Thank you very much for joining May members' session, Dissemination of Age-Friendly Care Across the Healthcare Spectrum. My name is Muyeon Oh Park. I'm the chair of the Age-Friendly Care and Rehabilitation Community. So today, first, I would like to start with why are we talking about this topic? So, the first of all, it's just too many people who are over age, not too many people, but a lot of people are age over 65 and older. And as a matter of fact, in one in four will be in that category in 2020, 2050, and just the centenarians. Currently, globally, there are about half a million who are over age, over 100. But this number will be six times more in about 25 years. And these individuals have healthcare conditions, most of them. And therefore, they're using the healthcare system a lot more than the younger people. And there is a higher rate of possible complications, not only because of their medical problems, but also age-related physiologic change and also complex social situations. So, having all said this, why are we talking about this in the rehab is that there is some common principle and philosophy in rehab can be applied to age-friendly care. So, for example, we focus on what's important to the patients. And also, we have a multi-pronged approach, and always we consider the balancing measures, and finally, functional independence. These principles are very well aligned with so-called age-friendly care initiatives started by Institute for Healthcare Improvement, as well as many other organizations. So, today, we have an outstanding panel of speakers. First, Dr. Amon Julia Wynne, and she is the Medical Director of Inpatient Rehabilitation, Assistant Professor in the PM&R, Albert Einstein College of Medicine, Montefiore Medical Center, Wakefield Campus, Bronx, New York. Second speaker is Dr. Malav Shah. He's the leading attending physician, age-friendly care, Assistant Professor in the PM&R, Albert Einstein College of Medicine, Burke Rehabilitation Hospital, White Plains, New York. And third speaker is Dr. Jonathan Kirshner, Fellowship Director of Spine and Sports Medicine, Assistant Professor, Clinical PM&R, Weill Cornell Hospital for Special Surgery in New York City. Last speaker is Dr. Hilary Stevens. She is the Principal in Stevens Patient Care Community Communication. So, we will start with Dr. Wynne. And Dr. Wynne, first, I want to congratulate you. You earned the age-friendly health system participant status last year, and I want to hear, I want you to share your experience with all the audience here today. Thank you, Dr. Park. Thank you, Dr. Park, for the introduction, as well as putting into context the importance of age-friendly care in this point in time where we're seeing this aging, growing aging population with increasing number of comorbidities, complex psychosocial situations. And so, we have in our toolbox now the 4Ms framework, which is the infrastructure for age-friendly care. The 4Ms, as a refresher for those who are not familiar, is a framework for improving the quality of care that we deliver to older adults and focuses on what matters most, meditation, mobility, and medication. And the literature thus far has shown that focusing on these 4Ms has improved patient quality and performance outcomes, such as decreasing falls, decreasing acute care length of stay, ICU length of stay, adverse drug events, and also increases patient satisfaction and patient experience. Next slide, please. Okay. So, to give a little bit of background into the age-friendly journey that I've gotten through with my unit, I will share that my unit is a small 16-bed inpatient rehab facility within an acute care hospital within a large hospital network that is Montefiore Health Systems. So, Montefiore Health Systems has been expanding age-friendly care throughout the system through the development of an age-friendly collaborative. This collaborative was built in order to share information, best practices, tools, and updates for those teams and lines of service that have been trying to implement age-friendly care. Montefiore also has developed its own goals for developing age-friendly care, focused around improving equity, quality of care, patient experience, and also increasing collaboration across sites, across disciplines, and improving interdisciplinary care. So, I've been very fortunate to have been brought into the age-friendly movement through a friend and mentor who is a geriatrician. So, with her help, she introduced me and taught me all about the age-friendly movement and the 4Ms and brainstormed with me on how we can implement this on my unit. So, she's also connected me to many resources and introduced me to subject matter experts, and she and I had a successful kickoff event where we presented to hospital executive leadership to kind of pitch the idea of working towards age-friendly recognition. We had a lot of stakeholders there throughout the hospital system, and we generated a lot of interest and support for the idea and also found that many people were already working on projects within age-friendly, and we could really collaborate in order to share ideas and lead to success for everybody. So, with this infrastructure at Montefiore, mentorship, I was able to, my unit was able to gain age-friendly recognition as a participant in less than one year. So, I would say that I had an excellent substrate for finding success, and of course, collaboration is key, but I think that inpatient rehab units are uniquely positioned to implement age-friendly care and gain recognition because so much of what we're already doing is required by CMS and the latest version of the IRF-PAI. So, there isn't too, too much extra to do. So, one of the purposes of this talk tonight is for this group here to serve as a source of information, support for anyone who's interested in taking on the age-friendly journey and becoming recognized themselves. So, we're hoping to be that supportive community within AAPMNR for others. So, going back to the requirements for age-friendly care that we are already doing in all inpatient rehab facilities per CMS guidelines, we are already screening for high-risk medications on admission and discharge. We are screening for delirium, dementia, and depression, again, on admission and discharge, and of course, our bread and butter, we're mobilizing patients. They are participating in three hours of therapy at least five days a week, and our nursing colleagues also score and mobilize our patients using the quality indicators tool. The area that we're missing, and it looks like a, you know, negative to have this symbol here, is that we currently are not asking what matters to me. So, we can think of it as a deficit, but this is also an opportunity to improve the care that we're providing, and the IHI also is very flexible about how they, what they'll, what they accept for implementation and addressing what matters to me. Okay. So, what matters to me is the area that we really needed to develop on the unit, of course. So, we found that, you know, these conversations about what matters do tend to happen organically throughout patient care, but they might not necessarily be documented, or when care providers are prompted to document formally, it makes asking these questions awkward and unnatural, or we receive very generic answers because it's very scripted and prompted, and maybe patients didn't have the opportunity to really think about a genuine answer. So, the difficulty is in reconciling these two situations. So, one thing that we've done is we've created a drop-down menu where the providers can ask, choose which what matters to me question to ask the patient, and hoping that that would provide more of a fluid communication. Our house staff who admit patients are the ones who are asking what matters to me on admission. So, we've also added into their didactic curriculum a lecture on age-friendly care in the 4Ms and a separate lecture on what matters to me. And so, we built this smart tool, which is part of the H&P template. In the other areas of the 3Ms, can you go back to the last slide, please? Thank you. We still wanted to develop more. So, in terms of delirium, we are already screening for delirium. However, we wanted to add the CAM tool to our acute event note template, so that will be a future plan. Now, the high-risk medications we are screening for, however, another piece to the age-friendly recognition is having a plan to look at prescribing patterns and deprescription opportunities, reducing doses of high-risk medications. So, what we did is we developed a work group with a couple of very QI and PI-oriented physiatrists, some geriatricians, pharmacists, a geriatrician who used to be a pharmacist, and residents as well, medicine and a PM&R resident, to work on analyzing our baseline prescribing patterns and then looking for those opportunities for deprescription. One of the next steps that we have is to have a grand round, which will involve the residents as well as the faculty on safe deprescribing. As far as mobility, of course, we're already doing mobility and meeting the requirements as an IRF. However, our nurses, who also mobilize patients and assess mobility, don't have, of course, as much expertise and training as our therapists, so we've developed a two-phase safe patient handling training, which is very exciting as an interdisciplinary effort because it is led by an occupational therapist. In addition, we're also developing educational support, study groups, coaching, and dedicated paid study time for our RNs to prepare for the certified rehab registered nurse exam. Next slide. Okay, so this is what our current What Matters to Me template looks like. You can see there's a drop-down menu. The resident can choose which question to answer to fulfill this, and you'll see that there are a few of the responses that we've gotten that I've posted here. Next slide. Oops, I apologize for the formatting there. So, moving forward with What Matters to Me, there are many ways in which we can grow this practice, so we can add additional questions. You can see here what would make tomorrow a really great day, what do you worry about, how do you learn best. We would also like to ask What Matters to Me on a daily basis and include this in the daily progress notes or have each of the disciplines ask within the context of their therapy sessions, and then also to discuss in our interdisciplinary team conference how What Matters to Me is being addressed as a team. And then lastly, we would like to display What Matters to Me in the patient's room on their patient-centered whiteboard. Next slide. So, we've developed this new patient-centered custom whiteboard which contains What Matters to Me, which can be posted for the patient as a reminder as well as for the staff. Thank you. Thank you so much, Dr. Nguyen. And I'm sure the audience has a lot of questions about, you know, more how to accomplish these things, but if you don't mind, we will wait until the end or the presentation is over and we will have a Q&A session then. So, the next presenter is Dr. Malav Shah. And Dr. Shah, also, I want to congratulate you for accomplishing the age-friendly health system, committed to the care excellence. So, this was this year's accomplishment, and I would like to ask you to share with all the audience about what is the role of the physiatrist and how you direct each member of the team to be able to accomplish this status. Sure. Thank you for the introduction, Dr. Opark, and congratulations to you as well for your efforts on the team for the commitment to care excellence designation. As Dr. Opark stated, my name is Malav Shah. I'm one of the inpatient physiatrists at Burke Rehabilitation Hospital, which is a standalone rehab hospital with about 150 beds that did recently obtain commitment to care excellence designation. I was initially drawn to the age-friendly idea because I believe it embodies the many of the core tenets of physiatry, particularly our unique position as the quality of life doctors. Extension of life is a goal of medicine as a whole, but physiatry is really what teaches us to dive a little bit deeper into what a life worth living is and what that means to that patients. That doesn't mean using metformin as a tool for longevity or lengthening your telomeres or uploading my memories to chat GPT so I can live forever, but helping our patients make actual macroscopic life changes that directly affect their subjective perceived quality of life. I spent the last hour writing that joke, so I hope that landed via Zoom. I'm an early career physiatrist and have already seen firsthand, as many of you have, what the data Dr. O'Park presented earlier in this talk has shown. We're treating more and more of an aging population, one that's living longer and living better and have a strong desire to continue doing so, and we as physiatrists are in a unique position to help facilitate that process. Skip to the next slide, please. So on this slide, we see data that I asked our team to pull showing our age trends, particularly at Burke Rehab over the past decade. Our population of septa, octa, nonagenarians continues to grow, and the way that we have to approach these dates grows with them. Last month alone, I had three new lower extremity amputees, all of whom not only survived their initial vascular pathologies but came to rehab with the goals of true functional ambulation. All three of them were on or around the age of 95, which is a trend that we are seeing more and more now, and two of them went on to become strong prosthetic candidates and are actually undergoing prosthetic gait training right now. The beauty of the age-friendly recognition is that it causes you as physicians to formalize many of the processes that you are already practicing, as Dr. Wynn had previously stated, in a way that hopefully will improve outcomes for this particular patient population. To make those processes work really takes buy-in not only from you as the physician and the patient who wants to survive and thrive, but really the entire patient-facing team. Next slide, please. So I'd like to discuss what that age-friendly team looks like, particularly at Burke. The physician is the front end of the rehabilitation team in the rehab setting, but I'll discuss our role last. You'll see how each of our team members directly contributes to the translation of the 4Ms directly to that patient care, and I want to thank Dr. Winnigan for providing that groundwork for what the 4Ms are and what the age-friendly initiative really is. So the first position that we talk about at Burke in particular is our AVP of quality. So for us, that is a woman named Maeve who's really an all-encompassing force who specializes in understanding all of the systems that are currently in place and identifying any of the gaps that already exist in the systems that we do have, as well as working with the whole multidisciplinary team to fill those gaps and determining what sort of new processes we can try. Her grasp of the quality improvement process is essential and it keeps us on track and accountable. Next, please. Next, we have our pharmacy team. Our pharmacists review each and every admission and perform an immediate medication reconciliation. They screen for dosing adjustments based not only on age, but weight and kidney function, etc. The pharmacist attends our weekly huddles, which is when we meet once a week with many members of the multidisciplinary team to do a quick run-through of all of the patients on the unit. The pharmacist attends that huddle, reviews each patient's medication profile as they're being discussed, and makes any new recommendations or identifies any possible culprits from a pharmaceutical standpoint to any medical or cognitive concerns that the rest of the team is seeing. They do the same at behavioral rounds, which is for our brain-injured or otherwise agitated patients, as well as at our post-fall huddles, which we hold for any patient event in which a fall has taken place so that the entire team can get together and identify the factors that contributed to that patient fall so actions can be taken to help prevent further falls. So, the pharmacist does provide that pharmaceutical background. They have a strong grasp of the beers list, and they make evidence-based recommendations based on that list. Next slide, please. Then we have our neuropsychology team. They're available to be consulted on any patient for whom we have a suspicion of any sort of cognitive impairment, whether that's delirium or dementia. They provide education not only to the patient, but to the family members and members of the care team, and provide them with recommendations on how we can best help that patient clear their acute issues. They also follow up with these patients while they are inpatient on our rehab unit, as well as after discharge, when they're discharged back to the community, or set them up with the resources available in their local communities to make sure that these issues are being addressed after discharge. Next, please. Then we have our patient experience representatives. They recruit a team of volunteers, who we at Burke call patient ambassadors. They see all of our new admissions by day two of their admission at Burke, and they provide those patients with an overall outline or orientation to what Burke has to offer, what the rehab process is, and clarify any issues that the patient might have that the medical team didn't immediately make clear on their admission. Most interestingly, these volunteers are responsible for the get-to-know-me boards, very similar to what Dr. Nguyen had been talking about that's built into their EPIC. For us, our boards are a physical board that hangs in the patient rooms. This helps communicate many aspects of the patient's care that the patient finds important for their team members to know. The patient experience team also identifies any new issues that the patient might not feel comfortable bringing up with the medical team, and they inform the appropriate discipline, whether that's us as the medical team, the nursing team, the social work team, the therapy teams. I do want to highlight some of the questions that we ask on the get-to-know-you board, one of which is things that make me happy, things that the patient still finds that they need assistance with, things that cause the patient any sort of anxiety, and that helps us to help identify triggers of this patient's frustration so that we, as the medical team or the therapy team or the nursing team, can avoid bringing up aspects that might worsen the patient's stay or their overall outlook on the rehab process. The question that I find the most interesting is the one that asks what is something I'd be surprised to know about you. I personally find these boards, as a physician, most helpful in patient rapport building. It's an immediate way for anyone who walks into that room to directly relate to the patient and establish a connection to the patient, let them know that they're in an environment where they are recognized, where we are understanding of what they are going through and what their goals are, and how we can help them reach those goals. Next slide, please. The nurse manager is instrumental because the nurses and the nursing assistants are often spending more time with the patients than anybody else on the team. Our nursing representative on the team helps to disseminate information that's directly related to signs and symptoms of delirium, as well as prevention techniques, and how to report any of those concerns to the appropriate medical team. Since formalizing this process through a didactic session that we provide for our nursing aides, we've actually had many of them come back and tell us how much they appreciate the education, how much more they're now recognizing what this means in the patients that they're caring for. I've had one nursing aide tell me that she had a family member in the hospital months ago who the aide says is now, she now recognizes was going through a delirium process, but it was something that was never explained to them while they were in that setting. Now she's using that education to better identify that in the patients that she's taking care of, so that we can help to address those as a team. This has been particularly helpful in our after hours staff, as delirium is often presenting itself through sundowning and at times when the primary teams are not available to see the patients immediately or at that time. Getting those reports from our night staff helps us to better prevent those issues leading into the evenings. The nurse manager also helps with identifying medication effects and efficacy. They can let us know if there are any adverse effects, particularly related to cognition or mobility related to the medications that we're prescribing and the timing of those medications. The nurse manager is also the leader of the falls huddle, which again identifies any factors associated with any patient falls so that they can be prevented in the future. The nursing staff is key in mobilizing those patients outside of therapy sessions. Therapy three hours a day, five days a week is fantastic, but there's plenty of other waking hours during the day that we like these patients to be up and out of bed at the very least and moving with nursing representatives who are trained in mobilizing that patient safely. Finally, the nurses help in encouraging the patient through the rehab process and goal identification, goal setting, and helping to fill out those get to know me boards as well. Next please. Finally, we have our therapy team. They're key and centered on mobility through strong collaboration with the patient, with caregivers, and modulating their approach based on the patient's presentation, what the patient's goals are, and what their mentation may be and may be fluctuating at that point. They're key in identifying any barriers to a safe discharge and they help the entire interdisciplinary team find solutions to those barriers. Next slide please. So finally, there's us, the physician, the physiatrist on the team. We pick up the baton directly from the acute care setting and help guide the patient down the rest of the care continuum. We address their acute medical need, which is usually their reason for admission, but at the same time, we're also responsible for helping to present the patient with tips and tricks and guides and education, whatever it takes to prevent future injury or pathology. We coordinate with all the other team members to ensure that the forums are addressed for every single patient and to facilitate a safe discharge. We're directly responsible for medication prescribing and for identifying and preventing any new medical complications that may be contributing to their, to their, to any adverse events during their rehab stay. I was raised as a Boy Scout and one of our mottos was, leave it better than you found it, and that typically refers to helping clean up nature, but it's also a way that I've found approaching medicine, approaching our patients, that as physiatry, as physiatrists, that's the role we can play with our patients, that we not only get them through their acute illness, but leave them with tools needed to improve their life outside our units. And so the age-friendly initiative is really formulating your process in a way that directly responds to this aging patient population in a way that allows them to improve their life, even if they're in their 80s, 90s, hundreds that we're seeing more and more often, because there's always something a physiatrist can offer that helps to lead to a better quality of life outcome. I'll hand it back to Dr. O'Park. Thank you. Thank you, Dr. Shah. Please save all your questions. So the next speaker is Dr. Jonathan Kirshner. Dr. Kirshner, I want to ask you, because a lot of things are happening in our body as we get older, and what are the things that are happening and how we can prevent it? And what is the implication of those changes when we are engaging in our sports activities in the advanced stage? Thanks so much, Dr. O'Park. So I have a slightly different practice. I'm basically outpatient-based and I practice spine and sports medicine. And I'm the fellowship director. And when we interview fellows, they always ask, you know, what sort of athletes do you see? And, you know, what sort of sports are they playing? And, you know, a lot of my patients, I really see the gamut, but a lot of my patients are 60s, 70s, 80s, and their sports are, you know, tennis, going to the gym, running around, chasing after grandkids. You know, there used to be stereotypes about older individuals playing sports, but now people really are playing through their lifetime. And we really want to encourage that. We want to encourage physical activity. So we can go to the next slide. You know, sports are fun and, you know, games, but they can be used as rehabilitation tools. So, you know, there are certain normal changes that happen to older individuals, and you want to take that into account as you're assessing patients and also prescribing rehabilitation programs. Many of us, you know, experience as we get older, you know, we lose muscle mass in the form of sarcopenia. We have reduced endurance, decreased cardiopulmonary reserve. And these are normal, but certainly if you have heart disease or pulmonary disease, that gets worse. The longer you live, the more likely you are to have chronic conditions, as Dr. Opark mentioned. So whether that's arthritis, neuropathy, vestibular issues, you know, these may impair balance and increase risk of either injury, falling, or other issues when exercising and, you know, engaging in rehab. So you want to keep this in mind as we're prescribing for older individuals. Patients can have stiffer joints, especially first thing in the morning. So that may affect the timing of when you may recommend exercise. Often I don't necessarily recommend exercise first thing in the morning for my older patients, just because they may need to loosen up and sort of warm up a little bit before they start exercising. They may be better, you know, later in the day for that. And then visual and auditory impairments, you want to keep that in mind too. So as you're giving instructions, you may want to make them larger, use larger font. I use lots of pictures, videos. I like to demonstrate exercises in the office with the patient and video the patient while they're doing it. That way they can bring it home and watch those videos as well. So next slide, please. When it comes to physical activity recommendations, there are different organizations and guidelines that have recommendations, but most are based on the CDC guidelines. And I think that's a great place to start. So this is true for all patients. And, you know, I tell my older patients, if anything, you need to move more than younger people, not less. But often older folks, you know, may not want to move. They may not be as motivated, whether that's for physical, social, you know, mental health reasons. You know, they may not have as many peers to exercise with. They may not know how to engage in a program, where to find it. So at HSS, you know, we have group classes for older individuals, things like chair yoga, tai chi gong. So, you know, I always tell the patients, there is something you can do. It doesn't have to be, you know, running a marathon, but there are basic, simple things that everyone can do and everyone has to do daily. So at a minimum, everyone needs 150 minutes of moderate intensity activity. That's defined by somewhere between three and 5.9 METs. A good rule of thumb is that you can talk, but you can't sing. So say you're walking on a treadmill. If you can talk and have a conversation, but you sort of can't sing to the music, then you're working at a moderate intensity. Or you can do 75 minutes of vigorous intensity activity per week. So that's more than six METs. In that situation, you can't talk. So you're on the treadmill, you're biking, you're sort of huffing and puffing, you can't quite sing along to the music. You also need to do at least two days of strength training. A lot of patients tell me, oh, you know, I live in New York City. Oh, I just walk a lot. You know, that's my exercise. My doctor told me that's all I need. That's great. You know, I tell patients walking is great to get around the city, but that's not really the best form of exercise. You know, you want to maximize your bang for your buck, so to speak. I don't know about you. I don't want to spend an hour walking around when I can burn the same amount of calories, you know, doing say 15 minutes of cycling or 10 minutes of strength training. And for a lot of older individuals, the walking actually can aggravate chronic conditions like spinal stenosis, trochanteric bursitis, knee arthritis. So I don't discourage walking, but I tell the patients that might not be your best form of exercise. It's usually not vigorous enough and it doesn't really involve strength training. So it's really important to provide strength training for joint protection, reducing symptoms related to osteoarthritis, other factors that prevents falls, especially hip strengthening has been shown to help with falls. Strength training is important for osteoporosis. So I find that patients really tend to shy away from strength training. And that's one of the most important things that I focus on. And then finally, flexibility. Lots of patients are not really engaging in stretching. You know, in the old days, if a patient doesn't know where to start, I say, remember back to high school gym class. If you can remember some of those exercises, that's probably a good place to start. A lot of people just start jumping right in and walking and jogging, but, you know, remember to warm up, cool down, do some stretches, work on flexibility, not just for muscle elongation and stretching the muscles, but for improving joint range of motion and maximizing the range of motion that they have. So in order to maximize mobility, you know, we need good hip, ankle, knee range of motion, spinal flexibility, things like that. So next slide, please. You know, patients need to do what they enjoy, otherwise they're not going to want to do it. So, you know, we talked about what matters most. You really have to ask the patients, what do you like to do? Do you like to dance? You know, other types of performing arts. There's ways to dance for an hour and get really good exercise. Some patients like to garden. That's a good form of exercise, you know, assuming that you're sitting on a stool, you're not bent over, hurting your back, doing other things. So you may have to be aware of the ergonomics and the positioning of how the patients are doing those activities. But most, you know, social recreational things can be gamified or turned into an exercise. When you're prescribing exercise, you want to think about the chronic conditions that the patient has, and you may want to modify and reduce certain activities or promote specific activities for that condition. So of course, osteoporosis, we want to, you want to teach patients balance training to reduce risk of a fall, to reduce risk of fracture, and then we want to engage them in weight-bearing exercise. So really teaching them how to do some strength training. Patients, I can't tell you how many times I say, well, I have osteoporosis. My doctor told me don't lift weights. I had a patient today who told me that. I said, no, it's the exact opposite. You do want to lift weights, but you want to do it in a safe and healthy manner. And the patient asks, well, how do I do that? I'm not sure. Usually I start with prescribing physical therapy, and then whether the patient wants to work with a trainer, you know, there are a lot of sort of other types of professionals that aren't at the level of a physical therapist that certainly can help out. Patients with Parkinson's disease, you want to, you know, focus on fall prevention. Patients with cardiovascular disease, aerobic condition is really important, improving their endurance, ability to climb stairs, things like that. Patients with arthritis, you know, many patients say, well, I have knee arthritis. I shouldn't be walking. I shouldn't be running. That's not true. Patients who have knee arthritis actually do better if they can walk and run, mainly through the effects on their weight and BMI. That being said, if someone has a bad knee, I don't necessarily say, yeah, go out and run. That may not be the best form of exercise, but I don't necessarily discourage them. You know, it's always patient-centered. What do you want to do? How can I help you do that? Maybe if that's a sport or activity I think they shouldn't be doing, I may nudge them in a different direction. But arthritis is not a contraindication to exercise. The other thing you want to think about is timing of medication. You know, diabetics may need to reduce their insulin before exercise, or if they tend to be, you know, hypoglycemic in the morning, maybe that's not, you know, first thing in the morning is not when you want to do exercise. You may want to affect, you know, not only insulin, but oral hypoglycemics, or make sure they're checking their sugar either before or after having a small snack either, you know, before or during exercise. Patients forget to consume enough protein. Protein requirements are sort of all off, you know, all over the map. And a lot of the USDA requirements are really minimal. I mean, some people think, and they require between, you know, 0.5 and 0.7 grams of protein per kilogram. Some people think older individuals could benefit from up to two grams per kilogram. And a lot of people think about consuming carbohydrates before or after exercise. But, you know, it's recommended to have a little bit of protein before exercise because it modulates the insulin relief, and then certainly having some protein within 30 minutes to an hour, hour and a half after exercise to promote muscle building, muscle formation. Patients with pulmonary disease, you want to make sure they have a broken dilator handy, and you want to maybe dose that right before exercise as well. So I think that's all I have. I have some references here, and I'm happy to talk further in discussion, answer any questions. Thanks so much for having me. Thank you, Dr. Kirshner. Okay, so our last speaker is Dr. Hilary Stevens, and the stage is yours. I'm going to stop sharing. You prefer to share your slide, right? Yeah. Dr. Stevens, you're still on mute. Hopefully, this will work. Very good. Well, first of all, thank you, Dr. Opark, for all your work on the logistics of this event. It's a very important topic. I've really been thrilled to see the progress in rehab medicine and learn more about this age-friendly initiative. From Dr. Wynn's explanation, what's going on at Montefiore in your unit, kudos from Dr. Shah right on target. Where were you all 20 years ago? Anyway, it's really good progress. Thank you, Dr. Kirchner, for your tips about this physical activity because it really is key. I also will just give a brief disclosure. Some of the work I'm going to be talking about, I do use when I do some consulting. To let you-all know, our work started years before this age-friendly care initiative. However, both efforts truly complement each other because they have the same goals of improving care quality for older adults with multiple problems. Now, the slide will be blank. I want to just give some quick background. In my career commitment to geriatric rehabilitation, and I did geriatric primary care along with rehabilitation on various rehab units, inpatient, outpatient, house calls, nursing homes, whatever. I became more than aware of the complexities in many of our older patients. Like you, I imagine, I experienced extreme pressures to see patients very quickly. At the same time, I was teaching rehab residents and conducting a randomized control trial of exercise in hospitalized adults 70 years and older. What emerged from these experiences was an organizing framework to consistently consider key issues in the care of rehab patients, especially older adults. This framework also helped keep a focus on the whole patient and the hecticness of care, as well as decrease risks because there was less likelihood that key issues would fall through the cracks. Here you see the framework has four domains organized in a clinically intuitive sequence and represented by the four overlapping circles. Domain 1, the key medical issues, medications, diagnoses. Domain 2, what's going on in the patient's mind, their preferences. Domain 3, function, of course, depends on the diseases and the burden in domain 1, as well as what are the patient's abilities? What do they want in domain 2? Then you have domain 4, the living environment, because everything with the context around the patient, because we know disability and relationship difficulties happen at this interface of the individual patient and what's going around them. Each of these domains looks at the patient from a different perspective, and together they create a whole picture to guide physicians and teams care. Also, these domains are just a standardized framework, and there's flexibility. The content depends on the expertise and is based on the expertise of the clinicians taking care of the individual to decide what are the key issues to be addressed in each of these domains, and that, of course, will depend on the situation and the time available. Now, could these domains explain rehab care? An experienced certified rehabilitation charge nurse was trying to convince a man who was in the acute hospital with new quadriparesis to transfer to the rehab unit, and he was having none of it. One day she came to me really excited. She said, ''Hey, Dr. Stevens, I'm on my third visit with him. I was about to give up, but then suddenly the domains came into my mind.'' I quickly explained to him, ''Now, this is what we want to do in rehab, in your health issues, your medications, we've got to work on those. We've got to work on your coping because this is really a lot to deal with. We'll deal with your function. How will you get out of bed? How will you move around at home? We've got to deal with what's around you, your environment, your family, how your wife will help you out, and how arrangements need to be made at your home.'' He right away accepted being the transfer to rehab. She was so excited. Anyway, a really good example. Next, a brief word about quality of life that I appreciate Dr. Shaw emphasizing. It's at the intersection of all of these four domains because as we know, issues in any one of these domains can affect quality of life. I just want to remind you in case you're not aware of something called the disability paradox, where researchers found that individuals who were in very difficult life circumstances rated their quality of life as high. When outsiders would look and think that their quality of life was poor. Quality of life really needs to be self-rated by individuals. Now, you're probably asking, is there any evidence this model works? Well, years ago, because of the really good feedback we were getting when these were used to organize documentation, team conferences, teaching PM&R residents, rehab. I got to thought perhaps this model could serve as a common mental model, a framework that could work in larger health systems to help treat the whole patient and manage the whole patient. Mental models can be unconscious, subconscious, or conscious, and they determine our behaviors, our actions. By the way, what we're learning about DEI, it's mental models that are underlying many of the equity issues we need to be addressing. Anyway, my colleagues and I in 2001 and 2002, decided to write up the concept with clinical examples. Then actual research evidence came in with Dr. Kim in 2013. Inpatient rehabilitation discharge summaries were really improved when they started using the four domains. Clinical outcomes of inpatient rehabilitation were definitely better, markedly improved when the domains were used to guide team conferences. This work was published by Dr. Kushner. Then work done by Dr. Connor, I'll get to in just a minute. Now, just a little bit more detail. Here you see the four domains and then sub-domains, the topics within each of the four domains. It's a list of 19 items that became an internal checklist to be sure that in the rush of clinical care neither I nor the team would be missing a critical aspect of care, or even missing an entire domain. Now, you'll probably say, well, what about issues like pain or falls? Where would you list them and document what you're going to do about it? Well, pain and falls can be multi-domain issues. Falls are a functional problem. Falls, we know, depends on medical issues, medication toxicities, peripheral neuropathy, cognition, poor safety awareness, function, gait disorder from stroke, environment, the chair is too far from the bed, there aren't grab bars in the shower. This quick checklist of looking at all four can be documented or thought about in conjunction with falls and may be documented under physical function because falls are in fact a functional problem. What about helping patients directly in terms of speaking up, which is going to become more and more important for older adults? How do we help them speak up, ask questions, share their preferences, what matters to them? Well, our group published in 2001 and 2005, the result of a quality improvement project on our rehab unit, in which patients were given three ring binders on admission to rehab. And then during the stay, the content was added, arranged by the four domains and individuals, patients, they took this home with them, and all the key information they needed was in the notebook. Because the project worked well, it was then disseminated across the entire 295-bed rehabilitation hospital. Well, since that work, we've refined the concept, and it's now referred to as the Notebook for Wellbeing and Health Care. And tabs indicate the four domains, and section headings suggest the type of key health information to keep in each one of these sections. Now, mind you, people can make their own notebook, and some people do, or if they're just getting outpatient care, have a single manila folder in which you keep the key recent information you need to manage your care. But the key issue is about teaching individuals to keep their key information in one place readily available. And using a tangible tool like a notebook helps individuals in their self-management. And as one patient who was very motivating for me said, Dr. Sebens, you gave me back the power over my health care with this notebook. So I know now she'll be able to speak up. And also, these kinds of notebooks can be really helpful for caregivers or care partners. I used one to manage the last five years of my mother's decline from dementia, and I'm using now one to help my husband. Well, here you see electronic devices. So a lot of you might be asking, well, what about patient portals, cell phones, and the like? Well, there are advantages and disadvantages to paper and electronic media. It really depends on patients' preferences, their abilities, and if they have access to electronic media. It's not a question of either or. And in fact, patients who were in our Parkinson's study, I'll mention in a minute, they all received personalized notebooks for well-being. They liked them. They used them. And they also shared with us they liked learning new materials by having them in print on paper. The last most recent project I'd like to describe is Care Management for Health Promotion and Activities in Parkinson's Disease, or CHAPS. This intervention was tested in a randomized controlled trial. The intervention was nurse-led, telephone-administered, a proactive intervention for outpatients with Parkinson's. The design team, led by Dr. Karen Connor, a nurse, health services researcher, and including the Parkinson's disease specialists, the design team decided to incorporate the domains. But I first want to mention that the results of the randomized controlled trial were positive. This whole multi-component intervention actually improved care quality. And there are five open access publications with all of the details, if you're interested. Now, one of the findings concerned the domain model. Why did the design team decide to use these four domains? One, they needed a way to organize the multiple health issues that can arise in Parkinson's. Secondly, they needed it to guide nurse care managers in whole person care. Third, they needed to standardize the intervention for this multi-site project. And then fourth, to really help in close collaboration and communication between the nurse care managers and the PD specialists. They worked as a team and others. And among the findings, the domains, it turned out, did guide whole person care. Over 4000 problems were identified and documented under the four domains. And this was determined through chart review. And you see the percentages here of how the problems were, in fact, distributed over all four domains. And then last year, we wrote up the entire protocol for individuals who might want to look at this kind of multi-component intervention and adapt it to their own setting. And each component also could be easily tailored to any individual with a chronic condition or to different patient populations. Now, full circle back to age friendly care. Well, we have this wonderful emphasis on the four M's. And as you see here, medications, it was focused on in CHAPS under a domain one issue, a medical issue. Mentation and what matters are domain two issues. And mobility, clearly a domain three, a functional issue to be focused in on. So I'll finish up there. Thank you very much for your attention. And I also want to share the gratitude with I have for lots of patients with chronic conditions, families and many, many colleagues who have worked on these ideas to try and make a difference and improve care quality for older adults with multiple health conditions. Thank you. Thank you so much, Dr. Stevens. So now we are going into a Q&A session. And any audience have questions, you can put it in the chat box or just simply raise the hand. Can I ask a few questions? I'm Dr. Paduri. I'm Dr. Paduri. Hi, how are you? Very nice to see you. Congratulations on all the four speakers and their accomplishments and also for the wonderful presentations. I thoroughly enjoyed them. But I have two questions for whoever can pick up the answer. I would really like to hear. You mentioned about during rounds, about checking their anxiety and, you know, how their day is going and so forth. Have anybody have gotten deeper to their anxiety about discharge? We talk about their mobility, their medications and whatnot, but we never ask them about their anxiety about discharge. More so, whether they want it or not, automatically on the acute side, they refer them to PMNR. Whether the patient is functional or not. I mean, I hate to point out to people. Patient is walking 300 feet with stems. You know, contact guard, excellent candidate for rehab. Naturally, they will be, you know, rejected by the insurance companies. And then, of course, the anxiety level goes up. Because they're going to nursing home. In spite of having so many nursing homes in every community at the patient level, nobody wants to be in a nursing home, whether it's rehab or not, even to this day. Even though a lot of nursing homes have dedicated rehab units. But nobody wants to go to nursing home. There's a big anxiety on the patient's part and the caregivers at home. There is maybe a spouse with dementia. The patient happens to be the caregiver. And now the patient is going to nursing home. And who's going to take care of the spouse? That's an anxiety provoking situation. How do you deal with it, or do you have any kind of intention to add more to the anxiety about discharge? I think that this is worth to hear both the speakers, Dr. Wien and Dr. Shah. So Dr. Wien, you want to go first? Sure. So I do think this is a very common situation, whether in acute care or discharging from inpatient rehab. So I think having that lens that Hilary shared, the four domains, can be really helpful in the situation because we're managing the functional need, the physical need, the emotional need. And then planning around the environment, right? We have this patient who is the caregiver of an ailing spouse. So that's a very important consideration as well, who's going to take care of that person. So it becomes a planning situation where you have to make sure that there are resources in the community if this patient is going to be discharged to the community for themselves as well as for the spouse. And so pulling social work into that very early can be very helpful. I do think this is a very borderline patient who could come into inpatient rehab, could go to subacute, could go home, depending on the circumstances. So I think really paying attention to the lenses and then working with the individual patient characteristics in order to come to a safe discharge plan. The other thing that I would, that I support is always setting expectations for discharge early, planning around discharge so that patients always know that it is inevitable at the end of the tunnel, but that we wouldn't send them home to an unsafe situation, but just setting the expectations early. I agree with much of what Dr. Wynn said, it's about setting those expectations early. I would say about 50% of our patients can't wait to go home and the other 50% want to stay with us forever. And we often have that conversation with the 50% that wants to stay with us forever. And it's a lot of letting them know that we are aware of the things that are giving them that anxiety. For most of those patients, it is a general sense of feeling overwhelmed about the idea of going home and taking care of X, Y, Z, whether that's ADLs, cooking, cleaning, taking care of their loved ones. Our job and one of the purposes behind the Get to Know Me board is really identifying and dissecting each of those factors so that we as a team, either medically or from the therapeutic side, the therapy side, can address them individually and let the patient know that these are concerns and anxieties that can be overcome by the skills that we're providing to you. And so when we specifically ask the patient, you know, is it the fact that you're concerned that you won't be able to make your spaghetti in the evenings? And then we take them to the ADL room and have them in the kitchen with the therapist and perform the exam that they are concerned that they won't be able to do at home. It provides them with that level of confidence that helps to melt away some of those anxieties. Thank you, both of you. Excellent points. And actually, I have a question, similar kind of a domain, this anxiety or even depression in the outpatient setting, Dr. Kirshner, so that sometimes, you know, the patient come in and then they are very high functioning at, you know, when you see them walking in, you don't even know what can be potentially wrong in this person. However, the person has a great athlete when they were younger and have some kind of injury and that injury can be circulating, meaning it was a shoulder, it goes to the back and now to the knee. And that's kind of, you know, all the time and the person is really feeling the age. Do you encounter that kind of issues and how physiatrists can manage or, you know, encourage or manage that situation? Sure. I mean, that's a really common issue when someone is used to being so high functioning and they can't do the things they used to do. I mean, you know, I have patients that used to be professional athletes and now they have trouble getting out of a chair. So we can't really focus on the things that you used to do before, but really what are their current goals? And like Dr. Wynn and Shah said, setting expectations is really important. Asking the patient what matters to them, what their goals are. Yeah, it may not be to hit a three-pointer or throw a 90-mile fastball, but, you know, transferring, dressing, toiling, doing ADL, things like that. And often, you know, mental health issues do manifest as immobility. You know, patients either don't want to leave the house, they don't want to exercise, they don't want to move. And we know the benefits of physical activity in reducing mental health issues, reducing anxiety and depression. So, you know, I was trying to find the simplest thing the patient can do and grab onto that. And you know, as I mentioned earlier, we do some exercises in the office. I try to show them a couple of squats, some very basic things, and I say, look, you just did it. So I know you can do it. We just did it together. Why don't you do three or four of those a day, then make it 10 a day, then make it 20. So, you know, having small and measurable goals, don't want to overwhelm the patient. You know, I don't give them a handout with 20 exercises, I give them one or two things to do, and that way they're making meaningful change, and they're proving to themselves what they can do. Just like making that spaghetti. You know, I can do those squats, I can do more. Thank you. Any participants, any other questions? Dr. O'Park? Yes. A question on this, I guess it was with Dr. Nguyen, maybe it was Dr. Shah, I can't remember, this issue of everybody on the team asking every shift what matters to you. Do you get into a problem of the patient being asked too many times, because I know in the past we had issues with patients saying, oh, everyone's always asking me the same question. And this would be in the outpatient setting, you have to fill in the same questionnaire. So when I heard your approach to being sensitized, does that ever seem to be an issue? Or it won't? I'm not sure Dr. Shah maybe wants to go first, because you might have more members of your team who are asking what matters to me. So we don't do it on an every shift basis. It's typically done on admission by the admitting physician, whether that's a resident or one of our nurse practitioners, and then by the multidisciplinary team within each of their own disciplines. In terms of the patient wanting to participate in that conversation, you're entirely right. Some of them are frustrated with getting those questions repeatedly. But because they're framed a little bit differently by each discipline, we often don't see that that patient feels that same way that they're repeating themselves over and over again. Some of the patients don't want to participate in the get to know me boards at all. They came to rehab with a very specific goal. They want to get better. They want to get out of there. And we're not there to impede that process. This rapport building process isn't going to be the same with every single patient. But it works with the ones that it works with, which happens to be, you know, most of them are willing to participate and looking forward to participating. But for the ones that aren't, we don't push this. This is not a requirement of being in the rehab facility. But it's something that we attempt to see if it improves their state. In our situation, what matters to me is asked upon admission formally. Now, the other disciplines have their own forms of asking what matters that pre listed the age friendly movement. So our therapists will ask for personal goals with they might ask even with each session. And then our nurses also ask what's called a patient individualization, which I think Dr. Shaw also showed a epic screenshot of. But as he also said, the context changes the questions that are asked. So what matters could mean what matters in this moment, in this session, today, or in the next three weeks. So the conversation changes. And I think can really be more organic and natural. It might be anything from, you know, the tea is always cold, I really need hot tea every morning to, you know, my goal is to dance at my son's wedding. So depending on the context, I think the conversation can be less tiresome, and more natural and in that way can be more patient centered and patient focused. Thank you. Thank you. Very thoughtful answers. So I see there is a question by Dr. Chobaro. So the question is in patients who have sustained brain injury many times, there have they have cognitive deficit and unable to, or unlikely to be able to reliably answer these questions. I imagine this means a substantial communication with the family and caregivers. However, are there any other modifications to this approach within the tenants of this initiative? It's a very long question, but Dr. Chobaro, you can ask questions yourself. Yeah. So basically, someone who is not able to express accurately about themselves, then the caregiver intervenes in that case, was there any modifications are done to capturing what matters to them? Very challenging question. I have another question. Actually, Dr. Wynne, you're about to answer. Oh, yes. I mean, that's a really excellent question. So especially when we have patients who have communication challenges, sometimes it takes a little bit of intuition or almost interpretation. So we can take an example of, you know, maybe playing music for one of these patients and just seeing a different look in their eyes, or see them light up a little bit, or the way that their behavior changes when a family member walks into the room. So rather than necessarily asking a question and expecting a verbal response, we might interpret this as, you know, this was a really meaningful thing for this patient today. That is probably what matters to them or is important to them. So there's a little bit of interpretation that sometimes we need to do as clinicians. Baked into the whole process is looping in the caregivers as well. So it is, like you said, Dr. Travato, substantial communication with the family and caregivers, and that's to help provide us a foundation, a starting point to try to anticipate what this patient is looking forward to or what their needs or goals are, so that we can build a program based off of that. Can I ask you my last question? You know, rehab unit stay is very short, right? It's getting shorter by the day, right? And keeping that in mind, we focus on so much about during the stay, right? What matters to them most during the stay, the first two weeks, they're focusing on walking, they're focusing on ADLs and so forth, but in the long range, what matters to them most is not really concretely addressed by us, okay? Putting that aside, social isolation becomes a big deal for these patients, especially when the family is working and they're at home with a two-hour aid or three-hour aids or no aids whatsoever. So during that time, social isolation is a big deal, even after a successful rehabilitation. Do you think you can incorporate that as a, you know, follow-up when you see the patients in the outpatient setting, post-rehab, three months later or six months later, when? I think that even our Surgeon General had said that majority of the individuals in this country are socially isolated, and more so with somebody who has gone through a catastrophic, you know, incident leading to acute rehab, and they need some kind of a support from organization like you. So how can you address that? Well, that's a very difficult question, and I was about to ask, but then I was thinking it's too difficult, but any, maybe Dr. Stephens. Yeah, but what I'll say, socialization is key to health. It's as important as oxygen, almost. And if you think about it, as part of your screening, it's true. Inpatient rehab, you've got to deal with the basics. You have only two weeks, you know, is their swallowing okay? Can we get them to walk to the toilet to go home alone? You're working on sort of the basic ADLs. However, if you can screen, and I think you're what matters, is a wonderful emphasis with this whole age-friendly movement on what I call advanced ADLs, which, you know, you have your basic, your intermediate, can you do a meal, manage your telephone, simple money, to the advanced. I mean, that gets into driving, going back to your job, playing your musical instrument, but also socialization is part of that. What are their activities in the prior life that they socialized? And I'll share an example, a woman that I had a bad stroke, I saw her in outpatient. And so I was asking about this, and she would go to church, but she didn't want to go to church because she was a wheelchair, and she would drool a little bit. But we worked on that, and we got someone to take her to the church. And then in follow-up, oh man, she was a new woman. She got over that hurdle, and just being with people, and usually your faith-based group, they encompass you, they're there to help you, you know them. So that was a key strategic move on our part to make sure we somehow got her to church. So that's part of sort of the advanced activities of daily living to just screen for during inpatient, and a lot of you probably already do this, but also keep in mind that when you're looking at the environment, in this sort of domain model, the environment has three key elements. It has the physical environment, their home and their neighborhood, are there parks nearby? Being in nature is so important, you know, for sanity, for health. And then be social, and you've mentioned, I think all of you have mentioned the family. That is sort of key to screen, is there a relationship there that you can bring back together? And you may have a niece who lives out of town that can take time off from work, or she can telecommute, and she can come into town for a month, and then you'll bring in another family member. Those kinds of things I think are, because you don't have much time, are quick ways of screening. How can we resume some element of socialization? You can see I'm passionate about it. I do quickly want to add a quick question. I'm sure you probably send your patients home with notebooks. I know that became a CARF credentialing criterion back in 2004, when we shared our experience with give the patients a notebook, not all these loose papers with their bedpans and their clothes in a plastic bag. So I assume you all give them a notebook. Think about adapting it to have it be their self-care tool to help them take control or the caregiver take control, and to continue using it once they leave rehab. Take out the stuff that's your rights while you're in rehab or whatever you have. But anyway, that's just a thought. I don't know if that's workable, but it's a thought I've had because of this need to get them to understand, keep your key stuff in one place, and bring it to all your appointments to coordinate care, et cetera. Thank you. Thank you, Dr. Stephens. So our allocated time is over. So thank you again for all the participants and all the speakers, Dr. Wynne, Dr. Shah, Dr. Kirshner, and Dr. Stephens. It's a really great session, and we have to leave a few things for the next time. And then I'm going to see you in the AAPMNR meeting. So thank you again.

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4Ms framework

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