CMS’s Age-Friendly Hospital Measure: Julia Adler-Milstein, Stephanie Rogers, and Shari Ling

Eric 00:55

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:58

This is Alex Smith.

Eric 00:59

And Alex, who do we have talking with us today?

Alex 01:01

We are delighted to welcome back Stephanie Rogers, who’s a geriatrician, medical director of UCSF’s Age Friendly Health Systems. And Stephanie’s standing right here with her fiddle at the ready. Stephanie, welcome back to GeriPal.

Stephanie 01:14

Thank you. So happy to be here.

Eric 01:15

Stephanie, you’re an Instagram star, too.

Stephanie 01:18

Yeah, I guess I am.

Eric 01:19

What is your Instagram handle for our listeners?

Stephanie 01:21

It’s agewellwithdrsteph

Eric 01:24

Millions of views per post, right?

Stephanie 01:28

Yes.

Alex 01:28

Yeah, check it out, check it out. We’re also delighted to welcome Julia Adler-Milstein, who’s a national leader in health information technology policy and research and chief of the division of Clinical Informatics and Digital Transformation at UCSF. Julia, welcome back to the GeriPal podcast.

Julia 01:46

Thanks so much.

Alex 01:47

And Julie’s joining us from Minneapolis, which is about to get a big snowstorm. So we hope that our Internet holds up throughout the podcast. And finally, we’re delighted to welcome Shari Ling, who is a geriatrician and deputy Chief medical officer for the Centers for Medicare and Medicaid. Shari, welcome to the GeriPal Podcast.

Shari 02:10

Delighted to be here with you.

Eric 02:12

It’s a huge honor to have you here, Shari. Before we jump into the topic of the podcast, which is going to be the age friendly hospital measure, we have a song request. Who has a song request? Is it Stephanie?

Stephanie 02:27

I do. We are going to play Riptide.

Eric 02:31

And why Riptide?

Stephanie 02:32

I don’t know. It’s just a catchy song. I really like it. It’s something that I’m always, like, humming and singing to myself.

Eric 02:38

And Alex has his guitar. Stephanie, you have the…is that a fiddle? Is it a violin?

Stephanie 02:43

It can be either a Fiddle or violin.

Eric 02:45

I forgot my cowbell. [laughter]

Stephanie 02:48

That’s okay.

Alex 02:49

Thankfully, Eric forgot his cowbell. [laughter]

Stephanie 02:51

We hit it.

Alex 02:52

That’s what we need is for this is to turn into like a Saturday live episode. [laughter]

Alex and Stephanie 03:11

(playing guitar and violin)

Eric 04:01

That was awesome. I think our listeners are going to agree that was amazing. But I was missing something.

Alex 04:07

What?

Eric 04:07

A little cowbell.

Alex 04:09

I thought you’d say singing.

Eric 04:11

Just a touch. Just a touch of cowbell. Maybe in the outro,

Alex 04:16

That’s so fun. I’m so glad we get to do some live music with not just me. It was great. Thank you, Stephanie.

Stephanie 04:23

Of course.

Eric 04:24

Okay, so we have done a podcast on age friendly healthcare Systems back in 2000, I think Julia and Stephanie, you were on for that podcast.

Stephanie 04:35

We were.

Eric 04:36

Remind me, what is an age friendly healthcare system?

Stephanie 04:41

So the way that I think about age friendly health systems is that, you know, a lot of medical care is very disease centric and when you build an age friendly health system, you can focus on all the other things that are very important, especially for older adults. There’s a lot of other aspects of people’s lives that should go into medical decision making. And so there’s a framework called the 4ms. That we use for the age friendly

Eric 05:08

health system and remind our listener what the 4Ms.

Shari 05:11

Are.

Stephanie 05:12

So they are what matters. Mobility, mentation and safe medication use.

Eric 05:19

My last question on that 4ms.

Alex 05:21

Or 5ms I have the same question sometimes. Isn’t there a 5th M and what is that M?

Stephanie 05:27

So Yeah, through the IHI and Hartford foundation we actually have the 4Ms, but I know some people add that 5th M multi complexity.

Eric 05:36

Yeah, I think in our last podcast we were adding other ones like muffins and other other M. I encourage all of our listeners to listen to our last podcast on age friendly healthcare systems because I think it really does a good job to summarize kind of where we are and what we’re doing with that. I am now going to turn to where we are now. And as we talk about now, the present and the future, Shari, there is this new thing that CMS is. Is it new? Has it been rolled out? It’s called the age friendly hospital measure.

Alex 06:08

Yes.

Shari 06:10

It is not really new. And you may be wondering why this, why now? And I will say that the measure itself, the timing of the measure really has depended on the evolution of the evidence and the readiness of the health system at large. Thanks to all of you who have been working hard at making and building age friendly care even before we thought of the measure.

And the measure also really reflects these. These Interacting, interdigitating concepts or domains that really translate to the opportunities to deliver care that better meets the needs of older adults, whether 4 or 5ms. Really it’s, it’s about putting the person who needs care at the center. So really the, the timing is built on the work that you all have been doing, but it’s not new. It is something that has been proposed and finalized in play 2025.

Stephanie 07:22

So, and we’re all submitting our first attestation this year, so in May. So we’ve been preparing for a while

Alex 07:29

to do this attestation. Tell us more. What are you attesting to and who’s attesting?

Shari 07:37

Yeah, so the question about attestation is, you know, the many of the quality measures people are accustomed to have, you know, specified data sources where information about who’s in the numerator statement, the population at risk and the denominator statement and reflects a evolution of the state of readiness of the systems for a quality measure. So the attestation is really reliant on the reporter that is, you know, the facility who has an opportunity to say, oh, we deliver care that is consistent with the domains of age friendly and all of the requirements. It’s kind of like an all or none thing reliant upon that attestation.

Now you may wonder, why is it? Why attestation? Why not just a fully baked quality measure? So the attestation is a means for us to have said we believe this is important in the care and keeping of the people who we serve. We want to send a signal that this is important and also create the opportunity for systems to develop the processes, the care processes and the infrastructure needed to fulfill all of the domains, but maybe do so differently. Some might start with what matters, others might start with mobility. There’s no one right answer. The right answer depends on, you know, where people are in the evolution of care towards age friendly.

Alex 09:25

So, Julie, it sounds like the CMS is asking institutions, hospitals in this case to say, attest that they have done this, but it’s not giving instruction about how they go about measuring these different domains. Is that right? What are your thoughts about this?

Julia 09:42

Yeah, it’s a bit of a middle ground and I think, you know, on the one hand we’re used to in healthcare like very prescribed protocols that say like exactly how to deliver types of care. This is not that, but it’s also not like totally Greenfield like, you know, there is, I’d say a fair degree of prescriptiveness. And so just to give an example, if we think about the what matters domain. It says that you need to have a conversation around a goal of care at like certain moments in a care journey, admission, discharge, when there’s a major change in clinical status.

So it is prescriptive. It’s not sort of wide open. But there’s also a lot that could be interpretive, like what counts as a major change in clinical status. Reasonable people, I’d say, would probably come to different conclusions about that. So I think it’s a really great place to start for our country where, like, it is prescriptive and it is evidence based, but there’s still a lot we need to learn about how to turn it into something that I would call like a really tightly prescribed care protocol.

Eric 10:42

Well, can I ask you this, Julia? Like, if you were. Had magic wand, if, if you were Shari, like, would you do that? Would that. Is that what you see in like five years from now, that you would be advocating for more prescriptive, or is this. We’re just still in the learning phase to figure this out?

Julia 10:59

I think we’re still in the learning phase. I mean, you asked a researcher that question, and so my answer is, of course gonna be it’s something we need to study because I don’t think we know which are going to be the pieces that are really critical to contribute to improved outcomes for older adults. And so that’s our North Star here. And this is going to be an opportunity for massive experimentation because all hospitals are going to probably approach this a bit differently. And so that will allow us to really understand what is the best approach.

And within that, I think the key is how do you deliver the 4ms. Or 5 domains as a set, because you can do each one and sort of optimize how do you have a good conversation about what matters or how do you safely prescribe meds. But where I hope will really focus that learning is how do you bring all the pieces together? How do you have a goals of care conversation that then informs how you prescribe, how you set a mobility plan? It’s really bringing all of them together. That I think is the holy grail here.

Stephanie 11:54

And I do appreciate a lot of leeway here at the beginning because every hospital system is so different, different. And you. There’s a lot to work out, you know, which discipline is going to do this screening and this action. And you know, we. I think that all has to be kind of negotiated and figured out and we have to all sort of work together as an interdisciplinary team in the hospital. And I think every Hospital is very different based on the resources that they have, etc.

And so, you know, I think it’s nice in the beginning to give us some leeway, but I know Julia and I have talked about before, we do want to get to a place where we can compare places, you know, different hospitals, hospitals and sort of understand, you know, are we improving outcomes with all of this?

Julia 12:37

And do you think, do you think

Shari 12:39

as far as, you know, that point about outcomes? So we’ve been thinking about this as well. So what would be the outcomes that would serve as our, our measuring stick? Right. And that’s part of the challenge of the current health system where, you know, care precedes whether or not an individual patient’s goals are even known or documented or what their preferences are. So, you know, I wonder how, how do you think about that, you know, from where you sit at the points of care and also how should we be thinking about that?

Eric 13:19

And maybe we can break that up for each, each of these like five domains. Would that be reasonable? What do you think, Julia?

Julia 13:26

I mean, I guess I might lean the other. I mean, I think it’s like the key question that we have to ask at this moment. And in some ways I think, you know, if we do break it down by domain again, we’ve like lost some of the purpose of like practicing these together in a way that improves like the big things that matter. And so I would say, like, let’s not pick one outcome, but let’s pick a set of outcomes that collectively represent the things that are important to older adults.

So patient experience of care, time alive and out of the hospital, frailty and functional status. So I think we’re going to want to sort of pull together a set of outcomes that sort of collectively represent the domains that we would say that age friendly care is striving towards.

Stephanie 14:08

Yeah, and I think we have different stakeholders too. I mean, obviously the most important is the patient and the caregiver and outcomes for them. But also myself as an implementer, I have to think about sustainability. And so finances are something that I need to prove to a health system in order to sustain all this work. It costs money. So, you know, there’s different outcomes for different people and I know we have to have a few of them in every domain.

Eric 14:35

Well, let me ask you this. Is there a carrot or a stick for this CMS outcome measure?

Shari 14:40

Oh, that’s a great question as to, you know, what is ready for which type of incentives. Right. Rewards or negative adjustments. It really all is going to depend on the State of readiness and the type of comments that we receive. Because you know we’re starting here with the inpatient quality reporting system.

Eric 15:05

Right.

Shari 15:06

Which is pay for reporting. And the evolution could be towards hospital value based purchasing after health systems, after hospitals get accustomed to reporting with the attestation based measure for public reporting and pay for reporting but no other positive or negative incentives are applied. So we’re thinking about like when’s the right time to move this further and also is this the right way to move this forward? Could we think about specific elements of one of the five domains or you know, the most important of the domains and think about spreading this across different care settings. So no one right answer. Just illustrating how one might think about this.

Alex 16:03

And to be clear for our listeners at the time of rollout, which is coming soon, there are penalties I believe. Right. For hospitals or systems that don’t report, don’t attest. Is that right?

Stephanie 16:15

They not the first year.

Alex 16:17

Not the first year.

Stephanie 16:18

Yeah. We have some time to get this together but probably eventually maybe next year we’ll see.

Julia 16:24

To be totally precise, you have to report but you could report all no’s right to get full credit. So there’s not a requirement of actually saying that you’re delivering age friendly care in this first wave. But you do have to report and I think that’s really exciting because we’ll have our first national baseline of what hospitals across the country are doing with respect to to these age friendly care processes. And then I imagine from a CMS perspective it then allows you to make some of the decisions about how quickly you can ramp up because we’ll have that national baseline.

Alex 16:54

Okay. So at this outset there is no penalty for not doing the attestation.

Stephanie 17:00

Well, you want to complete the attestation but you don’t need all yeses yet.

Alex 17:03

Okay, you want to complete it but still there is no penalty at the

Stephanie 17:07

outset when this I should probably confirm that with Shari.

Alex 17:09

I don’t or reward is there.

Shari 17:12

This is, you know, this is the run in period if you will. Right where we are trying to get people to just participate and you know there will. There’s always a score. Now this measure specifically because it’s attestation, it’s all or none. So the information hopefully will be useful to those who are actually submitting the data which is really you know what ideally what quality quality reporting is because it’s not just to satisfy CMS needs but it’s really to be able to improve at the points of care.

Stephanie 17:49

But I would like to say so I’ve been working on age friendly health systems for about eight years and I feel like I am nowhere near really good quality care for every single older adult that enters our hospitals. And so it will be interesting to sort of see how long because there’s, there’s actually a lot more requirements in the IQR measure than there are in the age friendly IQR.

Alex 18:13

What’s that?

Shari 18:14

That’s the Inpatient Quality Reporting Program. This is one of several measures, not all of which, so some of which are used for the STARS calculations which, you know, that is how you find top line facilities. But you know, it’s a possibility that this measure or a measure like it in the next iteration over time can actually also get there. Right. But we want to follow the state of the evidence, the state of the readiness and really, you know, keep in mind that one of the domains is, is having leadership. Right. Age friendly leadership. And so not being prescriptive about that. That was inserted as an opportunity for facilities to identify their own talent that can get them to the goal of providing age friendly care.

Eric 19:15

Maybe I can ask, since we are keep on bringing up the components of this measure, maybe we can just briefly talk about each component and like, is it the same as the 4ms? Is it different? Stephanie, Julia, do you want to start

Alex 19:30

with one in particular?

Eric 19:31

Let’s start off with eliciting patient goals. That seems like what matters. That’s a 4M right there, right?

Stephanie 19:37

Yeah, it’s slightly different than what we had been doing in the regular age friendly health system which you know, in initially in the age friendly health system work, doing advanced care planning and asking for surrogate decision makers was different than asking someone what matters to them. However, in these new hospital measures there are components of getting, you know, advanced care planning different tasks done like surrogate decision makers and things like that. So it, it’s slightly different. Yeah.

Alex 20:10

So I, I, my, the question I’m dying to ask is like what do you worry about? What’s the worst case scenario and what are you hoping for? What’s the best case scenario? And so I worry about, you know, the Patient Self Determination act, which mandates that every patient who’s admitted to a facility is given an opportunity to complete an advanced directive, asks if they’ve already complete one, they’re given an advanced directive and it just like, but we can

Eric 20:34

check it off, but it’s sedate such test.

Alex 20:36

It hasn’t really done much. Is there a concern that this approach is mirroring that or, and to what extent does it go beyond that?

Stephanie 20:47

I personally have concerns because I think there’s a couple, like if we’re following every little rule in the hospital measure, there’s actually like five things. Living will is one of the things in there. And so that is just not very reasonable during a hospitalization to complete. And, and so yeah, I think there’s opportunity. What’s great though is CMS is taking a lot of our feedback. I, I send Shari emails all the time and you know, a paper that Julia and I wrote so that we, as I’m trying to do this, I’m realizing what’s working and what’s not working. So I know that they’re listening. And this, what exists right now will probably not look like this, you know, in years. If you think so too, Shari, that’s sort of my understanding as well.

Julia 21:27

Yes.

Shari 21:28

And what we’re hoping that this will evolve to be more meaningful quality reporting. Right. And so you know, the attestation based measure is one start, you know, that can also be formulated as a structural measure or as a quality measure. In the meantime though, we started to hear the importance of these goals of care conversations. So have introduced the concept of advanced care planning with a variety of iterations including identifying healthcare agents. Right. Or a healthcare agent. And so of note, part of the quality measurement proposal process is that CMS has to take the measures that we’re thinking about or considering on the measures under consideration list. It’s a terrible acronym, it’s the muck list.

But nonetheless, you know, we take it to a consensus based entity for conversation, discussion, deliberation. Is this a good idea? Is there room to improve? Is the value or potential value of a measure? Does it outweigh the burden of the reporting? And so we took the advance care planning measure not only for acute hospitals, but also said, well, what about other care settings? To the consensus based entity. And there was a lot of support, in fact more support than concern. So that gives us the and CMS the ability to propose in rulemaking an additional measure for inpatient, the inpatient setting and also to consider what should it look like in post acute in other care settings, which is, I think evolution in a different way.

So IQR, the attestation based measure still stands, but we’re trying to push the system to move beyond the checkbox and I think that’s really important. And some of the details which CMS will may never be able to see, but you know, it’s how does it happen at the point of care? And you know, we have to take our own personal experiences of what it was like at the point of care for us and, you know, no secret. You know, one of, one of the things that keeps me motivated is so that others who may not be as aware of how things should roll in the hospital may not have the opportunity to really, you know, raise questions and say, oh, isn’t there someone else I can speak to other than the unit secretary about what my goals of care are? Which. That fulfills the checkbox. But so much more needs to happen. So long answer to your question.

Alex 24:28

Thank you.

Eric 24:29

And for each of these domains, like what matters, there are subdomains that you have to fill. I heard.

Stephanie 24:34

Yes, living.

Eric 24:35

Well, how, how far does it go down? How many subdomains are there subdomains of the subdomains?

Stephanie 24:40

There’s just subdomains of the domains. Some domains have more subdomains, like big

Eric 24:47

picture, like for what matters. Do you have a. Get a sense.

Stephanie 24:50

I mean, I think there’s like five things that I need to check off. But I think what makes it hard, and Julia and I talk about this all the time, is that these conversations have to happen at admission discharge and when there is a change in clinical status. And so we’re. I’m working with Julia and I’d love your thoughts to think about how we measure this. I mean, what matters is very hard to measure in itself, but these sorts of things are also. How do you measure from an EHR? If I wanted to prove to CMS

Eric 25:18

that I’m completing this hidden in most EHRs, it’s in some note. Is there some advocacy, well, even a

Stephanie 25:23

change in clinical status. How would you even mark that point of time? So that I can prove to CMS

Eric 25:29

that I’m hitting an icu. Admission is probably good. Like Julia, what do you think?

Shari 25:33

Yeah, so I mean, this is a really great question because, you know, this is also about the state of readiness of the depth of the information that’s required. And ultimately, you know, the question will be, you know, what will be helpful to track for the care and keeping and decision making of the patients. So I think we’re taking that, you know, at face value and saying let’s be flexible here. We want the information reported, but really that information is also meant as a mirror of what is care. Like how is the documentation rolling.

And what we are also learning is that where it’s documented could matter. Right. If you’re actually trying to vacuum up information from your ehr and all of the good stuff is in the social workers notes, which for me it always is, but maybe that’s not where people are looking for the measure construct. I mean that’s important for us to know too. So we’re going to all around we’re going to learn from the implementation on these measures.

Eric 26:48

What do you think about that Julia?

Julia 26:50

So I mean I think what we’re seeing, which is the most exciting part is that like hospitals are coming to the table around this in a new way because everyone is trying to figure this out and they don’t want to do it in a vacuum. And so there are like new groups, Vizient as an example that’s now stood up, you know, a working group around age friendly. So I think we’re just seeing a real broadening. You know, they’re the Die Hards like Stephanie who have been at this for eight years. But like the whole point to my mind of doing this at the national level is to like bring everyone else into the conversation. And so I think we’re really seeing that happening. And then do you think it makes

Eric 27:26

it easier to advocate for your what you should be doing and like for really true age friendly healthcare systems?

Julia 27:34

Absolutely. I think even for the Die Hards it allows them to go back to their hospital leaders and say oh now this isn’t a CMS measure. So this is not like a nice to have, this is a must have. And so we keep hearing this is like a revitalization moment. That’s great for age friendly.

Eric 27:49

Okay, so we talked about, we talked about one which is eliciting patient goals. Number two is medication management. Right. That’s a domain.

Stephanie 27:58

Correct.

Eric 27:59

And I’m wondering here because like I don’t know, we’re forced to do med rec here and it’s if it feels very performative in our current system. But how do we think about medication management? Because this is not just med rec, this is like bears criteria like high risk medicines. Is that right?

Stephanie 28:16

Yeah. So you want it. I mean the actual measure is asking you to, to review if the patient’s on any high risk medications and consider them for you know, alternatives or discontinuation or tapering, et cetera. You know, again it’s, it’s a pretty vague thing which is great and I think every place is doing it differently. But some of the questions that we’ve sort of had in the research space is, you know, is this every single beers criteria med because there’s tons of hypertension meds, et cetera on there or can we select the highest risk ones? And so Julia and her research team are trying to work with a lot of these other health Systems to sort of think through what should be the standard here.

Shari 29:02

That is terrific to hear really because, you know, as we’re thinking about the construct and the requirements for this measure, for future measures, what we’re hoping is that it creates opportunities for the experts to actually inform what the local policy, the local decisions. And Eric, to your point, to be able to ask for resources that are necessary. Right. So that you can succeed and success is not, you know, a plus or a minus on the dashboard of the quality report. It’s success or not. It should be like, are your patients actually doing better and are we delivering to better health outcomes?

Eric 29:49

Is this changing care plans and not just documenting that we’re giving bad meds, but we’re actually doing something.

Stephanie 29:56

Yeah, we found that our highest flagging med is gabapentin, so surprise there.

Alex 30:02

Okay.

Eric 30:03

Stephanie Rogers did a wonderful Instagram post. Gabapen. Check out our Instagram. That’s the second plug I did for that. Okay, so we got listening patient goals, medication management, which is not just med rec, frailty screening. This is when we’re thinking about EMS mobility, I’m guessing, like aligns with mobility potentially also mentation. Like they’re all interconnected. You know, I think for most clinicians their idea of frailty screening is eyeballing a patient and saying they’re frail, they’re not. Is that what we’re talking about, failed or what are. What are you doing at UCSF, Stephanie?

Stephanie 30:40

Yeah, I mean I think people think of this differently. So you know, I started in the age friendly work before this measure came apart where there is a screen and act on for everything that you do. So we do a daily mobility screen in the morning which actually sets a mobility goal for the patient for the day. And then it we can determine whether or not that mobility goal has been achieved. But every health system is doing this differently and this is where the two things sort of don’t align because the Medicare one doesn’t have that act on. Well, I guess it’s sort of vague about the act on component. Like I think it’s important to, you know, know what someone’s mobility is, but also make sure that they’re working to the highest of their functional ability and sort of tracking that. So there’s a lot of leeway and I think how Medicare is defining this. But again, I think we’ll learn over time because people are doing this very different ways.

Eric 31:36

Julie, I got a question for you. What do you think about the frailty screen domain? Again, there’s one thing to screen for Frailty. But then a lot of clinicians also will think, like, what do I do if they screen for failty in a hospital setting?

Julia 31:50

Yeah, I mean, absolutely. I think we have to make these actionable and there has to be a next step built in. And I think again, I, partly because I come from the technology world, I’m like, this is where technology’s opportunity to shine is. And so we should be able to sort of connect assessments to next steps, again, build that into the electronic health record. So it’s a clear workflow from start to finish. Yeah.

Alex 32:12

And we’ve had several podcasts about frailty. We had the creators of E Frailty on talk about all the various different ways in which you can measure frailty. We had Linda Fried on to talk about the Fried approach. I assume you’re using more of the like Rockwood type accumulation of deficits, like looking at the EHR to see like, do they have a history of this, that and the other, comorbidity and sensory impairment, mobility, et cetera, Is that right?

Stephanie 32:41

Well, it’s actually a frailty screen is not in that domain. I think it’s just sort of the gestalt of the domain. But in that domain is actually mentation screening and a couple other things. So it’s things that maybe affect people’s frailty, but it. There isn’t an official frailty screen.

Eric 33:01

I’m happy to happen to the 4M’s because mentation didn’t look like it was one of the big domains actually in

Alex 33:06

the frailty domain, so it was folded into there. Shari, any right or wrong? Yeah, yeah. History about how that came to be that you could share with our listeners.

Shari 33:19

Sure. So, you know, I mean, there’s a lot of conversation about like, what is the right frailty screen tool. And this is an opportunity to pick something that works for you and to the points made earlier, build some action around it, like what does it mean? It should be helpful for the care team. Right. Who’s. Who’s doing wherever they are in the system and in this case it’s in the inpatient setting. But one of the challenges is, and this also speaks to like why not why we are trying not to be prescriptive is same patient, same conditions, then transitions to post acute care. And how do we think about that?

And you know, more important is where do people, where are people starting? Where are they ending during the course of a stay and at the point of transition to the next location and to be able to use the information in ways that help them. So trying Very hard not to be prescriptive. And on a side note, in the maintenance of certification had the opportunity to answer the question which was which of the following, you’re a consultant in a clinic now and you can choose one of the following in five minutes or less that could be done. Which would you choose? The right answer was working speed. And I was like, huh, that’s pretty cool that we actually. And so it made a difference.

Alex 34:56

Hey, maintenance. Nice. Yeah, it’s working. We’re learning from it. Yeah, Julia.

Julia 35:01

Yes, exactly. Quick on domain 3 too. Because I think one of the really amazing things about this measure is that it’s actually started to really push towards thinking about transitions into the hospital and transitions out of the hospital. And so part of domain 3 is actually about ED boarding time and activities to reduce delirium. And the same thing in some of the domains we’ve already talked about. It’s about how do you continue that care in the post acute setting.

And so I think it’s like really one of the things that doesn’t get talked about enough in this measure and that I really want to highlight because we don’t want to deliver age friendly care setting by setting. We want age friendly care across the continuum. And I think this measure is like a really small, strong signal of like the importance of moving towards that. And so again, just didn’t want to lose that as we’re talking about.

Alex 35:47

Thank you.

Stephanie 35:48

Super important part of the requirement is that you have to report the mentation and the mobility baselines, all of that on discharge to the next setting.

Julia 35:55

So.

Eric 35:56

Wow, that’s great.

Stephanie 35:57

Yes, that’s very important. So I’m glad that’s in there.

Eric 35:59

That is wonderful. Um, so we get a better sense also of hospital associated disability. That happens. Okay, I want to talk about the last two real quick because they feel a little different than the forums. Social determinants of health. This is an interesting one because like we can identify social needs, but hospitals aren’t really social service agencies. Maybe. I don’t know. What do you think about that?

Stephanie 36:21

This one we’re really struggling with because we’re struggling with who owns this sort of screening. And then when we uncover these things, which are usually very big.

Eric 36:33

Yeah.

Stephanie 36:33

Who takes on those tasks with an

Eric 36:36

average hospital stay of probably two to three days? Like, can you fix social determinants of Hell, yeah.

Stephanie 36:41

Yes. You know, but there’s good things in there that we often forget, which is, you know, caregiver fatigue, things like that. So it is sort of having us standardize those types of Screens. But then I think the hard part is trying to know what the action is.

Alex 36:55

Yeah. Also call back to a prior episode with Kirsten Bibbins Domingo, who wrote about the need for health systems and clinicians to address and capture social determinants of health. She’s now editor at jama. Eric, you have a question?

Eric 37:06

Yeah, Shari, how did this one come up? If you’re, if you’re able to share kind of this, this is probably the most fascinating one for me…

Shari 37:15

And it tests the limits of CMS authority. It tests the appropriateness of attribution and capability to take action on what you learn and what you find. We thought it would be an important element that may determine people’s outcomes regardless of what the disease is or, or what the. But it does align very well in that interaction with the, the state of the human being and the context of how they, where they are, what their factors are. So, you know, was a first pass actually at really expanding the aperture on the, the limits of, of your impact. Right. And we, we actually went there also in a prior iteration on, on smoking cessation and you know, tried to, to think about, well, you know, where does everybody go?

They all go to the hospital. And the hospital’s like, yes, but that’s not our job to make people quit smoking. So you know, this is a chance actually to really explore with the community how do you synthesize and continue care even beyond what happens in the acute hospital. Let’s pretend they don’t go to post acute care, but they go immediately home. So this is one that we also are gonna learn a lot about how the systems are functioning.

Eric 38:51

Julia, real quick, any thoughts from you on this measure or domain?

Julia 38:56

I have heard people talk about is caregiver stress. I think everyone is stressed about caregiver stress because again it’s like from whose perspective? What do we do about it? You know? And so again it’s, it’s like everyone knows this is critical, but I have to say that is the one part of the whole measure that I probably heard the most chatter about because really like they don’t know what the right thing to do there is.

Eric 39:16

Okay, I gotta ask about the last domain, cause this one’s interesting too. Leadership and governance.

Stephanie 39:21

Thank goodness it helps me keep my job.

Eric 39:24

What is this one?

Stephanie 39:25

I mean it just is basically that each hospital has to designate leaders to of, you know, the age friendly health system work, which is great. At UCSF we have a nurse leader and we have myself. And so I think again it’s, it’s helping I. Because you need people to sort of lead this work. So I think it’s really helpful.

Eric 39:42

Do they have any need, any expertise in geriatrics or aging or gerontology or.

Stephanie 39:48

Well, from what we’ve heard from many different health systems, there’s all kinds of people that are taking these roles. And of course everybody who is taking these roles believes in what they’re doing, but they’re not. You know, there’s very few of us geriatricians.

Alex 40:01

And there’s no requirement that it be a geriatrician. No, not at this time.

Stephanie 40:05

That’d be impossible.

Alex 40:06

That’d be impossible because there aren’t enough geriatricians.

Stephanie 40:08

Correct.

Eric 40:08

That’s impossible stuff.

Stephanie 40:10

Well, that’s true. We’ll think big, right?

Alex 40:12

Right.

Shari 40:13

Always think big.

Eric 40:15

Yeah. Is that what CMS was thinking when they, when they put this is like we, we want. You need to have like that not just the stakeholders involved, but somebody leading the initiative.

Shari 40:25

We need leaders, right? Leaders who actually are engaged in care and know how hard it is and also engaged in evidence generation and taking up that evidence and putting it into play in patient care and policy. And so, you know, one thing that we have observed over time is, and this is just, this is well known, I mean we’re really good at acute care, right? In the care delivery, acute care, but we have the burden that our population actually endures in chronic illness and the complexities thereof. It’s not a great fit.

So I think the need for leadership is pretty clear and also how to improve upon the current state. So really converging age friendly with, you know, quality improvement in the context of care delivery I think is really a need and an opportunity going forward. And yes, we need more folks to understand this entire ecosystem. So we would be delighted if more people wanted to join us at CMS and even taking on fellowship projects that work on and focus on policy and translation.

Eric 41:44

So I’m going to go to lightning round question because we just have a couple more minutes. First, any of you, if, if people are interested in learning more about this measure, where should they go? Is there like repository places that they can learn more about the measure and how to, you know, institute in their hospital?

Shari 42:01

Ah, two different questions, right? Really two, maybe three different questions. So the measure details are published on the CMS website. Taking that into account though, the how of how to implement best place is starting within your own system looking for your leadership who actually can take the opportunity to say, hey, here’s what is what the broad strokes of what is expected. But here are our suggestions of how to get there. Right. Go to the experts. The experts are on this call and elsewhere.

Alex 42:38

Yeah.

Eric 42:39

And Stephanie, how would you answer that question? Like what are you using as resources to do this implementation? Obviously, CMS website.

Stephanie 42:46

Yeah. And the quality department now has to take this on at our institution. So I work with them. Yeah.

Eric 42:51

All right. And Julia, any other resources that would be helpful?

Julia 42:55

The communities of practice that are coming up around this again, some of them are at the Institute for Healthcare Improvement, Vizient. The Pepper Centers are now at the table doing a survey of how hospitals are operationalizing this. So I’d say go to your community of practice too and ask, you know, who, who’s sort of organizing ihi.

Eric 43:12

Hartford foundation has some stuff too. Right on this. So we’ll have links to that on our show. Notes, last question. Then we’ll get to the song Lightning Round. In five years from now, do you expect care for the older adults who are hospitalized to look different because of what you’re doing today? And if not, what do you think needs to change? Again, maybe two questions there, Stephanie.

Stephanie 43:32

I think it’ll look different, but I still think it’s going to take us a long time to do all of these things very well for all the older adults, which are about 50% of all hospital populations right now.

Eric 43:44

Whatever, Julia.

Julia 43:45

I’m going to go with a yes. I think we’re going to pay a lot more attention to the different dimensions within age friendly care and we’ll have a lot better documentation of sort of screening, but it gets to that actionability piece. And so I think that’s where we’re going to really have to focus if we want to have impact on outcomes.

Eric 44:02

All right, Shari, you’re last. Before the fiddle slash violin comes into

Shari 44:06

play, I will actually also go with yes, I am the eternal optimist, but I will say it will take all of us to get there. So just thank you for all the work that you’re doing and for the opportunity to be with you today.

Eric 44:21

All right, now a little bit more cowbell.

Alex 44:24

We’re just going to do the chorus here.

Alex and Stephanie 44:25

(playing guitar and violin)

Eric 44:52

Shari, Stephanie, Julia, thank you for joining us on this podcast.

Julia 44:56

Thank you.

Shari 44:58

Been an honor. Thank you.

Eric 44:59

And to all of our listeners, thank you for your continued support.

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