So good morning. Thank you so much for joining our session, Pioneering Aging-Friendly Care in Inpatient Rehabilitation Setting, Why Now? How to Implement and How to Demonstrate the Value. So my name is Muyeon Oh Park. I'm the Chief Medical Officer and Senior VP at Burke Rehabilitation Hospital, White Plains, New York. We are right above New York City. So aging-friendly care is actually nothing new. A lot of the acute care hospital where you are associated with, they're doing it and also the nursing homes. The issue is that this aging-friendly care is not fully implemented in many places in inpatient rehab settings. So today we have a speaker other than myself, Dr. Amon Julia Nguyen. She's the Medical Director. Maybe you want to stand up? Yeah, Inpatient Rehabilitation, Montefiore Medical Center, Bronx, New York. And Dr. Malavisha is the Unit Director of Orthopedic and Limb Loss Rehabilitation, Burke Rehabilitation Hospital. And Dr. Sonir Sabawal, who is the Chief of Spinal Cord Injury Medicine and VA Boston Healthcare System. So you can see all different settings, freestanding rehab, inpatient units, and the VA healthcare system. So what I will focus on, the three things we are talking, why now, how to implement it, and how to show the value of age-friendly care in rehab. So I'm gonna just focus the first and the third. How you do it in all different setting will be presented by this outstanding panel. So to facilitate your understanding about what I'm gonna speak a little bit here, I'm gonna talk a little bit about where I work. So this is our campus. It looks a little bit like a college campus and very old rehab center, relatively new to the physiatry world. We had 150-bed rehab hospital, inpatient, outpatient, inpatient beds, and 11 outpatient sites and physician practice. And we also have other gym. So seriously, it's a community gym, but somehow you will not be eligible because you have to be over age 40. So we became part of Monteverde Health System. A lot of us are belong to a larger health system, and we are the only freestanding rehab hospital. So we collaborate very closely with Dr. Wynne. So we are like 160-bed, 166-bed inpatient rehab operation. And half of our patient come from health system, and the rest of the half comes or tri-state area at our hospitals. So this was National Geographic published 11 years ago. So what they are saying is our human body is actually designed to live up to 120 years old. So this is becoming a reality. So when you look at like 100 years ago, the percentage of the people age 65 was only 8%. Now, it's expected to be 22% in 2050. And centenarians, those who are above 100, currently across the globe, half a million are there. But in 2050, it will be 3.5 million. And some of us will be for sure in that category. So really, microscopically, so this is the data Dr. Shah prepared. And when you look at our, this tiny microscopic environment, for last seven years, we see the increased proportion in every age bracket, which include 65 or older, 85 year older, even 95 year older are increasing two to 3%. So this is like a real issue. And then, so this is one of the reason we don't have to kind of dwell on this. So what is age-friendly health system? It is not just a doctor or nurse's job, but everybody who is involved, the care from the person who cleans the room, who greets from the desk, nurses, doctors, therapists, understand that it's not just about treating the disease, it's more about understanding some of these, or actually I should say most of these older individuals, they may have hearing issues or vision issues. And most importantly, they are such a unique individual. I cannot emphasize this more. So go back 20, 30 years when you were in college, and some of you go 10 years back, and you're friends and you are not that different. You know, you are eating the same food. And then now, when you meet them, you're so different because your life experience make you more and more unique and distinct individuals. So that means is that what matters to you is completely may not be matter to the other person. So recognizing this individuality is the key component of it. So why age-friendly health system is that they are the ones actually using the health care the most. And the complexity, it's not just that there are health issues, but social issues are super complex. Plus, you know, you feel the aging in general, so there is a physiologic change on the top of it. But the health system is not prepared for this complexity of the care for older people, and they suffer disproportionate harms. So there was a national launching of age-friendly health system initiative amongst a lot of the quality authorities, including Institute for Healthcare Improvement, John Hartford Foundation, American Hospital Association, and Catholic Hospital Association. So they gather together, 2017, with made three goals to accomplish this age-friendly health system. So number one was follow the essential set of evidence-based practice. We will talk about it a lot more, ORM. And cause no harm. And the last, most importantly, aligns with what matters to the older individual and their family, and the care according to it. So after this 2017 initiative was launched, about 3,000 age-friendly health system exists as of now. The sad part is even 0.1%, less than 0.1%, less than 0.1% is inpatient rehab at this time. So what is the 4M frame? It's very similar to what we do in PM&R, and I'm sure some of you are already familiar with. So what matters is, again, it's very different from what matters to you, maybe from another person. So we wanna align all these therapeutic goals with that person's goal. Medication, when your patient needs some kind of medication, always think about age-friendly medication, which does not interfere the patient's mentation or mobility. Mentation, we don't have to repeat. Prevent, treat for the dementia, depression, and delirium in all care settings. Outpatient, inpatient, and also rehab setting. And finally, we are the experts for mobility. But why you have to pre-reserve the mobility is, again, going back, allow them to do what they love to do. So just the third value, what kind of value? So this is no-brainer value, we know this. So when we address what matters to the patient, and it can reduce readmissions, some people, they may want to, don't wanna go to the hospital, right? They may, and then it may not be even fruitful from the medical perspective. There are lots of other things in that bucket. Mentation, the people preventing delirium can reduce falls, reduce pressure injuries, and so many other things, and reduce length of stay. Mobility, again, it reduce falls and other medical quality metrics. And medication, this is like a medical value. So we don't have to preach to a choir. So actually, what's interesting about Joint Commission's origin, right? So if we don't do the right thing, somebody else will come and let us to do the right thing. So it's always, we are lagging behind, always. Something is required that we have to do it. So the CMS, their eyes are on this age-friendly care now. So there is a proposed rule for this age-friendly hospital measures. There are different metrics, five domains. So I just highlight this yellow out of the five. So one is, all the way in the last bullet point is age-friendly care leadership. You gotta have age-friendly care leadership. And then the priority screening at admission. And social vulnerability, which is already a requirement anyway. So these are the things coming, and we would like to be prepared. Not because this is required. It is the right thing to do. So how we change, not so friendly, age-friendly health system to a very age-friendly health system. So there are some, this organizational transformation. There are literatures, Harvard Business Review writes articles about this. So basically, what you need is all this theoretical thing I was about to say, but just those are all, put it aside. What you need is will, W-I-L-L. That's all you need. After that, everything will follow. So sometimes, however, we love our administration and then they will come, okay, where is your business plan? Just do it, okay? So that there is an adaptive perspective. So the perspective is make it personal. You're getting older, too. This is very personal topic to me. Age-friendly is a personal topic to me, and that's what I love, I love it. And then when you think about what we are gonna do, you're gonna hear more about from other member of the team here, presenters, here is that it's really cost-neutral. It's about read, directing, and then just emphasizing what they know. And clear about what the expectation is. So most of the time, it's really not costing a lot. And also, do the analysis this way if they are demanding you. What is the expected short length of stay? The best scenario and the worst scenario. So that's sensitivity analysis. So you may not be able to do it by yourself, but go to IHI website. There is a business plan Excel file. So it already have a template, and you can work with your friend, the CFO, and you can make a case. So that much, and I'm gonna hand this to Dr. Nguyen. Thank you, Dr. O'Park. My name is Eamon Nguyen. I go by Julia, and I'm the Medical Director of the Inpatient Rehab Unit at Montefiore Medical Center. And I'm gonna be talking to you about how we were able to establish an age-friendly health system in a multi-specialty hospital at Montefiore. Okay. So the inpatient unit at Montefiore is a 16-bed unit. They're all private beds. And we are part of a large hospital system, as Dr. O'Park mentioned. Our hospital system encompasses over 3,000 acute and post-acute beds. And we have a number of recognitions in care excellence. Namely, the campus, which the inpatient unit is located, is at Wakefield Campus, which is a ANNC-certified magnet hospital, which is only within 8% of hospitals in the United States with this designation for nursing excellence. Throughout Montefiore, we also have a number of Joint Commission-certified specialty programs, including with our Comprehensive Stroke Center and our Total Hip and Total Knee Replacement Center. Again, co-located at the same campus as the inpatient unit. So why age-friendly in the inpatient rehab setting? So the care delivered in inpatient rehab naturally aligns with the 4Ms and the age-friendly mentality. Our patients have just suffered a major medical event. And during their acute care stay, they might have been too sick to really process their illness. So by the time they come to us and transition to post-acute care, they may have new realizations into what matters to them. They may have new perspectives on their health, their sense of self, their autonomy, their relationship to and their reliance on their family members. They may have suffered changes in their mentation because of a CNS injury, delirium, adjustment disorder, or any exacerbations in their chronic mental health conditions. They may still have medical problems that are resolving or are tenuous, may need ongoing titration of those medications, and we might start seeing adverse effects of the medications that were started in acute care. We see a lot of AKIs, electrolyte abnormalities, orthostatic hypotension, delirium. So we're catching those when they're in inpatient rehab. And our ability to titrate these medications on a day-to-day basis during a longer length of stay also helps us manage the impacts of these medication adjustments and see the changes in front of our eyes. Additionally, the individualization of the IRF plan of care to the patient's medical, functional, environmental, psychosocial needs aligns with the 4Ms. And whether we're looking at CMI or discharge to community rate or nursing-sensitive indicators like pressure injuries and falls, or functional outcomes, in inpatient rehab we are very quality improvement and performance improvement minded. This aligns with the age-friendly goals to reduce harm, improve patient safety, and align care with what matters to patients and to their caregivers. Physiatrists are also natural leaders in the age-friendly movement because we are already leaders of the interdisciplinary team who are collaborating in order to focus on all of these aspects of care. We set patient-specific goals, we create individualized plans of care that consider their medical status, their prior level of function, environmental barriers, and the patient's wishes. So now that we've built the case on why you as inpatient physiatrists are prepared to lead this movement in your hospital, we'll talk about developing the infrastructure for support. So at Montefiore, the age-friendly collaborative goals are to enhance equity, quality, patient experience, and improve interdisciplinary cross-site collaboration. On the right-hand side, you can see the Montefiore Medical Center Strategic Plan and our Department of Rehabilitation Medicine's vision. So the idea is to demonstrate how the age-friendly goals align with your institution's aims in order to get buy-in from the department, hospital, and health system leadership. And as Dr. Apark mentioned, having CMS-mandated reporting beginning as early as 2025 will also get your hospital system's attention. The benchmarking of those metrics may also begin as early as 2027. So the first step on the age-friendly journey for us was really tapping into all of the available resources from the IHI website, including the age-friendly toolkit. There as yet isn't a comprehensive toolkit and there as yet isn't a framework for having an age-friendly recognition in inpatient rehab, so we utilize the SNF paradigm. So during our discovery phases, we really relied on the frontline staff and particularly nursing to provide input on the current state processes and documentation. So we went to the nurses and asked them a lot of questions about their workflow, particularly, what does your EPIC layout look like? What do your flow sheets look like? Where do I find this information? Where do you document that? And then that really defined our current state. I was very lucky at MMC to have an infrastructure already in place for an age-friendly collaborative. So the group consists of senior leadership at the system level, governance committee, advisory committee, and a number of work groups. We have age-friendly initiatives going on in all phases of care at MMC, from inpatient to ambulatory to the EDs and the ICUs. And our collaborative meets virtually on a quarterly basis to share ideas, share tools, and provide team updates. And the age-friendly journey at 4East really would not have been possible without all of the mentorship that I received from key collaborators and stakeholders and subject matter experts. So I'm very grateful for the support that we had at Montefiore. And as mentioned in the previous slide, we then obtained buy-in from stakeholders in order to demonstrate the value of age-friendly care as a vehicle towards the quality and patient satisfaction objectives of the institution. We then rolled out new initiatives and were able to demonstrate attention to all of the 4Ms and gain age-friendly recognition within one year. So this slide describes the minimum requirements for age-friendly certification. So for mentation and mobility, these require the use of a screening tool at the discretion of the facility. Examples of screening tools for mobility may be the Johns Hopkins highest level of mobility or the timed up-and-go test, the TUG, in any other assessments done by therapy. Examples of screening tools for mentation may be various iterations of the CAM. For delirium and then for depression, either the PHQ-2 and 9 or the geriatric depression scale. For dementia, tools may include the SLAMS, the MOCA or the MINICOG. So for medications, these are screened on admission and discharge. Important to note also that there must be a plan for monitoring prescribing patterns, reducing doses and deprescribing. So we did not have this at baseline, so I'll speak more to this later. So this slide speaks to the ways in which CMS requirements are already in place in inpatient rehab facilities based on, the CMS requirements are already addressing the 4Ms in order to meet age-friendly care. So for mobility, as you know, in inpatient rehab, patients receive three hours of therapy at least five days a week. So within each of these sessions, patients are being mobilized multiple times. And additionally, they're being mobilized by nursing in order to get them into the chair and ready for therapy, to toilet them. And in our case, on the rare occasion that our patients wanna leave their private rooms for community dining. For the assessment tool, we use the quality indicators, which is part of the IMPACT Act for functional scoring. So this is happening during each therapy session and then it's also happening every shift by nursing. For high-risk medications, as I mentioned, the IRF requirements are that high-risk meds are screened on admission and discharge. And this has been in place since October of 2022. For mentation, the delirium screen is done on admission and discharge per the IRF requirements and per our hospital policy, nursing is doing this every shift. For dementia, again, screened on admission and discharge and any change of status. For depression, again, depression is screened on admission and discharge and any change of status. For what matters to me, this is where there is no CMS requirement as yet. So we did have to develop a workflow for asking what matters to me. And this is a quote that I picked up actually last week at the AMRPA conference in Miami. Not everything that can be counted counts and not everything that counts is counted. So as clinicians, we know that conversations about what matters to patients happen all of the time throughout the entire phase of care during inpatient rehab. Whether patients wanna go home to their dog or they would rather risk an aspiration pneumonia than be deprived of the joy of eating. So we are having these conversations all the time. Went a little too fast there. So we started by deciding how it was going to be asked. So a great appreciation to our resident physicians for allowing this requirement to be forced on them. But also to allow us to teach them the value of asking patients and treating patients as whole people. So we added some lectures to the resident curriculum to educate on age-friendly. And we had specific lectures on what matters to me. And then a practical how-to of what age-friendly care would look like on 4 East. And of course, because education is not enough of an intervention, we also developed some smart phrases in order to cue them into asking these questions. And prompting the what matters question. So this is what our Epic tool looks like. It's a drop-down menu where they can choose which question to ask and then free text a response. So this first one on the left, what are you most looking forward to about going home? Opening up the windows and letting the sunshine in. This is one of my favorite responses that was elicited. And actually it was elicited by a first-year medical student who was visiting our unit as part of an introduction to clinical medicine class. So essentially they were chart reviewing, they were reading about the patients, and they were seeing that in the H&Ps that residents were asking this question. So this student just started in their first, very first patient encounter started asking this question. So this response in itself is just so delightful. But also it just showed me that with the right mentality we can really change the culture of how we're talking to patients and how we're treating them as a whole person. I think also these moments of delight can increase provider satisfaction and reduce burnout, which are also goals of the age-friendly movement. So we also bolstered our care in some of the other M's before applying. So at Baseline we have Pharm-C available and we have consultants in psychiatry and pain management. So we just wanted to emphasize their availability in order to assist with deprescription of high-risk medications. We also added the high-risk medication screening tool to the H&P in order to increase visibility. So some ongoing initiatives are that we are developing a high-risk medication tip sheet for the residents to use. And we're working as a multidisciplinary group on a deprescription quality improvement initiative. So we have some team members from physiatry, from geriatrics, from medicine, from pharmacy. And we've analyzed six months of Baseline data on our prescribing patterns of high-risk medications. So our next steps are really to analyze these patterns and develop interventions and opportunities for deprescribing. We'll also be adding a Grand Rounds on safety prescription of Beardsless medications. Next steps again are going to include adding the CAM tool to our acute event note template. As we know that change in mental status is a frequent indicator of a change in medical status and also a frequent reason for a rapid response. For mobility, we recognize that patients are with their nurses for at least 21 hours of the day. And that nurses don't have the same expertise in mobilizing patients as therapists do, of course. So we've supplemented nursing education by adding in an annual two-phase safe patient handling training, which is led by one of our occupational therapists. And so we're currently in year two of that initiative. In addition, we've partnered with a assistive device startup called SedMed, which is a hydraulic lift toilet seat to improve safety around toileting and toilet transfers. We found that about 40% of our falls in 2023 were related to toileting. So we wanted to design an intervention to reduce these falls. We're also looking at nursing satisfaction because we know that musculoskeletal injuries are incredibly prevalent among nurses and can also contribute to taking time off and burnout of our nursing colleagues. So as for the future of What Matters to Me, so we're hoping to maybe add some additional questions, incorporate more of our interdisciplinary team in asking what matters to me. And then also making sure that we're discussing, such as in our team conference, how What Matters to Me is being addressed. Lastly, we are hoping to have What Matters to Me displayed on a patient-centered whiteboard, which looks like this. So this has been a project in collaboration with our marketing department and just a streamlined version of what our current whiteboards look like that is more patient-centered and does have the What Matters to Me in the right-hand column. So moving forward, hopefully our next steps are to apply for the Caring for Excellence status because if you can't measure it, you can't manage it. So we have all these initiatives, but we wanna demonstrate exactly how many patients we are touching with the 4Ms. And then also is it having an impact on our quality, right? Our falls, our patient satisfaction and things. So we're lucky, 4East, to be chosen to pilot the MMCH Friendly Collaboratives 4Ms dashboard in order to track the percentage of patients touched by the 4Ms. Moving forward, having this data focus will also help us stratify and add a diversity, equity, and inclusion lens so we can look at not only age, but primary language, ethnicity, race to make sure that we are addressing the 4Ms equitably for all of our patients. Thank you. Thank you, Dr. O'Park for that introduction and Dr. Nguyen for laying that groundwork for how to get age-friendly certified and what you guys are doing at Montefiore, which we've taken your lead with and thank you for that very much. My name is Malav Shah. I'm one of the inpatient attendings at Burke Rehab Hospital. I'm a relatively early career physiatrist at this point. I was a resident 10 minutes ago, it feels like, in Philadelphia, Pennsylvania. Shout out to my Jefferson colleagues here. We went from treating 20-year-old Philadelphia Eagle and Philly prospects to then bragging about how old our oldest patient was of the day. We started to see that those numbers were climbing with each passing year in the three to four years of our residency and now in practice, we're hitting patients who are in the 95s, 96, 100, 102. At first, we would be in the inpatient rehab acute setting thinking, what are these patients doing here? Why are they here? Is this the appropriate setting for them? Is three hours of intensive therapy really what I want someone my grandmother's age to be going through? And we quickly realized that, yeah, they're doing well. You know, they're thriving in that environment and quality of life is increasing with this exploding population. So I wanted to give a little bit of background about what it took at Burke to get age-friendly certified to really understand what this framework means and how we can provide a higher level of care for our patients. We knew at Burke that we were providing an extremely high quality of care. But what we didn't know was, were we following a specific process that allowed us to care for this aging population in the most efficient and effective way? We knew that we first needed to identify what our processes were and then put together a team to address what changes could be made to make those processes better. At Burke, we put together a full team interdisciplinary that ended up having three different components. That first component was the synthesis and translation team. These people were responsible for gathering information about what our current processes looked like and what gaps there were in those processes that we could improve upon. The next component was the support system. They were there to incorporate any logistics that were needed to make these changes happen, like incorporating the electronic health record to make these improvements easier for us to incorporate. And then finally, there was the delivery system, which is the patient-facing component. The people who were actually delivering that care directly to the patients and able to prescribe these forms to our patients to make their care as optimized as possible. So our team consisted of about seven different roles, again, from an interdisciplinary lens because that is the whole point of physical medicine rehabilitation. The first member was our quality team. In this case, it was our AVP of quality, Maeve. She was responsible for data collection, reviewing our established processes, thinking of ways that we can improve upon those processes and then helping to roll out any new processes. Our next team member was the pharmacist. Our next team member was the pharmacist. At Burke, we were blessed to have a pharmacist, Dr. Solomon, who also had subspecialty training in geriatric pharmacology. Like most rehabs, the pharmacists are responsible for an admission medication reconciliation in which they make sure that the patient's meds are prescribed appropriately as according to the discharge summary from the acute care hospital and that any changes that we make as the physiatry team have a reason behind them and we're not mistaken. She takes into account geriatric considerations for that population. She identifies areas where polypharmacy can be addressed in a way that allows us to deprescribe because as we know, polypharmacy is a huge problem in the aging population. The pharmacist is always involved in a weekly huddle. So not only is medication reconciliation taking place upon discharge and admission, but also on a weekly basis or sometimes multiple times a week, depending on how high risk that patient is, to again make sure that we are addressing all the medications they are on and should appropriately deprescribe or continue. The pharmacist is responsible for cross-checking the beers list, which helps to identify medication interactions in a patient's profile that may be putting them at risk for delirium, mobility issues, pain management issues. The pharmacist is also involved in behavior rounds, mostly for our brain injury patients or other otherwise agitated patients to make sure that pharmacology is addressed from that standpoint. And lastly, they participate in our falls huddle, which I'll talk about a little bit more later, but essentially the falls huddles at Burke take place after any patient fall in the inpatient rehab setting, usually within an hour. It's in the full interdisciplinary team is there between the nurses, the therapists, the physicians, as well as our legal team and our pharmacy team to address any parameters that might have gone into why that patient fell and how we can prevent that in the future. So the pharmacist is there to take a look at the medication profile, see what medications were given to that patient leading up to the fall and whether they may or may not have contributed to that fall. This is a small study that Dr. O'Park undertook a few years ago, just looking at an inpatient rehab unit and the number of patients who ended up testing delirium positive using the 3D-CAM assessment method. So 41 patients that tested positive, they took a look at how many high risk drugs for delirium these patients were on. 75% of them were on at least one of these high risk drugs. And as you can see, 25% were on three or more of these drugs. So again, this offered another lens into how pharmacology plays such a strong role in an area that we can intervene upon to help prevent these issues in the elderly population. So three of our other team members included our nurse manager. The nurse manager was responsible for training nurses, CNAs, to recognize delirium, to understand how to prevent delirium, to see delirium and report it, and then to help treat the delirium so we could lead to clearance as soon as possible. This ended up being a very interesting initiative as we rolled out education for our nurses and CNAs. We got a lot of feedback from our CNAs telling us that they didn't realize that their own family members had been in the hospital experiencing delirium. They had never been taught this word before, what it meant. And they were recognizing it in their own loved ones and seeing it in our patients as well. So they were able to respond to us in a way that made it personal to them and made them a little bit more vigilant in our patient population. The nurse manager also helps to educate the nurses in how to report medication efficacy and adverse effects so that we as the prescribers, who are only seeing the patients for a small window of each day, get a full picture for the other 23 hours of the day that we might not have eyes on them. The nurse manager participates in the falls huddle. They always act as the falls huddle leader. They help with mobility outside of therapy, which is something I'll also touch on a little bit later. And the first parameter of the what matters part of the 4Ms is making sure that we actually address that with the patient. So on admission, our nurses perform their admission assessment. One component of that admission assessment is within the EMR, similar to what Dr. Wynn's setup is. And the whole team can see a variety of questions of what is important to that patient? What are their goals for the inpatient acute rehab stay? What can we help them with to achieve? Our next team member is the neuropsychologist. We have a robust neuropsych team at Burke. They help with both psychotherapy as well as cognitive screening. So anytime we have a patient who we feel is at risk of delirium or experiencing delirium, we have an easy consult to our neuropsychologist who can then perform a more comprehensive battery of assessments for these patients, as well as follow that patient throughout their acute stay to monitor for clearance, and even follow them in the outpatient setting. One of the biggest components of the neuropsych team is their ability to educate not only staff members, physicians, residents, nurses, CNAs, on what delirium means and how to recognize and prevent it, but also go to the patient and their caregivers to teach them what delirium is, what they can expect over the next days, weeks, sometimes months of delirium clearance, and how they can help best move that patient along that process. Then we have our therapy team leader as a member of the team. They help us to set mobility goals for these patients, collaborate with the patients and the caregivers to help achieve these goals, modulate sessions based on each individual patient's level of fatigue, ability, endurance. As we know, as we age, those levels tend to go down, so we need to provide a tailored approach in the acute rehab setting to make sure that the level of intensity is not too much or causing more harm than good. They also help communicate barriers with the rest of the team members. That's often through the interdisciplinary team conference, but we also have an open door policy, easy communication among all members of the team so that they can reach out to the medical team if they find components of the treatment plan are contributing to some of these barriers. And then again, they help with planning for therapy outside of therapy. So what does therapy outside of therapy mean? Inpatient acute rehab is blessed to be able to provide patients with three hours of therapy a day, but that's three out of 16 to 18 waking hours, and I don't want my patients in bed or in the chair for the other 15 hours of the day. So what do we provide these patients with to address that first M of the 4M system of mobility? Our therapists help guide patients through a phone app called PatientPal PT Pal, which is a self-exercise program that patients can then use on their own, either from a chair-based program to a bed-based program to make sure that if they do feel that extra level of energy throughout the day, they have activities available to them to keep them moving. We also have a robust recreational therapy program that helps to address any patient interests outside of the normal three hours of therapy. So if they have horticulture interests or musical interests or art interests, then our rec therapists can provide that extra level of service to get these patients up, moving, mentally engaged, physically engaged. We have music therapy, and then again, we have our nursing staff. So like Dr. Nguyen said, the nurses, the CNAs, are not as specialty-specific trained for mobility in this patient population, but we've led initiatives to have our therapists teach our nurses how best to safely and conservatively mobilize them outside of those therapy hours to again, maximize their time up and moving. Next, we have our patient experience team that's led by a group of patient ambassadors. Our patient ambassadors see patients either on the day of admission or one day after admission, and they help with the overall orientation process. So what they do is deliver patients this one-sheeter, which essentially gives them an idea of what they can expect over the next one to two weeks of inpatient rehab, who they can expect to come in and out of their room. It gives them a list of all of the different types of uniforms and colors that our treatment team will be wearing. I tend to confuse everyone because I wear all of these colors under my white coat, so I try to keep that white coat on to not confuse and worsen everyone's delirium a little bit more. But this gives them an idea of what they can expect throughout their entire stay. One of the biggest components of the patient experience team is completing the physical Get to Know You board. So while the nurses have the electronic health record board, we also have a physical board in every single patient room. That board consists of a couple of different questions. The first is things that the patient might need help with that they often forget to ask for or maybe to embarrass to ask for. It gives everyone who walks into that room an idea of what that patient might need or expect from us. The next component are things that make them happy. So that gives us an idea of something that we can provide the patient if it's within our power or have family help to provide that patient. We also like to incorporate what the patients like to be called. If being called Mr. Jones is not something that they appreciate and they want to be called whatever it is, Skippy, then we see that's a patient I had last week. I shouldn't say that. But that's something that we are able to make the rehab environment a little bit more comfortable for all of these patients. My favorite part of the board is something that you might be surprised to know. For me, this is always the most interesting part of each patient. A few weeks ago, I had a patient who they had written that they knew Neil A. Armstrong personally, who was the first man on the moon. I went to Neil A. Armstrong Elementary School, so that was a big connecting point for me. I could sit and talk in that room for hours. As far as I knew, he was not delirious. So I took everything he said at face value, that he was good friends with the late Neil Armstrong. But it provides a different level of rapport that you're able to build with that patient, because you're automatically forming a connection just by walking into that room and reading these boards. Lastly, we have the physicians. We are the leaders of the interdisciplinary team within the rehab setting. We provide that direct clinical care. We address all Ms of the four Ms through our treatment plans, our medications, our therapy plans. We address the pharmacology, pain management, delirium management, delirium prevention, educating the whole team as well as patients and caregivers, identifying and preventing any new complications that might worsen this patient's care, educating residents who have played a big role in the rollout of age-friendly within our system, building that high-functioning, age-friendly team and keeping up with that team, and then sharing and disseminating that knowledge both within our system, outside of our system, in the outpatient setting, and then to all of you to make sure we can spread this high level of care for the specific patient population. So Burke was very proud to achieve age-friendly participant designation first in September of 23, and then finally upgraded to the commitment to excellence designation in January of 24. So we continue to roll out these measures with every single patient, every single new staff member gets trained in the 4M process within our rehab unit, and we make sure that we can continue to provide this level of care for these patients. That's all I have. Okay. Well, it's great to be part of this panel, and I'm the one person who is not at Burke. I'm actually at the VA in Boston and also mostly dealing with spinal cord injury. What I'm going to say really is very much congruent with everything that has been said and will apply regardless of what setting you work in and whatever kind of practice focus your group has. We did become, and I'll talk a little bit more about why we did this because it's slightly different in the VA, the different incentives. We actually got the level one recognition November of 2022 and then level two in March of 2023. A lot of it was really reorganizing stuff that we were already doing and just identifying the gaps and filling them. It is not that difficult. A big part of it is really engaging the entire team. Our service has about 40 people that would remote to me, but we have 150 nurses that we have to collaborate with. We have therapists who are from a different service. Really engaging the entire team in building the age-friendly health system is very important. And then our mission. This is our mission, and it hangs on the entrance to our spinal cord injury center, but I think this part of the mission is really relevant to us because we, even more than other folks in the rehab setting, really are committed to provide life to the veterans we serve in our system throughout their lives. We do have folks who might have been injured at a young age, but stay with us on to life, and actually some of them even come to the VA when it's time to pass away, and there's a big ceremony that goes with that. We really are committed to the throughout the life part, and then part of the throughout the life is that there's also a business case for making sure we are most effectively and efficiently providing value-based care that matters, and not wasting resources because that's what we're going to be providing care throughout their life. So this is really model systems data, not VA data. So as was mentioned, the U.S. population is getting older. Yesterday, there was a panel discussion that I was part of that we mentioned there was some U.S. census data, and there are many things that you can quote, but a 9% increase in the U.S. population predicted between 2017 to 2030. This particular article was from 2018, but a 44% increase in people 65 years and older because of the aging baby boomers. So in spinal cord injury, the average age of injury has increased since the 1970s from the 20s as the mean age to 43, because there's that second peak of people getting injured. And even in the model systems, the first boxes between 2015 to 2019 versus earlier, which I can't read from there, but it is before 2004, where the mean age significantly increased, the proportion of people over 60 increased, as they didn't collect over 65 at the time. But it was 20% between 2015 and 2019. And part of it is people getting injured at an older age, and part of this, which is a good thing, is people with spinal cord injury are living longer. This is our own VA data from the Boston VA, and I don't know if you can read that or not, but that's showing the age distribution. So as it is, we treat older folks. It's obviously people who are in the Army or US veterans. And so the minimum age is 18. But our mean age, and because we take care of people throughout their life, our mean age has increased over the years, that table at the bottom. And at the time that this was taken, it's actually even older now, it was 67 to 68 years was the mean age of people with spinal cord injury that we are serving. And that graph on the extreme left is that top one is people 75 years and older, and you can see how over the last 10 years that has increased. The other thing is that people with spinal cord injury age faster. And this is an older study from two or three decades ago, but basically showing that that green line is how normally all of us, our systems have a lot of reserve that peaks at late teens, early 20s. And so we are all past our peak, but it then starts declining 1% a year. The good thing is that there's so much reserve, obviously depends on the body system, but there's so much reserve that it isn't up till the late 70s that for a lot of body systems or mid-70s that it really falls below that dotted line where there are actually functional consequences or clinical sort of things related to that. And obviously this is an average, and every individual is different. But the red line is showing what happens in the spinal cord injury population, where actually for most systems the decline is steeper. So it's 1%, it's 1.5% per year. So when they cross that dotted line, that's at a much earlier year. So there's actually studies showing that people with tetraplegia typically need additional care at 49 years. People with paraplegia need additional care at 55 years as a mean in that study, versus what the US population average is not till your mid to late 70s or after. And there are multiple reasons for that, overuse, other kind of things, and a lot of things that are not quite known, but probably some immune or inflammatory reactions related to spinal cord injury. And then both spinal cord injury and aging affect all body systems, and I'm not going to go into that, but there is a lot of interaction obviously related to that. And then when you're looking as a health system, this is really why we did this, and why we did this across the board, not just for people 65 years and older. Because when you're looking at spinal cord injury, it's a whole person focus versus a disease focus. In fact, what got me into rehab, and maybe only a couple of you in the audience even know Krusen's textbook of medicine, but I actually was sitting in a library, I was thinking of doing rheumatology, and looking at Krusen's book, and looked at the first chapter where he talked about people being motor-oriented, interpersonally oriented, or symbol-oriented, how you need to base your assessment and actions related to that. And that really kind of struck me as fundamentally why I went into rehab. And so that focus has always been there. We know that people with spinal cord injury are really affected by fragmented systems, and that they have multiple comorbidities, and as was mentioned, they have a risk of disproportionate harm. They are fragile. They're not always patients, I mean, they're not sick, but they have a very low margin of health, so that they can get sick really fast. And so this adds to that multi-complexity of taking care of them, and they're on multiple medications. There was a study published out of the, it was a retrospective analysis of a couple of studies that were already done. But they saw that at, I think, around 30 days or 60 days post-injury, on average, people were on over 20 medications, 20 to 25 medications after spinal cord injury. And then, of course, there's a decline in functioning. And of course, all that also is what happens as we age. So it made sense for us to do this, not only for folks who are aging, but across anyone we serve in our system of care. And I won't go into this framework, which has already been talked about, but the couple of things I would say about this is that this is a framework. It's not a program that you layer on top of care that you're already providing. It's really meant to be incorporated in the care that's being provided. And ideally, it should be provided as a whole, not as, you know, obviously, it's better to do something if you're not doing anything about medications to address that. But really, as a whole, because it's all interrelated. What matters is really at the fundamental thing, is to know and align the care for each person that is served in your program based on their goals and preferences. But then the medication, for example, is providing, if medication is necessary, provide medication that does not interfere with what matters, mobility or mentation. Similarly, you know, mobility is to maintain or improve function safely so that people can do what matters. Okay, so it's all interrelated, and that's the reason to really kind of try to apply it as a whole. And then it's got two parts of it that really, then each of these four Ms, you really need to both assess and have a plan to act on. So what matters, as I mentioned, that's the definition of what matters. It really is the fundamental thing. And obviously, there are critical moments, you know, if someone has a change in status or, you know, that you might make sense to really revisit what matters. And then there are typical touch points, and in the outpatient setting, it could be an annual exam for spinal cord injury. In the inpatient setting, it could be morning rounds where you inquire about what matters. And it is a process because you really, it's one thing to ask those questions, but really you have to know, and we are lucky that in our system, we really get to know our patients and their lives. And it's very much aligned with the contextual factors in the international classification of functioning, is really aligning care with what is each person's goals and preferences. So this is something, you know, it's not easy. The what matters part is the least developed one. And even though it's good to talk about it, it's something we're still kind of struggling with doing consistently and reliably across all interactions and settings. So we've tried different things. There are things we were already doing. I don't know if you can look that, but whole health is a big thing in the VA. It's been in the last few years, is really looking at the person from a holistic perspective. We were actually one of the first services in our VA to sort of embrace that in terms of, you know, addressing things like relationships, spirituality over nutrition, you know, mobility, all those different components that are in that circle. But then, you know, to systematically capture that, this was something that was developed within the geriatrics department within our VA. And we kind of borrowed that in terms of making it a little easier to do is, you know, giving folks this kind of card to say, just circle the top three things that are important to you. So at least it starts the conversation. And then, you know, the IHI has this sort of what matters sort of guide, which I would, you know, because those things definitely don't come naturally to me. And I think that even to physicians, you know, we're comfortable asking, you know, what would you like to focus on in this visit? But not the more deep questions of what brings you joy and happiness. You know, we can, but it gives practical things you can ask, you know, what would you like to do more of? You know, what more scares you about your health or healthcare? So there are things that you can do. So there are these guiding questions that you can, you know, practice and get more comfortable asking. And then, you know, in the VA, you know, just as was mentioned that, you know, if there are ways to document. So there's one thing, I don't know how many of you are familiar with the My Life, My Story movement, but it's a big thing within our VA. And we get our medical students, sometimes our different staff, residents, fellows, you know, talk to patients. It's a semi-structured sort of thing. And they write up the patient's story related to, you know, their time in the service, what's really important to them, you know, again, those same questions. And what really helps me, so that top thing is really a book, a unit published on some of our patients' life stories. And it really is touching. We actually give it, when people pass away, we give it to their family. And it's really very meaningful. What I've found most useful is when patients are having compliance issues or behavioral challenges, and I don't really know them well, and I'm going to talk to them as the Chief of the Service, I read the My Life, My Story, and there are many things that really makes you, just like Malav mentioned, the ability to connect with patients and be able to do that. It really gives you that. And, of course, there's adaptive sports, whether it's kayaking or skiing in the VA. That picture at the bottom is just maybe a couple of months old. That was related to ballroom dancing, wheelchair ballroom with their loved ones for patients who were on an inpatient rehab unit. This little, this thing at the bottom is really touching. It was a memorial service that we did maybe three months ago. We do something yearly for people who have passed in our system that we are aware of. And this one, actually, some of the veterans in our system who had friends, who were friends with them, as well as some of our staff, painted these stones, and I don't know that you can make out, but, you know, there's chess pieces, there's fishing, there's music instruments, there's the sun, people, for the person who just wanted to sit in the sun. So they painted things that most matters to the person who had passed. And so it really sort of permeates the entire care system. In terms of mobility, that's one that we can most relate to, you know, as rehab professionals, it comes naturally to us. I think the, and this is something that we were already doing. I think the most important piece is to more sort of consistently connect the mobility goals to what matters, and really ask about that systematically, and make sure it's not just asking, it's also documenting that. It's one thing for the nurse to ask that, and then it stays there, but it's also a question of it's documented and shared, that people actually, whether it's in a team meeting, whether it's an outpatient huddle, whether it's written on the whiteboard after patient rounds, but something that connects what matters to mobility is important. And then, of course, you know, there are different things, issues with mobility, I wouldn't go, you know, with wheelchair mobility, for example, wheelchair falls, there are different risk factors, and as people are aging, you need to, you know, provide adaptive equipment and modify their function to make sure that they are moving safely to do what matters. Medications, these are, the one, we were really lucky to have a pharmacist on our team, full-time pharmacist be on our team, just a few months prior to this, so, you know, prior to this, doing this, we were doing medication reconciliation, struggling with that, but really a more focus on systematically deprescribing was the pharmacist was instrumental, and any of you who have pharmacists, there's a potential to, there's a real value to having a pharmacist be part of your team. And, you know, there are, those medications, that is the list from the IHI form, and a lot of folks, these are medications that people with spinal cord injury are off and on, you know, opioids for pain, anticholinergic medications for bladder, whether they're on the tricyclic antidepressants for pain or for depression, so, and benzodiazepines, not just for anxiety, but for spasms, so a lot of things that we, that put folks with spinal cord injury at risk. And then the important thing is really to avoid prescribing cascades, because, you know, someone has shoulder pain, you have spinal cord injury, put on non-steroidal anti-inflammatory medications, they get heartburn, and they're put on a PPI, and then they get C. diff, and then they get, so it's really avoiding those prescribing cascades, and the polypharmacy and the drug interaction. This is actually a tool that's available in the VA, it was developed in the VA as one of their innovation things, it's there, but it's not used, in fact, in our VA, this is just a screenshot of the things that I took, that really is all our pharmacists within spinal cord injury that is really doing it mostly at the Boston VA, but what it does is, and this is something that you don't need an electronic tool for, but it helps to capture the data, is it kind of divides the medications into vital, like insulin for diabetes, to indicate it, where it's clearly indicated whether it's pain, constipation, whatever else, where it's optional, is where the bottom three are the most important ones. The optional is where there's maybe antibiotics, maybe not, vitamins and things, maybe okay to leave them on, maybe not. N is things that are not indicated, like the non-steroidal that were given for shoulder pain at one point, but are no longer indicated. And E is the most important piece, which is every medication has an indication. Physicians need to know what they're taking the medication for, the prescribing team needs to know what they're giving the medications for, so our pharmacists will do that, and then they'll work with the providers to, not every medication, even high risk, can be stopped, but we try to minimize the dose, see if there are alternate options, those kind of things. In terms of ventation, the three components has already been discussed. Really important for all of these to make sure, as people are aging, that we are assessing their vision and their hearing, because that impacts both cognition, delirium, as well as people being diagnosed as dementia if they can't really hear properly. This is the PHQ-9, and obviously with some of the somatic symptoms really overlap, whether it's fatigue, appetite, weight loss, can overlap with a lot of medical issues people with spinal cord injury have. So the first two questions are the most important in terms of identifying depression, and of course question nine is the key, one for suicide prevention, which there's a big push in the VA to really make sure that we are identifying and screening and preventing suicide in veterans. Well, mentation was talked about, you know, Mini-COG or the MOCA, for example, unfortunately a lot of them have clock drawing kind of things that require hand skills. So what we've started doing for people with tetraplegia is use the MOCA blind that was adapted, that's validated, adapted for people with visual problems who can't draw, and we kind of use that for folks who don't have the hand function to draw a clock. And then we have these programs like the STAR-V, it's in the geriatrics folks where we're teaching nursing staff, frontline staff, how to interact with folks with dementia, and you're really educating them about the behavioral issues that may happen and how to respond to that to avoid, to deescalate the situation as well as address that. One of my pet things, and this is real, this is of course pet, but is this companion, these robotic pets that dogs and cats that you can get off Amazon at the time, I looked, it was under $100, probably slightly more than that now, but maybe just a little bit more. But we've had folks with dementia, and this is something that we got for them, and I ran into a nurse who was taking out this robotic dog and says, oh, Mr. P just asked me to take him out to pee. And so it really calms the folks down in these companion pets, it's a wonderful thing. Delirium, we won't talk about, that's the definition of delirium, and that's the NEJM article, that's a good summary of delirium. I think the most important thing is really identifying the factors that precipitate delirium, whether it's dehydration, whether it's infections, whether it's medications, whether it's sleep deprivation and addressing all of those proactively. So last slide is a couple of reflection points. I think there's a lot of things here that you're thinking probably we're already doing this. So think of one thing, or at least that you're already doing that is consistent with this 4M's framework. And then the second question is, what is one change or addition you could make to your practice to enhance age-friendly care for the folks you serve? And I'm going to stop there, and I think we have about five minutes for questions, too. Right. Thank you. Okay, so I think we are going to follow up on this. Questions or some things, maybe you are thinking about doing it in your place, or already doing it, would you like to share with us? I'll just break the ice. Hillary Stevens. This is fabulous. You all are setting a new gold standard for inpatient rehabilitation. So I just commend this work and keep it up. A question on the deep prescribing issues. Is there any way you can tie it into the money saved? Because that will help with your business case, plus one of the things patients are most worried about are the finances. So I just wanted to know if someone could comment on that. And also, how do you run your team conferences? When everyone's together, do you run them any differently, given this initiative of what matters most? Thank you so much. Is this on? Oh, it is on. Okay. Thank you for the questions, Dr. Stevens. Dr. Stevens has been such a champion of age-friendly care and also a mentor to this panel. To speak on the business aspects and the cost-saving aspects of age-friendly care, Dr. O'Park spoke a little bit about this and really the cost neutrality of implementing these things. But really, there are a lot of cost savings. Whenever we are reducing the side effects, the adverse effects, when we are catching delirium, preventing delirium, preventing falls, we are saving healthcare dollars. So there's the patient safety piece for, of course, number one is the patient care. But whenever there are fewer adverse events, we're also saving healthcare dollars. So in the inpatient rehab setting, this is preventing acute care transfers, preventing interrupted stays, preventing the need for expensive workup, head CTs, multiple x-rays for falls and things. So I don't have the data on this, but I think that it exists in the literature and that is part of the foundation of establishing the 4Ms evidence-based model. My question. Yes, I appreciate all that wonderful response. Was specifically at Burke where you're doing very active deprescribing and looking specifically at estimates. Oh, you got rid of these two medicines. I recently heard one health system decided to stop, hospital decided to stop Colace and they saved over a million dollars. So what, can I just follow up on that, is that actually the hospital cost accounting is extremely complex. So actually, as a matter of fact, just historically, when the Burke was not part of a health system, our pharmacy cost was certain amount. And after the merger, because patient population completely changed, that we start to get a transplant patients, all kinds of complex patient came in, our pharmacy cost went up 300%, 300%. So that was, there was a big motivation, you're hitting the head of the nail. So that this deprescribing, this gives me a very good idea of actually looking at the things. So to be able to do that, we needed to restructure the cost accounting of the hospital. So it didn't do like a spinal cord unit, how much is the cost for the spinal cord unit, brain injury unit, stroke, it wasn't set up that way. It was pharmacy, it was nursing. So that right now, what we are doing is we established that cost accounting by unit, so we are almost there. But you're so right about that, because there is nothing more powerful than, you know, this is reducing the billion dollar from the correlation, that's a great one. And you can reinvest that to the nursing or other tools. So great question. And then second question was about the team. Yeah, to address your team conference question, I think this is a question that highlights why rehab in particular is best suited for age-friendly care. Because at baseline, I think a good team conference is already addressing all four of these M's, right? Mobility, obviously, that's the reason they're in rehab, mentation so that they can better participate in rehab and with their caregivers, medications to help them be able to better participate with their caregivers and in their rehab. And then what matters is that last thing that maybe doesn't get addressed as much as it should, and that's why we've tried to build out these new systems to make what matters to that patient so visible to everyone who's taking care of that patient. Whether it's within the electronic health records that the therapist can see what their mobility goals are, or posted on the wall of their room so environmental services, food services, the neuropsych can go into that room and immediately see what's important for that patient. Thank you. And the money. I'll just add to that a little bit. In terms of the team conferences, although you're completely right, we're doing that in a good team conference, the problem is consistently, reliably documenting and capturing that information and sharing that information. So what we've tried to do, and we're still struggling with that, so what we've done is add performance pay measures related to capturing the forums. So V actually has a way that we can capture health factors related to each of the forums in our electronic medical record. So we are doing that as an incentive, and it may not be just the physicians who are actually documenting each thing, but they're driving the conference, and at least they're engaged in the process to make sure that they're captured. And in terms of the quantitative data, I think it's very hard to get. We're struggling with that ourselves. But sometimes where you don't have quantitative research, you have qualitative research, and one of the ways that we got a full-time pharmacist was really tell some compelling stories and examples that illustrate the cost-saving and the value-added. And I think doing that and incorporating that in your annual reports, in the executive leadership briefings, and those kind of things are also kind of strategies. Hi, Sam Mayer. Congrats on doing a great job of really incorporating all of this in your work. I mean, it's really a yeoman's job. I wanted to ask you kind of a challenging question, and that is sometimes the forums run in conflict with each other. And let me give an example of fall prevention. So typically, if we got a patient on fall precautions, we're going to put bed alarms on them, we're going to tell them not to get out of bed without the nurse, we're going to trap them in their rooms, which goes against what matters to them, and then we're, on top of that, going to run into issues with medications that they want to continue, you know, they've been on Ambien for 10 years, and that matters to them. So how do you deal with all those conflicting issues with the M's? I can start. It is a tough question, but it's not difficult if you focus on the what matters piece. So I mean, we've all had personal experiences. My mom was in an ICU, post-ICU, post-surgery, delirious, and then she came home and wanted to be, you know, sleep was important to her, she wanted to take this sleep medication, but then she also wanted to use the iPad in the morning to connect with her kids and grandkids, and so it was a conversation, what is important to you, balancing those things. And similarly, an inpatient unit, whether it's sedatives, whether it's restraints, you know, are there non-pharmacological ways in an environment, you know, instead of giving sleep medication, at least minimizing the dose, give the most age-friendly option if you do have to give medications, but, you know, environmental things like noise reduction, those kind of things, and minimizing the interruptions for nursing taking routine vital signs late at night. So I think there's a way to do that. It's always a balance, but I think focusing on what matters is the most important piece. I was just wondering, sort of similarly in an inpatient setting, when you have conflicts sort of between specialties, you know, if you have a cardiologist who, you know, ideally everything would be based, again, on patient preferences, but if you do have someone who's maybe focused in on their disease portion, and maybe you're prioritizing blood pressure or something, what strategies have you, I don't know if you have formal systems or like personal strategies that you use to get buy-in across specialties to, you know, maybe we back off on medications here to prioritize mobility. It can feel touchy sometimes, you know, stepping on a cardiologist's toes or, you know, different situations like that. So I just wondered what strategies you've used for that. That's a great example, right? Metoprolol and Lasix and our patients who are in AFib and tachycardic or they're hypotensive. And so one thing that I've really noticed is the vital signs that are often documented are the ones at rest. They're the ones that nursing is taking. So we have our therapists document vitals in the same place that the nurses do in order to make sure that there is that visibility, right, because as, you know, different disciplines document in different ways, in different places, different flow sheets, so unifying that process for increased visibility. So I found that, you know, the cardiologists are not seeing the orthostatic vital signs and so we may consult them for orthostatic hypotension and then, you know, their rest blood pressures look okay and they're really not seeing everything. So there's the documentation piece to assist with that and then there's also the communication piece and really being clear about our consult question in the context, having a conversation. In our system we have a secure chat where all providers of all disciplines are able to access this communication tool and we found that that's been very helpful as well. We know that in rehab everything is about relationships and communication and so working together with not only our interdisciplinary rehab team but the interdisciplinary team throughout the hospital has been really important. I think adding on to that, I think the language that every medical professional speaks is evidence, so show them the evidence that early mobility helps, upright tolerance will be improved with that mobility, that those numbers that they're so closely following will be completely different in the home setting if they're not following that bed rest that you're prescribing in the hospital. So the whole point is to recreate sort of that, you know, ADL environment for them to make sure that they can accommodate that in the home setting as well to lead to a discharge. So if you can prove that across the interdisciplinary spectrum to your referring physicians, to the primary teams, then that buys you that level of trust and responsibility for that patient. I have a question that you kind of just touched on and then blew by, but I'd be interested in your follow up on it because it strikes me that part of the importance with age friendly medicine is access to the ideal environment. And you said when you got to Burke... Was it Burke? Correct, yeah. Are these patients even supposed to be here? They're so old. And I kind of get the feeling that so much in our healthcare system, just to get into DEI, we practice ageism, well they can't possibly do this and then they end up in a subacute and they're not getting mobility or access to physicians. What is your value proposition and how did you... Because you said you asked the question, but you didn't say how you answered it to yourself or what would you say to that issue of getting the right... Because I noticed somebody... You're in a total hip and a total knee specialty center. Do some of those patients still have access coming if they come early after their surgery? I'd be interested in some of those thoughts. So for me, just from personal experience, it was seeing what the outcomes look like for these patients. We know what the skilled nursing environment looks like as compared to patients who go through the acute environment. And so for me, it was a personal goal of wanting the best for my patients. I initially, as a trainee, had that doubt that maybe this isn't the best environment for these patients. But as we saw more and more of them go through the system and I could see that there was a marked benefit to going through the acute process, it became clear to me that this was the right environment for them. So then our job as physiatrists is to spread that knowledge to the acute side of things that they know the proper disposition for these patients. Obviously there is insurance authorization issues for certain patient populations if they don't meet the specific criteria, but advocating for that patient or presenting them in a way that does show that they would meet that criteria for one reason or another, comorbidities or otherwise, and proving that the outcomes for these patients are better is helpful to demonstrate that, to make that valuable. So some of the things that we all know in America, the healthcare is driven not necessarily clinically, right? Clinically driven. It's whole thing. The other day I was looking at how many percentage of the people who are meeting the 60% rule is in the Medicare before service for MA plans. It should be equal, but it's not. So I saw the MA plan is like 75%, 75% is 60% rule. Before service was 60%. It doesn't match. That means that a lot of patients who actually needs inpatient rehab is not coming in if you have a MA plan. That's what it says. So there is a certain limitation. Having said that, we are the advocate, we are the final frontier for this population, the aging population. That's how I feel it. And then I think about my future. So let's end here, and thank you so much for coming for this session, and we continue. Thank you.

age-friendly care

inpatient rehabilitation

aging population

centenarians

4M framework

Montefiore

VA Boston Healthcare

interdisciplinary care

patient outcomes

ethical considerations

medication management

mobility