Shifting Culture Toward Age-Friendly Care: Lessons From VHA Early Adopters.

Background: The need for a health care workforce with expanded skills in the care of older adults is increasingly evident as the US population ages. The evidence-based Age-Friendly Health Systems (AFHS) framework establishes a structure to reliably assess and deliver effective care of older adults with multiple chronic conditions: what matters, medication, mentation, and mobility (4Ms). Half of veterans receiving Veterans Health Administration (VHA) care are aged ≥ 65 years, driving its transformation into the largest AFHS in the US. In this article, we offer lessons on the challenges to AFHS delivery and suggest opportunities to sustaining age-friendly care. Observations: Within 3 months of implementation, 85% to 100% of patients received 4M care in all care settings at our VA facilities. Key lessons learned include the importance of identifying, preparing, and supporting a champion to lead this effort; garnering facility and system leadership support at the outset; and integration with the electronic health record (EHR) for reliable and efficient data capture, reporting, and feedback. Although the goal is to establish AFHS in all care settings, we believe that initially including a geriatrics-focused care setting helped early adoption of 4Ms care in the sites described here. Conclusions: Early adopters at 2 VHA health care systems demonstrated successful AFHS implementation spanning different VHA facilities and care settings. Successful growth and sustainability may require leveraging the EHR to reduce documentation burden, increase standardization in care, and automate feedback, tracking, and reporting. A coordinated effort is underway to integrate AFHS into VHA documentation, performance evaluation, and metrics in both the legacy and new Cerner EHRs.

Inpatient Diagnosis of Delirium and Encephalopathy: Coding Trends in 2011-2018.

BACKGROUND: Ten medical societies have called for scientific literature to integrate research on delirium and encephalopathy, while physicians continually debate how to accurately document diagnoses of acute confusional states. OBJECTIVE: To promote this integration, we evaluated trends in diagnoses of delirium and encephalopathy among hospitalized adults and physician specialties, incorporating transitions to the Diagnostic and Statistical Manual of Mental Disorders-5 and the International Classification of Disease, tenth edition. METHODS: Using the 2011-2018 IBM MarketScan datasets, we identified delirium/encephalopathy patients aged ≥18 years using International Classification of Disease 9/10 codes among hospitalized patients. We identified physician specialties associated with the hospitalization and comorbidities within one year before the diagnosis of delirium or encephalopathy. Log-binomial models were used to evaluate diagnostic trends, adjusting for age, gender, insurance, and comorbidities. RESULTS: We identified 10,509 hospitalized patients with a diagnosis of delirium and 94,438 with encephalopathy between 2011 and 2018. Although the number of patients with either diagnosis increased over time, the use of delirium diagnosis was less than it was for encephalopathy compared with 2011 after adjusting for covariates (adjusted risk ratio 0.45; 95% confidence interval 0.43 to 0.48). During the 8 years, neurologists and internists increased their use of both diagnoses, whereas only psychiatrists increased their use of delirium. Family practice physicians and nurse practitioners presented no significant change in either diagnosis for this timeframe. CONCLUSIONS: Our results suggest that refined diagnostic codes and criteria may alter trends among clinicians in diagnosing delirium and/or encephalopathy. Additional diagnostic clarity may be necessary to support refined diagnoses among family practice physicians and nurse practitioners.

Health Professionals Palliative Care Education for Older Adults: Overcoming Ageism, Racism, and Gender Bias.

Purpose of review: Most aging Americans lack access to specialist palliative care aimed at those experiencing serious illness and/or high symptom burden at end of life. The curricula used by training programs for all healthcare professions should focus on helping learners develop the primary palliative care skills and competencies necessary to provide compassionate bias-free care for adults with serious illness. We believe there is much opportunity to improve this landscape via the incorporation of palliative care competencies throughout generalist healthcare professional programs. Recent findings: Several recent publications highlight multiple issues with recruitment and retention of diverse students and faculty into healthcare professional training programs. There are also concerns that the curricula are reinforcing age, race, and gender biases. Due to these biases, healthcare professionals graduate from their training programs with socialized stereotypes unquestioned when caring for older adult minority patients and caregivers. Summary: Important lessons must be incorporated to assure that bias against age, race, and gender are discovered and openly addressed in healthcare professional's education programs. This review highlights these three types of bias and their interrelationships with the aim of revealing hidden truths in the education of healthcare professionals. Ultimately, we offer targeted recommendations of focus for programs to address implicit bias within their curricula.

GRECC Connect: Geriatrics Telehealth to Empower Health Care Providers and Improve Management of Older Veterans in Rural Communities.

A telehealth program supports meaningful partnerships between urban geriatric specialists and rural health care providers to facilitate increased access to specialty care.

Acute Care for Elders (ACE) Team Model of Care: A Clinical Overview.

The Institute of Medicine (IOM) Reports of To Err is Human and Crossing the Quality Chasm have called for more interprofessional and coordinated hospital care. For over 20 years, Acute Care for Elders (ACE) Units and models of care that disseminate ACE principles have demonstrated outcomes in-line with the IOM goals. The objective of this overview is to provide a concise summary of studies that describe outcomes of ACE models of care published in 1995 or later. Twenty-two studies met the inclusion. Of these, 19 studies were from ACE Units and three were evaluations of ACE Services, or teams that cared for patients on more than one hospital unit. Outcomes from these studies included increased adherence to evidence-based geriatric care processes, improved patient functional status at time of hospital discharge, and reductions in length of stay and costs in patients admitted to ACE models compared to usual care. These outcomes represent value-based care. As interprofessional team models are adopted, training in successful team functioning will also be needed.