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Age-Friendly EMS
Our population is aging. The US population 65 and older is expected to nearly double over the next 30 years, from 43.1 million in 2012 to an estimated 83.7 million by 2050.1 Older populations have an increased risk of multimorbidities, adverse drug events, and dementia. Older adults who utilize emergency services deserve specialized attention to address these complexities.
The Age-Friendly Health Systems (AFHS) initiative is a movement of the John A. Hartford Foundation in collaboration with the Institute for Healthcare Improvement (IHI), American Hospital Association, and Catholic Health Association of the United States. The AFHS has 3 goals in improving care: Follow an essential set of evidence-based practices, cause no harm, and align with what matters to older adults and their family caregivers.2
The AFHS approach centers around 4 elements called the 4 M’s: what matters, medications, mobility, and mentation. What matters means to know and align care with the older adult’s goals and preferences, including end-of-life care. Addressing medications means ensuring necessary medications do not interfere with the other elements of AFHS. The element of mobility examines the safe movement of older adults to maintain function and participate in what matters. Lastly, mentation means addressing dementia, depression, and delirium in all care settings.2
The benefits differ by care setting. In the inpatient setting the biggest are reduced costs resulting from fewer iatrogenic complications, fewer undesired medical interventions, and improved patient safety. Savings are reflected in fewer and shorter hospital stays and lower costs per day. In the outpatient setting the gains come chiefly from added revenues resulting from expanding appropriate outpatient services.3
When applying the 4 M’s to emergency medical services, the benefits include avoiding unnecessary transports and helping patients stay healthy and safe in their homes. When looking at what matters, this could translate to avoiding unwanted emergency room visits or hospitalizations and focusing on quality of life. Regarding medications, the benefit is to avoid mismanagement of medications or adverse drug events. The value of AFHS related to mobility is to avoid injurious falls, wandering, or decline of functionality. Lastly, the benefit of addressing mentation is to avoid or address behavioral issues related to dementia, depression, and delirium.4
Previous projects within the University of North Texas Health Science Center (UNTHSC) and other partnerships have addressed the AFHS components of mobility and mentation.5 In 2021 UNTHSC, SaferCare Texas, the Alzheimer’s Association, and MedStar Mobile Healthcare partnered on a project to implement the remaining AFHS components of what matters and medications. Funded by UNTHSC’s WE HAIL (Workforce Enhancement in Healthy Aging and Independent Living) project, we aspired to designate Fort Worth-based MedStar the first AFHS in the country within EMS practice.5
Setting
MedStar is a local governmental agency created by 15 cities in north-central Texas and serves more than 1 million residents. It provides a wide range of services that include acute emergency medical response, flu vaccines, and a mobile integrated health (MIH) program. In 2009 MedStar implemented MIH to identify high system users and develop individual care plans for them. The typical care plan has several interventions but consists mainly of regular home visits by paramedics who perform medical and medication assessments and encourage patients to follow up with their primary care providers.6 MIH goals are to provide health care services directly to patients on location, minimize unwarranted trips to hospitals, and reduce persistent readmissions for the same conditions.
Our AFHS interventions targeted MedStar 9-1-1 calls and the MedStar MIH program. Embedding the interventions in the electronic medical record (EMR) ensured their use by MedStar providers each time they evaluated a patient.
In 2021 there were 1256 people over age 65 served by the MedStar MIH program. Almost half had significant multimorbidities or were receiving home health services or hospice care. MedStar answered 34,337 9-1-1 calls in 2021, transporting 28,120 patients. About 10% of patients were assessed, treated, and stayed at home.
Embedding AFHS screenings in emergency care empowers paramedics to ascertain the true issues patients may be encountering and consider solutions that do not require transport, thus minimizing future usage. Older adults face a high risk of low health literacy due to age-related changes that compound previous baseline gaps in understanding health information. In Tarrant County, where MedStar is based, approximately 52%–91% of seniors read at or below the 5th-grade level.7,8 With these facts in mind, our team developed interventions to address these challenges faced by both seniors and paramedics.
Methods
We selected the plan-do-study-act (PDSA) cycle frequently utilized by health care systems as our implementation method. The components of the PDSA cycle are:9
- Plan—Develop a plan to test a change;
- Do—Carry out the test;
- Study—Observe and learn from the consequences;
- Act—Determine what modifications should be made to the test.
What Matters
Plan—The aim was to deploy one simple question, “What matters to you today?” to implement within an EMR algorithm for paramedics. This algorithm establishes needed actions to help meet the what-matters component within the AFHS plan. The PDSA period ran from August 1–September 30, 2021. We additionally coached 9-1-1 staff to acknowledge what’s important to the patient and then have the patient answer the what-matters question. We then developed an EMR algorithm for 9-1-1 staff to follow for the act piece. We developed categories to guide patients on what matters, including family, health, religion/spirituality, friends, activities/hobbies, and other subjects.
Do—When the 9-1-1 staff asked what matters, 23% of respondents selected the other category. Details ranged from critical patient and language barrier to unable to complete.
Study—We discovered a majority of patients, 52%, answered health when asked what mattered to them most on the day of service.
Act—As a result we modified the EMR by creating a “hide” option for the what-matters question for patients unable to respond due to clinical complexities, confusion, or critical illness.
Medication Screening
Plan—Both MedStar 9-1-1 and MIH collected and documented whether patients were taking any high-risk classes of medications such as benzodiazepines, opioids, anticholinergics, sedatives, muscle relaxants, tricyclic antidepressants, antipsychotics, or any medications on the Beers list, a list of high-risk medications for older populations. We deployed another PDSA from May–September 2021 to identify patients taking medications on the Beers list and examine their appropriateness. Steps to fulfill this plan included flagging the medications in the EMR, generating a warning message within the EMR system, and recommending follow-up with the patient’s primary care physician (PCP), specialist, or pharmacist.
Do—After deploying the flags and warning messages, we discovered there was not a consistent method to document the actions taken by the paramedics in response.
Study—As a result the numbers of follow-ups and referrals to the patient’s PCP, specialist, or pharmacist were not trackable using the current EMR system.
Act—We therefore modified the EMR to require the MedStar team member to verify they reviewed the warnings/flags. Additionally, each client has a standardized method to document the care plan. The care plan includes education provided, referral for services, and deprescription recommendations.
Mentation Screening
A Geriatric Practice Leadership Institute (GPLI) project between UNTHSC and MedStar in 2019–2020 developed training to identify patients who may be suffering from dementia. MedStar MIH added dementia or functionality screenings to its EMR, including the AD8, Montreal Cognitive Assessment (MoCA), Barthel Index for ADLs, and Lawton IADLs. The depression screenings remained unchanged but noted inclusion of the Patient Health Questionnaire-2, Patient Health Questionnaire-9, and Geriatric Depression Scale (short form). MIH paramedics were then able to share the results with their patients, provide educational materials, and refer them to community organizations for education and/or support.5
Mobility Screening
In 2018 the GPLI project examined the feasibility of using mobility and fall screenings within the MIH program to ensure seniors at risk received appropriate services. Fall assessments were added to the EMR for patients enrolled in the MIH program, allowing paramedics to identify those at risk and implement a multifactorial fall-prevention protocol. Paramedics have additionally provided patient/family education and managed impairments that reduce mobility such as pain, balance, gait, and strength and made recommendations to improve the safety of the home environment.5
Results
What Matters
The preliminary result in the PDSA described above showed 52% of older adults answered health when asked what mattered most to them today. However, updated data from January 2022 showed an overwhelming 6732 patients (69%) provided that answer out of a total of 9685 responses. Family and friends was the second-most important topic for older adults. Religion/spirituality, activities/hobbies, and finances were less important to the population sampled.
Medications
High-risk medications are now being identified. MedStar 9-1-1 and MIH paramedics flag Beers list medications in their EMR when obtaining patients’ medical histories. Additionally, paramedics verify potential risks and develop care plans based on the medications taken. Since the EMR did not track referrals during the PDSA, no data exists to report this.
Discussion
Implementing AFHS components allows for better care delivery and outcomes as our older population grows and becomes more complex. We were able to implement the 4 M’s with the support of the leadership at MedStar. Our methodology meets the AFHS criteria by reliably providing the 4 evidence-based elements of high-quality care to all older adults the organizations sees.2 Ultimately, governmental support through the WE HAIL program enables community partnerships to serve older adults.5 The data is still novel but promising, requiring longitudinal information before conclusions can be considered.
As of January 2022 MedStar continues using the what-matters question in its EMR. Staff training continues. In September 2021 an in-person what-matters continuing education session took place with the entire MedStar staff, emphasizing the idea and its implication. Another in-person training followed, with an emphasis on communication with emergency department staff.
Most important, for any patients for whom there are identified gaps in care or for whom paramedics are unable to address what matters, patients are referred to the MIH team for follow-up via a simple Refer to MIH button on the EMR. By these actions MedStar exemplifies efficient and effective execution of the 4 M’s framework.2
Obstacles
What Matters
EMS work is fast-paced, and paramedics integrate a wide variety of critical information. The challenge of implementing what matters for older adults is taking the extra time to address this important age-friendly component of health care. We hope the algorithm embedded within this EMR will ease the time limitation. Ultimately this could allow for implementation of AFHS for the older adult into every EMS system.
Medications
The Beers list is challenging to consider in patients’ medical plans. The reasons are twofold. First, paramedics need training on what the Beers list is, what it means, and what to do with it. Second, the list includes many medications frequently used within the older population. Some patients may have difficulties understanding why paramedics are recommending changes or consultations around their longstanding regimens. This will require health-literate patient education to facilitate understanding and compliance with recommendations and follow-up care.
Conclusion
The IHI created an evidence-based AFHS model for ambulatory, nursing home, clinic, and hospital settings. The Age-Friendly Emergency Medicine Services team used the existing evidence-based tools and resources from the AFHS 4 M’s model and identified ways to integrate the model within EMS at MedStar. We developed EMR templates that utilized the validated tools and resources offered through IHI to achieve AFHS.
IHI is currently reviewing opportunities to expand its models of care into emergency medicine, behavioral health, and other settings. We applied to IHI for an AFHS designation for ambulatory care with MedStar. MedStar sets the example that EMS can practice the AHFS approach in the EMS environment. We are currently awaiting feedback from IHI regarding our request to designate MedStar the first AFHS EMS practice in the country.
Sidebar: Plan-Do-Study-Act
The plan-do-study-act cycle is frequently used by health institutions to test and implement policy changes.
The components of the PDSA cycle are:
- Plan—Develop a plan to test a change;
- Do—Carry out the test;
- Study—Observe and learn from the consequences;
- Act—Determine what modifications should be made to the test.
Access the IHI's PDSA worksheet here.
References
1. United States Census Bureau. An Aging Nation: Projected Number of Children and Older Adults. Published March 13. 2018. www.census.gov/library/visualizations/2018/comm/historic-first.html
2. Institute for Healthcare Improvement. Age-Friendly Health Systems. Accessed April 8, 2022. www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx
3. Tabbush V, Pelton L, Mate K, Duong T. The Business Case for Becoming an Age-Friendly Health System. Institute for Healthcare Improvement; 2021.
4. Institute for Healthcare Improvement. Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults. Institute for Healthcare Improvement; 2020.
5. University of North Texas Health Science Center. Geriatric Practice Leadership Institute. Accessed April 8, 2022. www.unthsc.edu/center-for-geriatrics/education-programs/healthcare-professionals/geriatric-practice-leadership-institute-gpli/
6. MedStar Mobile Healthcare. Accessed April 8, 2022. www.medstar911.org/
7. University of North Carolina at Chapel Hill. Health Literacy Data Map. Accessed April 8, 2022. http://healthliteracymap.unc.edu/
8. Doak C, Doak L, Root J. The Literacy Problem. In: Doak C, Doak L, Root J. Teaching Patients With Low Literacy Skills. 2nd ed. J.B. Lippincott; 1996.
9. Institute for Healthcare Improvement. Plan-Do-Study-Act (PDSA) Worksheet. Accessed April 8, 2022. www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx
Kate Taylor, DNP, FNP-C, CPPS, is a nurse practitioner in geriatrics, assistant professor at the University of North Texas Health Science Center, and clinical executive for SaferCare Texas, a state-funded patient safety institute. Reach her at kate.taylor@unthsc.edu.
Desiree Partain, CCP-C, MHA, is transformation manager for MedStar Mobile Healthcare in Fort Worth, Texas.
Brandon Pate, MPH, CPH, CP-C, CCP-C, is assistant operations manager for mobile integrated health care at MedStar Mobile Healthcare in Fort Worth, Texas.
Laura McEntire, LCSW, ACSW, is regional health systems director for the Alzheimer’s Association in Fort Worth, Texas.
Audrey Kwik is director of programs and services for the Alzheimer’s Association of North Central Texas.
Teresa Wagner, DrPH, MS, CPH, RD/LD, CPPS, CHWI, DipACLM, CHWC, is clinical executive for health literacy at SaferCare Texas and an assistant professor in the School of Health Professions, University of North Texas Health Science Center, Fort Worth, Texas.
