unintended outcome was the development by Dr Boult and IHI of five new questions
to be added to the Clinician & Group Consumer Assessment of Healthcare Providers and
Systems (CGCPS) patient satisfaction surveys. Four new questions align with the 4Ms and
one aligns with general age friendly care. The CGCPS measures patient satisfaction in
outpatient and general practice settings. As a result of this there is potential for a new
study to measure the questions outcomes and effectiveness.
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Trinity Health System St Alphonsus Regional Medical Center Boise, Idaho 29th – 30th May 2019
Implementation factors
• Project officer worked across seven team in four program areas. 1. Inpatient services 2. Outpatient services 3. Post-acute services – three teams 4. Hospice services – two teams
• Team attended IHI training
Success factors
• Motivated teams involved
Barriers
• Limited support from Executive leadership and not reinforce implementation.
• Determining “what matters” takes time and fit within the current business model.
• Multiple medical records system – so no organizational connectivity.
• Implementation not fully structured or integrated. Teams worked independently.
• Nursing staff were positive of the new direction - but initiative overload was very real - ”there are enough initiatives we are tackling”.
• Data collection – no clear data was collected and as such were unable to prove positive progress.
• No champion currently across the organization,
• Framework not seen as part of core business model.
Unintended Success
• Establishment, in partnership with IHI, of patient satisfaction measures for national that target the 4Ms as part of Press Gainey’s Clinician & Group Consumer Assessment of Healthcare Providers and Systems (CGCPS). This is a standard survey to assess patient perceptions of care provided in both primary care and specialty care settings
Five new questions will be included into the CGCPS. Four covering the 4Ms and one for age friendly care. Potential for a new study to measure the questions outcomes and effectiveness.
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Kaiser Permanente
Woodland Hills, California
3rd April 2019
Overview
Kaiser Permanente
Woodland Hills is located
some 46 kilometres
northwest of Los Angeles. It
is a 280 bed health service
that services 160,000 Kaiser
Permanente Health
insurance members. The
Woodland Hills campus is
part of the large not-for-
profit Kaiser Permanente
health plans and health
system. Operating across
eight states and the District
of Columbia.
I was hosted by Shant
Bairian, Managerial
Consultant - Performance
Improvement and Karineh
Moradian, Assistant Medical
Canter Administrator - Performance Improvement.
During my day at Kaiser Permanente, I participated in “The Spread”, the staff training
program around the 4Ms. The implementation at Kaiser Permanente Woodland Hills of
the AFHS framework was to date been successful due to;
• Extensive change management effort,
• Multiple bed side tools to assist the framework implementation with patients,
• Strong Executive leadership support,
• Passionate operational leadership and staff,
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Kaiser Permanente Just Like Home place mat
Kaiser Permanente Exercise place mat
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Kaiser Permanente
Woodland Hills, California
3rd April 2019
Implementation factors
• Initial Roll out – Acute for Elderly (ACE) unit/ward
• The goal to reach 41,000 people across the catchment.
The Spread
• One hour intensive training on the 4M’s for all nursing staff across Kaiser Permanente Woodland Hills. Also 3 Ds training provided to support care of dementia, delirium and depression.
• Focus deeply across the ACE unit to cover all staff on the floor.
• Implementation across remaining wards to occur from July 2019 onwards.
• Implementation with medical staff to occur separately. Physician training will be lighter with a greater focus on the AFHS language and terminology rather than the full model implementation. This is to enhance referral opportunities and to enable receipt of referrals.
Age Friendly Tools The following tools were created by Kaiser Permanente and tested and implemented across the health service.
1. Admission Packet – received by all new patients across Kaiser Permanente
• Just like home information pack – providing information for patients to bring in what you wish – No weapons please.
• Medications – list of medications
2. Place mats – All patients regardless of age. Food tray placemat each patient.
• Crossword and mind games – Mentation
• My Daily Exercises – Mobility plan for individual patients i. Precautions advised ie lower limb orthopaedics
patient restricted exercises. ii. Inclusion and exclusions - wounds etc
iii. Patient expectations noted iv. Nursing expectations noted
• Educate
• Motivate and promote
• Assess
• Remove barriers to exercise
• Documentation of all of the above.
3. All about me cards - addresses mentation
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a. Extra questions asked and held in medical record. i. What do you fear about your visit?
ii. What matters today?
Unit culture
• Mobility is a priority on the ward.
• Preventing and treating delirium a strength.
• Nurses trained in BEERs criteria
• Call don’t fall implemented across the ward
• Inhouse research found delirium prevented by mobility – presented as a 2017 NICHE conference poster.
• Volunteers on the wards – Patient activity room manned by volunteers all day for ad hoc patient drop in and activities.
• Encourage patient’s family to be with their loved ones as much as possible during their stay.
• Patient’s bedside board – family encouraged to add to it.
• What matters on care board
• Patient rounding on what matters
• All about me forms – Completed by patient to provide personal details, interests and background they are willing to share encourages a conversation and connection with patient.
Patient rounds
Geriatrician and Nurse Practitioner split patient’s cases and review patients with lead nurses off the floor.
Process for rounds:
• History o Medical o Living – ADL/IADL o Medication o Specialist needs ie. O2 etc o Mobility o Diet o Sleeping o Mentation
• Objective update
• Any concerns for the patient or patient concerns
Success factors
• Highly engaged and motivated teams.
• Senior Management support very strong – “we should be doing this”.
• Videos of a patient story has been a strong way to sell the concept and successes up to senior management.
• “No pass zone” – no one owns a patient. If something needs doing with a patient then it is everyone’s business.
• Teamwork across the ward due to combined commitment to the framework and desire to achieve positive patient outcomes.
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• No pass zone – No one’s patient – every patient is every ones patients
• Teamwork – Open communication, consensus decisions
• Kaiser Permanente ratio 1:4. Health department recommends 1:5
• Doctors always at the table with planning and implementation.
• Fortnightly meetings held with physicians and nurses to develop what Kaiser would introduce.
• Work was marketed through the right forums – therefore was accepted – ie. used Geriatrician to get approval and this enabled medical staff to accept it such as exercises despite it being straight form the PT.
• IHI do not provide direction, but rather allowed the site develop the approach they wanted to make “Trust the process”.
• The feedback provided by regional leadership and medical and nursing informants enabled feedback loop to improve the model whilst in action. “what can we do, what can we remove form our practice”. There was a strong open mindset of all involved.
• “The Spread” and the tools.
Who is on the floor
• Geriatrician
• Pharmacist
• Physiotherapists,
• Nurse practitioner
Barriers
• Need champions and key drivers in the team to keep pushing the framework again and again.
• Patient voice on the team difficult to implement.
• Having enough staff to fully implement.
• ACE unit stands alone with regard to AFHS roll out – not implemented in any other part of the health system to date. Need to justify to management.
• Space to have patients eat together.
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Conclusion
The aim of my Churchill Fellowship was to explore how to improve the quality of care of
older people in our health system. To do I visited a significant international contributor to
healthcare improvement. There I was able to be immersed in the key elements of
improvement science, scaling and sustainability of healthcare improvement. I was then
able to explore this in action across five health systems. The key finding from this were
that leadership support for improvement is critical and that any improvement is linked a
strategic priority or core value. To grow and sustain any improvement, partnerships are
crucial. Strategic partnerships, formal partnerships and the most powerful of all, informal
partnerships.
My exploration enabled me to witness an evidence based framework of improving care
for older people that has been researched, evaluated, tested and scaled. This framework
is available and able to localised and implemented with significant implementation and
improvement science embedded. I was privileged to have been the only person who has
explored this framework and visited all of the five pioneer implementation sites. The
learnings and tools from this, embedded in the report, are the opportunity to reorient
how we care for older people in Australia.
The openness of IHI to share their resources and findings along with the introduction to
multiple leaders in ageing research, communicators, influencers, clinicians and service
providers, has enabled me to exceed my fellowship aims.
I now bring to Australia a network of people and framework insights and research that
can change care for older people in hospitals and in general practice. Along with partners
locally that include Safer Care Victoria who have now a strategic relationship with IHI and
Better Care Victoria’s funded applicability scoping project in northeast Victoria of the
localisation of the Age Friendly Health System Model to Australian conditions, introducing
this movement to Australia will be supported and localised.
The overall value of the Fellowship experience was meeting incredible leaders in health
care, health care research, health care leadership thinking, leaders and authors in quality
improvement science and implementation science.
The overall passion of the people I met and experiencing their challenges and successes in
changing cities, towns, hospitals, general practices and thinking about older people was
inspiring. Age Strong, Longevity, Elders, Age Friendly, SenAgers – the abilities, economy,
employment, sharing, insights, learning, teaching and the social capital and positive
presence of older people in our community brings so many opportunities.
The recommendations are addressed to:
• Health care services
• Aged Care services
• Local Government
• General Practice
• Employment agencies
• Researchers
• Policy makers
In addition to:
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• Members of the community
• Other industries that work with, employ and service older people in our
communities.
To realise my recommendations they must be aligned with the vison and values of who
every wishes to partake or assist in their realisation. There would minimal resourcing of
initiatives to implement significant change in thinking and health care practice.
Resources would benefit the capability development in improvement and
implementation science, the implementation of the Age Friendly Health System
framework across health services.
There is a movement current occurring in Australia, especially in rural areas, where the
value of older people’s contributions and presence is becoming increasingly appreciated.
Now, is an opportune time to explore and realise the potential in every community.
The findings in my report should be controversial.
The framework in the health care setting that I explored not only enables savings in
healthcare costs, it also provides value by improving the outcomes of older people in
health care. Reducing falls, delirium, medication usage or errors reduce healthcare and
personal costs.
.
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Recommendations
1. Reframe ageing The value of older people must be recognised in our communities and society. We need to change the narrative to acknowledge older people as a significant contributor, with significant skills, are articulate and courageous.
2. Self-actualisation of older people Ask and act on what matters to older people. Older people need to be included, consulted and participants in the design, development and implementation of things that affect them. Ask then what matters and what they will tolerate.
3. Utilise the strength in the community Utilise the existing skill, awareness and diversity that is our older population. The provision of employment, opportunities and inclusion as a community resource that is underutilised.
4. Promote the Age Friendly Health System framework Disseminate and promote the Age Friendly Health System framework to better engage and care for older people in our health services and general practices to reduce unnecessary harm and better communicate with health professionals, individuals, families and cares.
5. Implement the Age Friendly Health System framework Disseminate and promote the Age Friendly Health System framework to better engage and care for older people in our health services and general practices to reduce unnecessary harm and better communicate with health professionals, individuals, families and cares.
6. Develop and promote values based leadership Leadership that is values based is driven and evaluated on values rather than specific metrics. In healthcare, values based leadership will drive care that is inclusive, outcome based and will contribute and participate in the wellbeing of the community as a whole.
7. Engagement in the advancement of care for older people. Establish and support participation in interstate and international networks and exchanges that promote knowledge, sharing and lessons learned about the care of older people and their specific needs.
8. Build trust and relationships Create the environments within our health care system where people can develop deep collaborative relationships to address the needs of the community. This must go beyond the normal understanding of external relationship management and will require new methods of engagement to create enduring personal and professional relationships.
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Dissemination
This content of this report will be disseminated through the Victorian Healthcare
Association, the Department of Health and Human Services, Safer Care Victoria, chronic
disease, age relate and health care improvement conferences and communications
channels.
I have already presented my findings to colleagues across Victoria and plan to extend this
through COTA and other organisations that support older people.
I am currently developing an organisational approach to Age Friendly Health System
implementation where I work and am supporting neighbouring health services to do the
same.
My Churchill Fellowship has been the subject of several newspaper and radio interviews
prior to my departure and since my return.
I plane to work with the Victorian Department of Health and Human Services, Seniors,
Ageing and Aged Care Branch to disseminate my findings.
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Appendix 1
AgeLab Research
Mapping the caregiver journey
http://agelab.mit.edu/sites/default/files/caregiving/
A large portion of the population is involved in providing unpaid care for a family member.
However, not much is known about what caregivers are doing on a daily basis, what services
and resources they use, and how they balance caregiving with work and personal life.
Researchers at the MIT AgeLab has conducted an exploratory study to learn more about
caregivers and the caregiving experience. The research process and results are presented in
this website.
People desire to age in place. This is creating carer pressure.
Panel to look more broadly – infuse data to create products that can support caregivers.
What is the day in the life of a caregiver? What caregiving jobs, tasks, and responsibilities
pose the biggest burden? How does caregiving affect an individual's health and wellbeing?
Where do caregivers need help?
Use of interactive dashboards to illustrate specific caregiving tasks.
Caregiving and Tech
http://agelab.mit.edu/home-services-and-logistics
The home is more than simply a place to live; it is a platform to engage with new
technologies and services, and enable a better life tomorrow. Unprecedented changes in
household composition call for innovative approaches to social and service connectivity. At
the AgeLab, we are exploring the future of technology-enabled home services integrated
into everyday living to enhance well-being and safety and what types of services will be
desired by older users, and their families and care providers to facilitate aging in place.
Further research examines the impact of home design and the decision-making processes
regarding whether to move or age in place.
Product offerings available and the role they play and how they are accessed by older
people.
• Voice activated support (ie Alexa) and how they can benefit older people
• Access to tech explored
• Impact on isolation being explored
Retirement viability
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Financial planning is critical to enabling individuals to address traditional long term planning
questions, however, ensuring quality in longevity is equally important. How will you stay
involved in your community or grab coffee with a friend? Do you want to volunteer or work
part-time? Are there opportunities for lifelong learning?
AgeLab works with financial service firms, banks, and insurers to explore how people think
about longevity issues throughout the lifespan and take action to plan for life tomorrow.
Furthermore, we examine the role of engagement, advice and trust across generations to
ensure financial preparedness for a variety of paths.
http://agelab.mit.edu/prompting-savings-behavior-through-social-comparison
Imagine being 70 – Hopes vs Tears
Health is the biggest fear of ageing.
Findings: Connection to self – Those with a stronger sense of their future self had greater
financial planning
The Language of Retirement
https://www.onefpa.org/journal/Pages/AUG18-Describing-Life-After-Career-Demographic-
Differences-in-the-Language-and-Imagery-of-Retirement.aspx
Lee, C. & Coughlin, J.F. (2018). "Describing Life After Career: Demographic Differences in the
Language and Imagery of Retirement," Journal of Financial Planning 31(8): 36–47
How we plan for retirement is dictated by what we think retirement is, which is far from
uniform or universal. To obtain a better understanding of how people visualize the phase of
life called retirement, the AgeLab asked individuals to provide five words for how they
imagined their "life after career" - a phrase lacking the built-in connotations of the word
"retirement."
The results uncovered an impoverished cultural vocabulary around how people think about
their lives after their career. Just 28 words accounted for half of all responses received.
Females tended to be more relationship based. People not really sure of what their
descriptions of retirement, indicating both an ambiguity and limitation in relating their
current selves to possible future states.
Student Loan Debt & Longevity Planning study
The effect of student loan debt on decisions such as moving out of the family residence,
buying a home, getting married, and having children has been well-documented. But there
may be further impacts of large-scale student debt that have gone relatively unexplored.
College costs are extending across the lifespan. Retirement savings are being affected by
student loans.
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The AgeLab is holding focus groups of student loan borrowers, organized by age group and
by level of debt, to better understand how student debt is shaping peoples' life decisions
and relationships across the life course.
In particular, the study will explore the information-gather and decision-making that people
undergo prior to taking out loans, the effect of student loan debt on family relationships,
the way that debt affects how people plan for and save for retirement, and how the burdent
of debt impacts their socioemotional and physical health and financial well-being.
This study will be one of the first studies to explore the intersection of student debt and
retirement planning, and will be the first to explore these concepts through a mixed
methods approach and with borrowers of different ages.
Machine Learning
This study explores the level of trust in decision support?
• Decision making support tools
• Image recognitions
Decision support decreases bias, but will doctor’s feel undermined or supported by decision
support?
Multiple expert assessment is currently underway.
Diagnostic support is also being explored.
MIT influenced entities.
Care Coach
Person works behind an avatar to establish on screen relationships. Piloted at Element Care.
Element Care initiated a four-month pilot in which participants received a care.coach™
avatar to provide 24x7 support, wellness coaching, and intelligent reporting. Element Care
used the devices in participant’s homes to improve continuity of care and social support,
and to encourage better self-management of chronic conditions. The devices, which each
get named by their owners, appear as a virtual dog or cat on a touch-screen device.
Participants interact with the avatar by speaking with it or touching it. This interface allows
even older adults who have complex functional impairments to be engaged effectively and
in a joyful way, regardless of ability, or technical inclination. The goals of the program were
to reduce nursing visits, reduce ED utilization and provide additional social support and
health education .
https://www.care.coach/
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Rendever
Virtual Reality headset. Rendever is overcoming social isolation through the power of
virtual reality and shared experiences. In the past three years, Rendever have installed their
virtual reality platform in more than 100 senior living communities across the US and
Canada. Rendever’s resident engagement platform has been used by hundreds of staff
members and provided more than 400,000+ experiences to thousands of residents.
https://rendever.com/
Gogograndparen
Massachusetts Institute of Technology that connects older people to ride sharing services
like Lyft. Looking to expand the program for meals, groceries and medicine.
GoGoGrandparent aims to be a virtual caregiving platform that delays or even ends the
need to hire a caregiving agency or move into a retirement community.
https://gogograndparent.com/
People walker
People Walker is a digital platform that connects people with safe and reliable walking
partners on-demand. It’s marketed as a quick and easy way to get people moving, improve
wellbeing and get connected .
https://www.peoplewalker.com/
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Appendix 2
Ascension St Vincent
Indianapolis, Indiana
16th May – 18th May 2019
Center for Healthy Aging Geriatric Assessment Clinic overview
The model of care at the Center for Healthy Aging was quite comprehensive. Referrals were
received from an individual, family member or general practitioner has concerns regarding
the individual’s cognitive and/or functional health. The individual and their family, or carer,
would then attend the clinic for a geriatric assessment which runs over three consultations.
Initial Appointment 1. Functional review of patient with family
2. “What matters” survey is completed by the patient to determine what matters
to the patient.
3. Neuropsychological appointment is organised if required, such as when it is
suspected that there cognitive impairment. No dementia diagnosis is ever made
without neuropsychological assessment.
4. Pharmacy reconciliation is organised of the patients medications.
5. A medical review is performed by the geriatrician with the assessment following
the 4Ms framework utilising the Annual Older Persons wellness assessment
payable under Medicare and includes Patient Health Questionnaire (PHQ) self-
administered assessment for common mental disorders32 and development of an
advance care directive33.
Following this consultation, the geriatric team meet and discuss the patient and confirm a
plan moving forward.
Second Appointment (week two) A nurse review of the patient is performed with family members in attendance. This would
include:
1. A mobility review using SLUM and STEADI and therapy prescription of required. 2. Pathology test results are reviewed. 3. A diagnosis discussion with the patient and family. 4. Recommendations are then discussed with the patient and family. 5. Resources and referrals are organised for the patient and family
32 Kroenke, K., Spitzer, R. L., & Williams, J. B. 2001. The PHQ-9: validity of a brief depression severity measure. Journal of general internal medicine, 16(9), 606–613. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495268/ 33 An instructional direction that articulates ones legally binding instructions about future medical treatment, should they lose decision-making capacity. https://www2.health.vic.gov.au/about/publications/FormsAndTemplates/advance-care-directive-for-adults
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A dementia education session is run monthly which is oriented toward family members to
help them understand and meet the needs of their loved ones with dementia. The series is
free and open to anyone who is interested to learn about dementia and how to navigate
through the progression of the disease.
Third Appointment (week three) 1. Geriatrician and patient get together and discuss the diagnosis and the plan
moving forward. 2. A social work review and discussion with family also occurs at this point. 3. Then the patient, their family, the nurse, social worker and geriatrician all come
together to discuss recommendation and future plan. 4. Generally, a 6-8 week follow-up will be scheduled at this time.
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Appendix 3
IHI Age Friendly Health System Action Community Wave 2
Boston Gathering
5th & 6th April 2019
The following are some notes of the highlights of the IHI Age Friendly Health System Action Community Wave 2 Boston Gathering.
People don’t buy what you do; they buy why you do it.
Simon Sinek
Deep Dive: Asking and Acting on What Matters
Mary Tinetti, MD, Gladys Phillips Crofoot Professor of Medicine (Geriatrics); Professor, Institute for Social and Policy Studies; Section Chief Geriatrics, Yale University. Kevin Little, PhD, Improvement Advisor, IHI
This session provided tactical ways to get started asking and acting on what matters, based on lessons learned from different perspectives highlighting the key support provided in the IHI Age Friendly Health Systems What Matters to Older Adults Toolkit . Determining What Matters. For patients
• What matters most….. as there may be so many things to consider – all are relevant.
For Health Systems
• Determine unnecessary and harmful utilisation. How are we reliably to determine What Matters?
• Purpose: General getting to know person and what important
• Purpose: Inform care
Patient centred care = Relationship centred care Acting on What Matters…
• Use patient’s preferences
• Collaborative negotiations may need to be entered into
• Understanding that just attending a clinic can cause anxiety for patients. So to relive this anxiety
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IHI Psychology of Change Framework Julie Trochchio – Health Research & Educational Trust (HRET) American Hospital Association.
This session stepped through the IHI Psychology of Change Framework White Paper as an approach to advancing and sustaining improvement together with the people directly and indirectly affected by that improvement. The session introduced this Framework and practiced an approach to begin engaging others in their age-friendly efforts. Technical fix Vs Adaptive change Bridges’ Managing transitions – transitions and emotions – our work is to move people into exploration to move toward. The main strength of the model is that it focuses on transition, not change. The model highlights three stages of transition that people go through when they experience change. These are:
• Ending, Losing, and Letting Go.
• The Neutral Zone.
• The New Beginning. Need to shift our language;
From: How can I get all these people to do what I want them to do? To: How can I get all these people to what they want to do?
It was emphasised that there is a clear need to understand W Edward Deming’s learnings and tap into people internal motivations. Using Stories to Accelerate Change
Kate Hilton, JD, MTS, Faculty, IHI This session introduced the art of change through the use of stories to emphasis a point, engage or support change; Psychology of change: Science and Art of change
Agency Unleash intrinsic motivation
Power Courage Imagine a patient that you have cared for that you remember that was treated in a way that was not ideal – this is what we are here to change.
Reach into your heart: Consider the faces of those that you care for…. Partnering with patients and families to improve quality of example being Anne Arundel: given back 9.95 years of life to patients through the framework reducing negatives health outcomes.
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Ask three questions 1. If not for myself, who will be for me? 2. If I am for myself alone, what am I? connect with others and their influence and
success 3. If not now, then when? Learning does not proceed action. We learn from doing.
Use Authenticity
It’s not about a gloss outside but the glow inside Use of detail – images of detail “leaning into his ear”, “siting on the mower” Use reflection:
Why are you called to take action in this effort? Why you? What is valuable about story telling? How can stories help with adaptive barriers to change and unleash people’s intrinsic motivation?
The Work of Leadership To be key primary drivers
• Priority driver – Integration into strategic plan and executive Future AFHS leadership support through IHI leader calls
• Strategy
• Spread Rush Video Rush Health released their new video which give a good seven minute overview of the AFHS framework. https://aging.rush.edu/professional-older-adult-family-care/age-friendly-health-system/4ms-framework/