Implementing the Age-Friendly Health System in VHA: using evidence-based practice to improve outcomes in older adults

Philadelphia Va Medical Center, Philadelphia PA

Investigators

Linked publications, trials & patents

Abstract

There are currently more than 4 million Veterans aged 65 and older, yet the VA is not yet optimized to provide them with the most consistent, highest quality care. A large body of research shows that inappropriate care and unmet care needs among older adults accelerates cognitive and functional decline and increases medical harms, leading to poorer quality of life, more frequent hospital utilization, and premature nursing home admission. In VISN 4, 62% of the approximately 275,000 enrolled Veterans are aged 65 or older, and hospitalization and long-term institutionalization rates vary substantially across VISN 4 and the VA nationally. The Institute of Healthcare Improvement and John A. Hartford Foundation recognized addressing persistent patient safety gaps in care for older adults will require a systematic approach, and are leading a national campaign to make all health systems ?Age-Friendly.? This movement emphasizes four ?M?s that must be addressed synergistically: 1) what Matters (i.e., attending to each person?s goals and preferences); 2) avoiding harms related to Medication; 3) preventing, identifying, treating, and managing cognitive impairment (Mentation); and 4) promoting safe movement to maintain function and independence (Mobility). Although the VA is not one of the hundreds of health systems making the transformation to being ?Age-Friendly,? this transition is directly aligned with VHA priorities, including VHA modernization (e.g., commit to zero-harm), VHA network and medical center director performance plan goals (e.g., spreading evidence-based practices), and public benchmarks (e.g., reducing hospitalization rates). Shifting to an Age-Friendly Health System will require implementing evidence-based practices (EBPs) that address the four ?M?s,? training Age-Friendly Health System leaders, and building sustainable operational networks. Our QUERI program is built around five core functions to accomplish these goals: 1) an Implementation Core that will rigorously test implementation strategies; 2) a Methods Core that will evaluate quantitative and qualitative outcomes, including a return-on-investment analysis; 3) a Mentoring Core that will help train future leaders at the crucial intersection of geriatrics and implementation science; 4) a Rapid Response Team that will address the operational needs of stakeholders; and 5) a Technical Expert Panel including leaders in Age-Friendly initiatives, Veterans, and VA local and national leadership. We will focus on four EBPs, each addressing one of the four ?M?s?: 1) a preoperative screening and referral tool to ensure the goals of surgery are aligned with the personal goals of frail older adults that reduces operative mortality (What Matters); 2) a direct-to-consumer intervention with demonstrated efficacy in discontinuing high-risk medications among older adults (Medications); 3) an intervention that improves the ability of functionally impaired older Veterans to age in place (Mobility); and 4) an intervention that reduces caregiver burden and improves the function of Veterans with dementia (Mentation). Each EBP has been evaluated in multiple randomized controlled trials, yet none are part of routine clinical care in the VA. We will implement each EBP across all 9 VA medical centers and 45 outpatient clinics in VISN 4, using a type III hybrid effectiveness-implementation stepped-wedge trial design informed by the PRISM implementation framework and using a tailored, facilitated approach to implementation that addresses potential barriers identified in our preliminary work. Reach is our primary implementation outcome, while ?facility-free days? is our primary effectiveness outcome across EBPs. Our Specific Aims are to: 1) Implement four EBPs to address core tenets of the Age-Friendly Health System initiative, rigorously evaluating a facilitated, tailored implementation strategy across centers in VISN 4. 2) Train the next generation of leaders in aging in the principles and practice of implementation science. 3) Build capacity to respond to the needs and priorities of operational partners.