Enhancing Care for Older Patients with Age-Friendly Health Systems

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Tom Haederle
The population of adults age 65 or older will exceed 95 million of the United States by the year 2060. As Americans age, our hospitals and health systems need to adapt their models of care to address the unique needs of older adults. Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. Age Friendly Health Systems is a movement that aims to enhance care for all older adults by implementing the "4Ms" framework, focusing on what matters to the patient...

00;00;51;10 - 00;01;21;22
Tom Haederle
their medications, mentation and mobility. Age Friendly Health Systems is an initiative of the John A. Hartford Foundation and Institute for Health Care Improvement, in partnership with the HRA and the Catholic Health Association of the United States. In this podcast, Sonja Rosen, M.D., chief of geriatrics at Cedars Sinai, shares updates on the health system's age friendly journey and discusses a multidisciplinary approach to providing quality care in the face of a workforce shortage.

00;01;22;08 - 00;01;28;14
Tom Haederle
She's in conversation with Raahat Ansari, senior program manager at the AHA.

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Raahat Ansari
Thank you for joining us again, Dr. Rosen. We're so excited to continue our conversation with you and get updates on your age friendly journey. You've collaborated with us on a few resources to date. And for those listeners who might be joining us for the first time, can you tell us how and why Cedars-Sinai Medical Center decided to begin their age friendly journey and talk a little bit about your role?

00;01;50;26 - 00;02;20;06
Sonja Rosen
Absolutely. And thank you again so much for having me back. It's so exciting to be able to share this work with you and with your listeners. Cedars-Sinai has the very unique distinction of caring for more patients over the age of 80 than any other academic medical center in the country. And that population is going to more than double in less than a decade.

00;02;20;06 - 00;02;48;25
Sonja Rosen
So by 2030, we're going to have more than 70 million people over the age of 65 in this country. And that's really because of the baby boomers all aging in within the next decade. And so nowhere are we going to feel that growth more acutely than the Cedars-Sinai, where our demographic is already that we care for more patients over the age of 80 than anywhere else.

00;02;49;02 - 00;03;08;25
Sonja Rosen
And so we really saw the need to focus on optimal models of care to take care of our older patients and help them successfully age in place. And that is really best personified in the age friendly health system movement.

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Raahat Ansari
That's so great. Thank you so much for sharing. And I want to talk a little bit about what your role was with the geriatric fracture program and how it got started and what you did to initiate it.

00;03;23;09 - 00;04;10;17
Sonja Rosen
So the geriatric fracture program was a great example of an organic program where you had different specialists interested in the same outcome. We all came together to make that happen. It really started in the Department of Orthopedics. The Chair of Orthopedics, Dr. Mark Morris, was a big champion of optimal perioperative care for older persons. He had come from MGH and came to Cedars with that in mind, and he had an amazing nurse practitioner who was the leader of that program, Kathy Brita, who had also helped create that model in her prior institution.

00;04;11;10 - 00;04;59;13
Sonja Rosen
So when they came here, they look to partner with geriatrics and found me. And together we really and and also with the partnership of the leading hospitalist group in our health system, created the geriatric fracture program. And that involved reviewing what other programs fracture services had existed, had been put into practice, and then really creating something that would work in our system, which is a pluralistic health care system where we have three hospitalist services, multiple private physicians, a robust orthopedic trauma department, and a lot of different outpatient physicians.

00;04;59;29 - 00;05;33;00
Sonja Rosen
And so what we ultimately created was a very organized service that really touches the patient the minute they step into the emergency room with focus on decreasing time to surgery, ultimately thereby decreasing length of stay. And were pleasantly surprised, but maybe not completely surprised that this also decreased direct cost to our health system. And that, of course, helped secure future funding for additional members of this program.

00;05;33;00 - 00;05;51;16
Sonja Rosen
And the program has really grown. And then in addition to that, we really focused on how to make sure that when patients leave the hospital, they still have their bone health addressed and strategies for future fall prevention addressed so that these things don't happen again.

00;05;51;29 - 00;06;13;10
Raahat Ansari
That's fantastic to hear and I'm so impressed by those outcomes that you shared. We're going to get back to that in just a little bit. What we'll do will delve a little deeper on that piece. But what I want to start out with was I know that the last time we spoke, we had talked a little bit about COVID and the impact that it had on your organization and how you cared for your patient population.

00;06;14;09 - 00;06;46;10
Raahat Ansari
With our conversation today, I want to start with a different challenge that many health care organizations are experiencing. Workforce. We understand there is a workforce shortage fueled by the great resignation, and there is a significant percent of the aging population moving toward retirement, which could potentially result in gaps of coverage in the workforce. Additionally, on the flip side, a large portion of the population is turning 65 and older, and we know that there is a current shortage in primary care providers and geriatricians.

00;06;47;03 - 00;06;55;02
Raahat Ansari
With all of that in mind. Can you talk about how age friendly care can help alleviate some of that burden that stems from these workforce challenges?

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Sonja Rosen
Yes, those are such great points. One of the great advantages to the Age Friendly Care Model is that you're creating a model of care that really anyone involved in the care of the patient within that model can participate in. So as you said, we have really always had a shortage of geriatricians. So we know that most care for older persons is not going to be directly provided by geriatricians.

00;07;29;06 - 00;07;58;26
Sonja Rosen
As geriatricians, we can serve as subject matter experts, as leaders in creating and implementing these models of care, and certainly also providing direct care. But it's never going to be enough of us to provide all the direct care to older patients. Nor does there really need to be, right? Because they're really every specialty other than pediatrics is providing that care for our older population.

00;07;58;26 - 00;08;29;14
Sonja Rosen
And the majority of care for our older population is going to be provided by non-jury commissions. And so and that's great. That's you know, that's sort of the way of the world. And what we want to do is we want to help all of those providers taking care of our older patient population, provide the best care possible. And the 4M's framework allows for that to happen.

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Sonja Rosen
So creating programs that encompass the 4M's or EMS framework to focusing on what matters most to our older patients. Patients mentation, patients mobility and medication safety. By doing so, really in any program, we're going to help ensure that we're providing optimal care for our older patient population without necessarily having a geriatric provider directly providing that service.

00;09;04;25 - 00;09;31;00
Raahat Ansari
That makes a lot of sense. I love hearing how you're finding success in that interdisciplinary work. Let's talk a little bit about the impact of this work, which I know you were starting to touch on just a moment ago. So last time we spoke about 2 to 3 years ago, a few of the outcomes you shared specific to the geriatric fracture program were an improvement by more than 40%.

00;09;31;04 - 00;09;55;23
Raahat Ansari
in timed surgery, which meant that patients were not waiting for surgery, and that resulted in fewer complications. You saw a decrease in length of stay by more than 10%. You saw that patients had quicker recovery times. You saw a decrease by more than 12% in direct cost of patient care. And ultimately patients were less likely to be readmitted or returned to the hospital with similar injuries.

00;09;56;28 - 00;10;07;21
Raahat Ansari
That was all amazing work, and I can imagine that you have additional outcomes to share. Can you talk a little bit about some of those outcomes and any new impacts over the past few years that you would like to share?

00;10;08;23 - 00;10;45;04
Sonja Rosen
Yes, thank you for that. So that those results for our first year pilot program results. Since then that we have studied this population for a total of three years and recently published that work in this special age friendly issue of health services research in February this year. So we study patients 65 and older with non-spine traumatic fractures who are managed by the orthopedic faculty, surgeons and participating hospitalist groups.

00;10;45;29 - 00;11;18;27
Sonja Rosen
And again, this program is led by a geriatric nurse practitioner or R.N. in the hospital for direct day to day care. We enrolled 746 patients over three years in this program, in the GFP program, and we compare that to patients that were not enrolled in that program or 852 patients over that same time period. And we collected that data from July of 2018 to June of 2021.

00;11;19;16 - 00;11;53;12
Sonja Rosen
And our principal findings remained. Our patients that were enrolled in the geriatric fracture program had lower length of stay with statistical significance. So patients that were enrolled in the program, their average length of stay was four and a half days, and patients that were not enrolled in the program, their average length of stay was 6.3 days. And we also looked at the visit length of stay index and all that was also statistically significant.

00;11;53;23 - 00;12;30;27
Sonja Rosen
The length of stay index for patients enrolled in the geriatric fracture program was .9 and for those not enrolled, 1.2. And again, probably not surprisingly, with a decreased length of stay, we found a significant decrease in direct cost in patients of about $5,000 or a quarter of the care. So very significant findings that sort of reinforced what we had seen in the first year pilot to over a three-year period of time.

00;12;31;19 - 00;12;56;02
Raahat Ansari
Those are amazing stats and something that you and your team should be so proud of. Thank you for sharing. I do understand that this age friendly work has now expanded across Cedars-Sinai Medical Center to other departments. This is a great example of what a successful age from the organization looks like. You started in one department and worked to implement the framework in a way that made sense to that department that had amazing outcomes to show clearly.

00;12;56;22 - 00;13;15;24
Raahat Ansari
Then you spread this work to other departments, tailoring the same framework to fit those other departments processes. Can you share some outcomes or talk a little bit about the work that is being done within these other departments at Cedars-Sinai? And talk a little bit about the next steps of this work at your organization.

00;13;16;08 - 00;13;49;06
Sonja Rosen
Absolutely. So first of all, share a little bit more about our geriatric fracture program. So that has grown in that we have increased its scope and focus. We have added a more formal fraction liaison service with a transitional coach and bone health coach within orthopedics and then placed a lot of focus in the outpatient setting on ensuring that these our patients come to see us in ambulatory geriatrics for bone health and call prevention.

00;13;49;25 - 00;14;13;29
Sonja Rosen
And this program is now expanding to all of the providers in the hospital, including the private physician. So it's been really wonderful to see that take place. It's been very organic in that people who have not been involved with the program want to be involved with the program because the outcomes are so great, everyone sees how well patients do in the program.

00;14;13;29 - 00;15;12;06
Sonja Rosen
So that's been very gratifying. And as I said, really wonderful to see that sort of organically happen over time. And really what we've seen throughout the health system is so many incredible leaders and cures for older patients. Formally doing so and writing the age friendly way. For example, our incredible emergency department under the leadership of Dr. Sam Trapani, has become a geriatric certified emergency room, or GETA certified and actually has a and now has a geriatric education nurse specialist helping to provide that care and now has a designated senior care unit space for appropriate patients adjacent to part of the emergency room.

00;15;12;22 - 00;15;59;04
Sonja Rosen
And that that's just happened over the last couple of years. And that's really been an incredible service to our older patient population in the emergency room. We've also seen the growth of a dementia care program under Dr. Zaldy Tan in the last five years, and that is both in the outpatient setting and the inpatient setting as well. Our amazing volunteers have done incredible work in what's called the TLC program, where specific volunteers and we have such a robust volunteer workforce here that sort of joined forces with the emergency room efforts in seeing patients in the emergency room who are at risk for delirium and helping to intervene and to help prevent delirium in those patients.

00;15;59;20 - 00;16;29;15
Sonja Rosen
Obviously, these are volunteers that have specialized training in how to do so. But that program has been incredibly helpful and well received by our patient population and also the the emergency room staff. So we're looking at expanding that to other parts of the hospital. And then I want to mention our lead program, leveraging exercise to age in place to combat social isolation and loneliness.

00;16;30;01 - 00;16;59;28
Sonja Rosen
I think I might have touched on this before and our in the last podcast, this is a program with Dr. Alice Mayes who's the principal investigator where we demonstrated that evidence based practices in the community helped decrease social isolation and loneliness. So these classes that help prevent falls also with statistical significance as measured by the the UCLA three item loneliness scale, decreased social isolation and loneliness.

00;17;00;16 - 00;17;30;08
Sonja Rosen
During the pandemic, these classes went virtual. We're now able to offer them both virtually. We learned that's a good thing for some people that can't come into classes. But we've also gone back to in-person classes. And that program, which was initially funded by a grant from the AARP Foundation, has now become a sustainable program taken on by our community benefits program because we thought what a great success it was and already have these partnerships in the community.

00;17;30;08 - 00;18;22;02
Sonja Rosen
So that's now an ongoing program that we're able to offer our not only our patients, but our community. So a lot of just wonderful things like that where we have incredible physicians, nurses, leaders in their area formally riding the wave of age friendly and formalizing these incredible programs. I'd like to add one more thing. When we're a program that's really grown in the last few years, and that has been our efforts in addressing social determinants of health in our entire population, but with a specific focus on our older population, because we know that our older population in Los Angeles is at such high risk for housing insecurity and financial insecurity and social isolation and loneliness.

00;18;22;15 - 00;18;53;24
Sonja Rosen
And our community benefits department, under the leadership of social worker Katy Brand, has developed a robust social determinants of health screening tool that's actually embedded in our electronic medical records and hired community health coaches to help our patients who screened positive. And this is done in several different settings. This is done in the emergency room. This is done in the ambulatory clinics, and this is also done in the hospital.

00;18;54;13 - 00;19;25;08
Sonja Rosen
So we've seen a lot of increased awareness and ability to address social determinants of health in our older population with this program. This program links to community partners who can then help our patients in these different areas. So I really encourage implement formal screening programs for social determinants of health and connecting to community partnerships to help meet our community's needs.

00;19;26;04 - 00;19;54;28
Raahat Ansari
That is so amazing to hear. And I love how you touched on two important groups of people that might not always come to the forefront, but when people are looking into support, one being the volunteer group and also leveraging your community partnerships and making sure that you are able to make the best use of those partnerships. So, love how you tied those two really key partners into this work.

00;19;55;09 - 00;20;12;28
Raahat Ansari
One more question for you. As you are expanding this work, can you talk a little bit about some specific successes or challenges that you and your team had to work through? And any tips that you would share for other other organizations that might be experiencing similar things?

00;20;13;13 - 00;20;45;07
Sonja Rosen
Yeah, I think probably the first one that comes to mind is sort of starting out the geriatric fracture program several years ago, but at the time it was a completely new concept for the hospitalist and also many of the orthopedists and also for the other health care teams involved in the care of the patient. From admission to the ED...anesthesia is critical in this. Pharmacy is critical in this, physical therapy, etc..

00;20;45;07 - 00;21;13;08
Sonja Rosen
And so what we had to do was really bring everyone together. And that involved a lot of meetings with our key stakeholders. And everyone that I just mentioned were our key stakeholders and anyone involved in the care of a patient during this transition from coming into the hospital with a traumatic fracture to leaving the hospital and having those regular meetings.

00;21;14;07 - 00;21;55;04
Sonja Rosen
As we created the program, as we implemented the program, as we began to see results, that was really key in everyone being a part of the change. And so rather than prescribing a program and asking others to adapt it, having them actively engaged in the development of the program was absolutely key to the success. And then in terms of challenges, starting smaller with one partner in our hospital program, one hospital's group and demonstrating success was really key to other hospitalist groups wanting to be a part of that success.

00;21;55;14 - 00;22;10;21
Sonja Rosen
Listen, it's great to start smaller demonstrate results. It's easier to implement with a smaller program and then spread the program once you've demonstrated success. So I think that would be the other the other problem.

00;22;11;09 - 00;22;34;28
Raahat Ansari
Thank you so much for sharing that. And I just love hearing those pieces of advice as that's exactly how we share our educational content during our action communities, which you have been a part of. So joining an action community to support the implementation of the 4M's framework at your organization. So I know we're coming up on time.

00;22;34;28 - 00;22;51;10
Raahat Ansari
And the one last question that I want to leave our listeners with is, as a person who has worked in this age friendly space for some time now, what is the one thing you wish you knew earlier in your journey or one piece of advice that you would share with a care team who is contemplating starting this age friendly journey?

00;22;52;04 - 00;23;20;15
Sonja Rosen
Don't hesitate. You're probably already doing the work. This is an opportunity to formalize that work to share the importance of that work with your larger community in your health system. So I would say don't hesitate. Join an action community. Begin the process of becoming age friendly today and be vocal about it. Share that work with your with your health system

00;23;20;15 - 00;23;52;07
Sonja Rosen
colleagues, with your health system leadership so that they too want to ride the wave to become friendly. This is something you want to celebrate. You want to help get internal recognition for because that's going to motivate others to join. And the other part of that is collaboration. Collaboration is key, that that is really, I think, ultimately the only way to successfully implement sustainable programs across the health system.

00;23;52;20 - 00;24;31;12
Sonja Rosen
So working with many different disciplines, different people in different disciplines, different health care professionals in different disciplines, whether it's physicians, administrators, nurses, volunteers, etc., be open minded, and where you see there's passion or you see there's a spark of interest, that's a great place to start. It might not be necessarily who you thought you were going to start a program with, but it's who's doing the work right now and take it and run with it.

00;24;32;16 - 00;24;43;10
Raahat Ansari
I love that. Thank you for all of your insights and for your expertise for being here with us today and for most of all, for your dedication to this important work. Thank you again, Dr. Rosen.

00;24;44;00 - 00;24;45;07
Sonja Rosen
Thank you so much.