The Centers for Medicare & Medicaid Services measure requires hospitals to implement age-friendly strategies in inpatient, emergency, and surgical services.
Authors: Nicole Brandt, PharmD, MBA; Michelle Adelstein, ACNP; Lara Wilson, MHA; Chris Wells, PhD, PT; Dave Milzman, MD; and Barbara Resnick PhD, NP
Photo: Participants in the Older Adult Voices panel.
Background
The University of Maryland, Baltimore has been collaborating with the University of Maryland Medical System (UMMS) since 2019 in efforts to advance statewide age-friendly efforts. As part of these efforts, various partners meet monthly to help prioritize and focus on this important work. In 2024, UMMS, including the University of Maryland Shore Medical Center (UM SMC) at Chestertown, recognized the new Centers for Medicare & Medicaid Services (CMS) Age-Friendly Hospital Measure set for implementation in 2025. This requirement mandates hospitals implement age-friendly strategies in inpatient, emergency, and surgical services.
The CMS Age-Friendly Hospital Measure requires that all participating hospitals report on all elements within five domains:
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Eliciting Patient Health Care Goals: Ensuring that patient goals and treatment preferences are obtained
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Responsible Medication Management: Optimizing medication management to avoid inappropriate drugs
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Frailty Screening and Intervention: Screening for cognitive impairment, mobility, and malnutrition
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Social Vulnerability: Recognizing and addressing social issues that impact older adults
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Age-Friendly Care Leadership: Identifying a champion or committee in the hospital to ensure compliance
The following highlight areas of strength and opportunities within UMMS.
UM SMC at Chestertown
As an Institute for Healthcare Improvement-designated Age-Friendly Health System and American College of Emergency Physicians-accredited geriatric emergency department, UM SMC at Chestertown plays a key role in supporting this initiative. However, our current efforts do not fully meet the scope of this new requirement. In collaboration with our quality, regulatory, and patient safety teams, we are conducting a gap analysis to ensure all required service areas comply with the new measure.
Early findings reveal that the new CMS measure will require additional focus on interventions in the emergency department, improved screening for health-related social needs — especially social vulnerability and isolation — and the alignment of workflows to streamline documentation and intervention. Over the coming months, we will engage in further discussions to determine the best approach to operationalize these requirements across the system. Our strategy is aligned with our commitment and ongoing journey toward high reliability in patient care.
UMove Early Mobility Program
Since 2018, UMMS has been implementing the UMove Early Mobility Program, which is a nursing and physical therapy-driven early mobility program created at UMMS to empower nurses to engage patients in safe and timely out-of-bed activities. The goal was to mitigate the effects of immobility, improve the patient experience, and discharge more patients to their homes. The UMove Mobility Screen is an easy, reliable, and valid tool for nurses to assess the patient’s basic functional ability and identify patients who can safely ambulate (Wells 2021).
UMMS Patient Care Services is promoting the UMove Program to all our health care team members to promote improved communication and place mobility front and center to assist in improving patient outcomes like reducing falls and pressure injuries. For our vulnerable patients who are critically ill, mobility can contribute to decreased mechanical ventilation support time and ICU length of stay and improve patient’s strength and function at time of ICU discharge. Our teams can track mobility by leveraging our electronic medical record to generate mobility reports for better understanding of the effects of our clinical practices to improve our patient’s lives. This effort aligns with the Age-Friendly Health System movement and the CMS measures.
R Adams Cowley Shock Trauma Center
The practitioners at Shock Trauma have recognized that the demographics they serve have changed through the decades. It is estimated that of the nearly 10,000 annual trauma patients admitted approximately 33 percent are over age 65 with an increasing number over age 85. This shift presents unique challenges, as older patients often have lower physiological reserves and increased vulnerability to trauma-related complications. Compare this to 1990, when less than 10 percent of our admitted trauma patients were over 65. Recognizing this evolving patient population, we have made significant efforts to align with national standards of geriatric trauma care. However, gaps remain in ensuring consistent, high-quality outcomes for these older adult patients.
One of our key challenges is insufficient staff with specialized training in geriatrics. This can contribute to delays in interventions and poor long-term outcomes. To address this, Shock Trauma has implemented a Geriatric Trauma Committee, integrating a multidisciplinary team that includes acute care surgeons, trauma advanced practice providers, geriatricians, PharmDs, physical therapists, social work, nursing, information technology, and transitional care coordinators. This committee focuses on integrating the 4Ms (Mentation, Mobility, Medication, and What Matters Most) into practice.
To begin with, What Matters to the older patient must be assessed and remains one of our key focuses. Our work will integrate the Age-Friendly Health System resources specific to this into our initial assessment. Rapid review patient’s preinjury health status, frailty scoring, and patient and family end-of-life choices have been identified as a starting point. Ultimately, our goal will move to integrating this into our tertiary survey upon admission.
Next is to determine acute delirium, which is a life-threatening process that markedly increases morbidity and mortality by over 10 percent per 24 hours in the ICU when undiagnosed in this patient population. Our work is focused on pulling in screening tools to identify early recognition of delirium, offering nonpharmacologic interventions via an algorithm, and furthermore, working with our PharmDs in directing pharmacologic interventions tailored specifically to this patient population. An order set is in process of being built out.
We recognize the focus on life-saving operative fixation, which we have always excelled at, fails to adequately address the Age-Friendly Hospital Measures and can lead to poor long-term outcomes. To improve mobility, physical therapy is a key stakeholder on our committee. Their role is to drive integration of the UMOVE program into our workflows. Our program will include early mobility programs, increased family presence, getting patients out of bed, and establishing goals of care early and allowing for modifications as a patient’s condition changes.
Lastly, to be mindful of pain medication management of this patient population, we have created an order set specific to patients age 65 and older with built-in guardrails. This order set drives a dose-specific, American Geriatric Society Beers Criteria-driven multimodal approach to pain, specific to this patient population. This is active and embedded in all our intermediate care unit and acute care Shock Trauma team admissions.
Thirty-day survival goals of this patient population fail to track our unfortunate failures in management of the trauma patient over age 65. We are dedicated to making and improving our care to better reflect such proven improvement markers. Over 75 percent of our geriatric patients fail to return home, and post-injury-related surgical fixations and institutional rehabilitation sites are poorly followed for long-term improvement marker tracking. We know this can be improved upon with better adherence to the 4Ms and age-friendly measures.
Conclusion
We know it takes a team to drive meaningful change and through shared experiences, we have maintained progress. Ongoing resources and support are needed to implement change, but we are hopeful that through national measures such as those instituted by CMS, we will be able to increase awareness for the importance of this work.
Reference
Wells, C., Pittas, J., Roman, C., Lighty, K., and Resnick, B. (2022). Reliability and validity of the UMove mobility screen. Journal of Nursing Measurement, 30(4), 576–588. https://doi.org/10.1891/JNM-D-21-00001 PMID:34518415