Engage at Any Age: Providing Safe Medical Care for the Aging Population

This was originally printed in our Second Quarter 2023 issue of The Scope: Medical Edition.

By 2030, one in six people in the world will be over the age of 60, and the demand for healthcare services in this population is increasing exponentially, as the elderly population experiences more chronic conditions and comorbidities when compared to the rest of the population.¹ According to the National Council on Aging (NCOA), approximately 95% have at least one chronic condition, and 80% have at least two chronic conditions.² How can healthcare providers be prepared amidst the lingering effects of the pandemic coupled with the increased demand for care?

Elderly patients, especially those with chronic health conditions, require extra precautions when receiving their care. One way to be prepared is by improving access to comprehensive and safe primary care. This is an important first step toward quality and safety outcomes in this growing patient population.

Providing a safe environment and remaining sensitive to the needs of this patient population will enhance patient care, improve patient satisfaction and minimize exposure to claims of negligence and professional liability.

Starting with the physical aspects of the office setting, it is important to assess all the following:

• There is adequate and comfortable seating for the elderly.
• Office waiting rooms and examination rooms are clean, welcoming and comfortable.
• There is adequate space in waiting rooms to accommodate those in wheelchairs.
• Sufficient lighting is maintained throughout the office.
• Floors and carpeted areas are in good condition.
• Hallways and waiting rooms are free of obstacles and trip hazards and allow space for those with walkers to ambulate.
• Hallway safety rails and bathroom grab bars are regularly evaluated and inspected.
• The building/office is evaluated for handicap accessibility and to ensure sufficient parking is available.
• Wheelchairs are readily available for patients.

It is then crucial to perform a comprehensive geriatric assessment that includes:

• a thorough and complete client/family interview ;
• a full history and physical examination;
• a detailed fall assessment;
• a health literacy assessment for the patient and/ or caregiver;
• a review of the patient’s medication history and usage and the patient’s understanding of their medications; and
• a comprehensive medication education program, including written materials utilizing a clear, large font.

In addition:

• Consider a review of the patient’s cognition, support systems, and finances, as well as the patient’s willingness to accept help.
• Consider a visit to the patient’s home. As part of that engagement, you should provide resources when English is the second language, use everyday language and avoid technical terms.
• Be sure to document all materials given to the patient and/or caregiver. Written or typed materials should be in a 12-point font or larger.
• Give caregivers their own credentials to sign on to the patient portal in order to allow the practice to track who is accessing the patient’s information. Portal access can increase compliance with the treatment plan.

Care Models to Consider for Effective Patient Engagement

In 2017, the John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI) partnered with the American Hospital Association (AHA) and Catholic Health Association of the United States to develop a social movement so that all older adult care is age friendly. The 4Ms, an age-friendly health system, utilizes a patient-centered approach to make care of older adults more manageable.³ The 4Ms identify issues that can drive decision making in the care of older adults.

The 4Ms framework includes:

• What Matters — Know and align care with each older adult’s specific goals and preferences.

• Medications — If a medication is necessary, use one that is age-friendly and won’t interfere with what matters, mentation and mobility.

• Mentation — Prevent, identify and manage dementia, depression and delirium.

• Mobility — Ensure older adults move safely every day and do what matters.

A 4Ms approach to care can transcend disciplines, specialties and disease states and can have equal importance with providers in all settings.⁴

Additionally, IHI’s Ask Me 3 educational program encourages patients and their caregivers to ask these three specific questions of their providers to better understand their health conditions and what they need to do to stay healthy:

1. What is my main problem?

2. What do I need to do?

3. Why is it important for me to do this?

Designed by health literacy experts, Ask Me 3 is intended to help patients become more active members of their healthcare team and improve communications between patients, families and healthcare professionals.⁵ Consider placing signage about Ask Me 3 in exam rooms, as this will empower patients and family members to begin the conversation with their provider.

Develop Effective Engagement Strategies

When documenting in the electronic health record, remember the importance of face-to-face time. Be cognizant of external noises while speaking to the patient. Providers should speak slowly, clearly and loudly when talking with older patients to enhance hearing and understanding, without sounding condescending. Repeating words and phrases verbatim can particularly help those older adults with dementia.⁶ If current infection control protocols allow, consider removing your mask when communicating instructions to your elderly patients.

Encouraging patients to set goals and actively participate in their plan of care can increase compliance. Effective communication can help build a rapport with older patients to appropriately manage their care and strengthening the provider–patient relationship can lead to improved health outcomes and make the most of limited interaction time.⁷

Educate Your Staff

The office staff should be aware of mobility issues and be trained for safely assisting, contact guarding and transferring elderly patients. Consider older adult sensitivity training as part of annual staff competencies.

Additionally, staff should be aware of any vision, hearing and transportation limitations when scheduling office visits or telehealth consultations.

Educating your staff about the needs of elderly patients will enhance their ability to demonstrate understanding, patience, respect and compassion. Interactions between older adults and healthcare professionals are influenced by the expectations and stereotypes that each party brings to the encounter.⁸

Medication Management in Eldercare

A high liability area in this population revolves around medication. It is important to educate patients/caregivers about each medication, including its name, appearance, purpose and effect. Include any potential side effects and/or interactions associated with the medication regimen. To ensure the patient understands, ask them to repeat what the medication is and what they are taking it for. Be sure to stress the importance of contacting a healthcare provider should any reactions, questions or concerns arise.

Some other points to keep in mind:

1. Query patients regarding any underlying issues with medication selection to resolve any concerns.
2. The importance of using only one pharmacy to obtain all medications should be emphasized to patients and/or their representatives. Collaborative team efforts may be necessary to address the need for the consistency of one pharmacy. Suggest to family members that they request pharmacy history printouts to cross-reference what meds are being refilled and when. Emphasize to patients how compliance with the prescribed medication regimen will help keep them at home and limit admissions to the hospital.
3. Patients should also be advised to:

• keep an accurate list of all medications, dosages, dosing frequency, and the reasons for taking the medication. This list should include generic and brand names, over-the-counter medications, and herbal supplements
• bring a list of all medications that they are taking to each and every appointment
• maintain a complete list of medical providers and their contact information
• post the name and telephone number of their physician and local pharmacy in a prominent location in their home. These should be posted near the patient’s POC (plan of care) and MOLST (Medical Orders for Life-Sustaining Treatment) form so that they are readily available in case of a hospital transfer.

– Establish a daily routine when taking their medications.

– Make patients aware of the various medication adherence aids and devices available, such as dosing reminders, pill boxes and refill reminder programs.

– Provide useful written information, in plain language with a large font, that clearly explains how patients can correctly manage their medications.

 – Consider the “teach back method” when explaining medications. Teach the information first, and then ask patients to repeat it back in their own words.

– Advise caregivers about the importance of giving not only medication reminders but also the timing of certain medications. For example, not wanting to shower a patient when their blood pressure medication is at its peak effect.

Social Determinants of Health

As part of good patient engagement, it is vital to address the social determinants of health. These are factors that play a key role in better health outcomes and overall well-being. Factors to discuss with this patient population include accessibility of housing, food and transportation. Internet bandwidth is another important factor to discuss as part of an assessment of whether telehealth encounters and home monitoring are viable options for your patient.

Research shows that a lack of understanding about cultural practices, along with an unwillingness to acquire such information from the patient, can result in inaccurate patient evaluation and diagnosis. It may also increase the possibility that the recommended treatment plan will not be followed due to the patient’s dissatisfaction with the healthcare provider.

It is estimated that in the next several decades, the elder patient population will triple. Knowing their everyday physical and social environments will help providers better address this population’s health concerns, lead to better outcomes and minimize exposure to claims of negligence and professional liability.

Sources:

1. https://www.who.int/news-room/fact-sheets/detail/ageing-and-health
2. https://ncoa.org/article/the-inequities-in-the-cost-of-chronic-disease-why-it-matters-for-older-adults
3. https://www.johnahartford.org/grants-strategy/current-strategies/age-friendly/age-friendly-health-systems-initiative
4. K., Fulmer, T., Pelton, L., Berman, A., Bonner, A., Huang, W., & Zhang, J. (2021). Evidence for the 4Ms: Interactions and Outcomes across the Care Continuum. Journal of Aging and Health, 33(7–8), 469–481. doi.org/10.1177/0898264321991658
5. https://www.ihi.org/resources/Pages/Tools/Ask-Me-3-Good-Questions-for-Your-Good-Health.aspx
6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5426314/
7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9299469/
8. https://gerontology.ku.edu/sites/gerontology.drupal.ku.edu/files/docs/GSACommunicating%20with%20Older%20Adults%20low%20Final.pdf