This is the fifth in a series of seven issue briefs. This is the fifth in a series of seven issue briefs.

The John A. Hartford Foundation Change AGEnts Initiative accelerates sustained practice change that improves the care of older adults. It does this by harnessing the collective power of The John A. Hartford Foundation’s interprofessional community of scholars, clinicians, and health system leaders.

In December 2015, nearly 100 John A. Hartford Foundation Change AGEnts gathered in Philadelphia, PA to identify challenges and opportunities for improving care of older adults in several care settings and issue areas. Each group worked toward identifying actionable areas for John A. Hartford Foundation Change AGEnts, the Foundation, and colleagues in the field to pursue. The brief below represents the summary of the Acute Care group’s proceedings and should inform future work to create widespread and systemic changes in the care of older adults.The remaining issue briefs will be published on Health AGEnda in the coming weeks.


Acute Care

According to the Merck Manual, almost half of adults who occupy hospital beds each year are 65 or older, and this proportion is expected to increase as the broader population ages. Medicare spends more than $100 billion on this acute care, representing 30 percent of health care expenditures for all hospital care in the United States. Hospitals provide critical, often life-saving services, but they can present challenges for older people, who suffer higher rates of infection, delirium, falls, and other complications.

Efforts around the country are seeking to improve the hospital care of older adults, and the Acute Care Issue group at The John A. Hartford Foundation Change AGEnts Conference included representatives from many of these hopeful endeavors related to better surgical outcomes, delirium reduction, reduced length of stay, and improved transitions. The group’s discussions centered on many aspects of practice change in hospitals, pointing to both the challenges and successful strategies toward improving care.

challenge_mountaintop_100pChallenges

Practice change is difficult in all health care settings, but a number of elements or issues seem to be particularly challenging in promoting improvements in acute care for older people.

  • Getting to scale. Several Issue Group members shared success stories where smaller, feasible pilot initiatives often proved successful. However, there were challenges in scaling the program or initiative, either more broadly in the hospital or to other places in the health system or to other systems.
  • Resources matter. Too often, these successful pilot programs or initiatives are under-funded initiatives. With some external support notwithstanding, their success is ultimately dependent on significant doses of volunteer time and personnel. As such, change leaders struggle to sustain these promising practices or lack the ability to replicate or disseminate them more broadly.
  • Creating culture change. Making improvements in the acute care of older people often requires leadership, clinicians, and staff to think very differently about this population. Developing a hospital culture that truly values ideas such as care coordination, person-centeredness, or other key aspects of good geriatric care requires deliberate and sustained attention.
  • EHRs: Possibilities and problems. The successful deployment of an electronic health record (EHR) is central to most practice change in health care today. Participants related stories where the EHR helped drive their success. Just as many shared counter examples where their practice change foundered in large part because of challenges with the EHR.

opportunity_key_shutterstock_163152722_100pOpportunities

Given the group’s experience, there was a good deal of wisdom to share about successful strategies for change.

  • Celebrate wins. This is a generic lesson that is important whether talking about organizational change in the hospital or elsewhere. Multiple stories were shared where celebrating wins, regardless of the size of achievement, helped to recognize the team, note positive effort, and maintain momentum. That said, most everyone agreed that while important, celebrating wins is probably not done enough.
  • Mission before margin. Creating a compelling vision and maintaining the team’s focus on what it is trying to achieve and why are critical elements of successful practice change. Issue Group participants noted that when the focus was on patient care, the team “buy-in” was routinely present and not a problem. When the focus was on other things, such as finances or regulatory needs, buy-in could be problematic. Making better patient care a core value is part of the needed glue in building support for improvements in the care of older adults.
  • Build teams. In the hospital setting, creating an interdisciplinary change team is extremely important. One discipline alone cannot achieve improvements in geriatric care, and efforts that try often end up with siloed practices that are hard to sustain. “Vertical” teams, or integration, is needed as well. Successful change efforts engage front-line workers, clinicians, managers, and hospital leadership. Without the buy-in and incorporation at each of these levels, it is difficult to develop or maintain a program or initiative that will generate improvements over time.
  • Think about the system. As noted above, starting with smaller or unit-based programs or initiatives may be more feasible, and—at least initially—more successful. Understanding any practice change in the context of the entire hospital or system up front, however, is critical. How can your practice change be adapted into other units or specialties in different parts of the hospital and generate much bigger benefits for patients and leadership alike? Alternatively, starting with a system-wide “fix” based on geriatrics principles may be harder to accomplish. But ultimately, that approach may be more likely sustained, rather than a simpler or smaller “work around” or “one-off.”
  • Work the numbers. Meaningful data helps get all stakeholders on the same page, and achieving practice change absolutely necessitates the use of good, accurate, and believable data that can influence the C-suite, clinicians, staff, and patients alike.
  • Talk the (right) talk. Language matters. Calling something a “geriatrics issue” does not always create needed support, but referring to a practice change as a patient or hospital issue can indicate to a whole range of stakeholders that it is something that matters more broadly.

An opportunity for collective action

Aligning clinical practice across hospitals and systems presents a significant opportunity for action. For example, there are at least eight validated ways to measure delirium in the hospital. Currently, there is disagreement regarding which one to use and which data to capture. Thus, the burden of the problem is not really known, and the fix/solution is not even on the table. If, however, acute care stakeholders could come together and identify a best or common practice, much more could be achieved. Developing consensus on one or more of these practices central to the care of older adults could have a powerful impact on improving their hospital care.


Acute Care Issue Group Participants

Clifford Ko, MD, MS, MSHA, FACS (Senior Respondent)
Division of Research and Optimal Patient Care
American College of Surgeons

Linda Krogh Harootyan, MSW (Facilitator)
The Gerontological Society of America

Paul Smith (Notetaker)
Hartford Change AGEnts Initiative
The Gerontological Society of America

Kathryn Agarwal, MD
Baylor College of Medicine

Sheila Barnett, MD
Beth Israel Deaconess Medical Center

Julia Berian, MD
American College of Surgeons

Elizabeth Caine, MSHA, MBA
University of Alabama at Birmingham Hospital

Amy Cotton, RN
Eastern Maine Healthcare Systems

Fayron Epps, PhD, RN
Iberia Rehabilitation Hospital

Kellie Flood, MD
UAB

Bryan Ford, PhD, LGSW
VA Medical Center

Caroline Kim, MD, MS, MPH
Beth Israel Deaconess Medical Center,
Harvard Medical School

May Reed, MD
University of Washington

Karen Reynolds, DNP, CNS-BC, FGNLA
Sarasota Memorial Health Care System

Ronnie Rosenthal, MD
VA Conneticut Healthcare System

Martha E. Rounds-Watson, MS, APRN, GCNS-BC
The Miriam Hospital


Read the previous posts in The John A. Hartford Foundation Change AGEnts Issue Briefs series:

Primary Care

End of Life and Serious Illness

Elder Justice

Dementia Care