As the U.S. population ages, improving the care of older adults is more important than ever. Mary Tinetti, MD, Gladys Phillips Crofoot Professor of Medicine and section chief (Geriatrics), describes a $3.75 million Geriatrics Workforce Enhancement Program (GWEP) award as an opportunity for Yale School of Medicine (YSM) and its partners to create an age-friendly health environment across parts of Connecticut, Rhode Island, and New York.
The five year grant from the Health Resources and Service Administration (HRSA) is led by Project Director Richard Marottoli, MD, MPH, professor of medicine (Geriatrics) and co-Project Director Barry Wu, MD, professor of clinical medicine. The project is called the Connecticut Older Adult Collaboration for Health 4M (COACH 4M). HRSA notes that the essential elements of an age-friendly health system are the “4Ms”: mentation (cognitive assessment and management), medication (appropriate medication use), safe mobility (mobility assessment and management and fall prevention), and matters most (patient outcome health care goals).
Tinetti was one of the leaders who developed the 4Ms, through an initiative the John A. Hartford Foundation and Institute for Healthcare Improvement led, in partnership with the American Hospital Association and Catholic Health Association of the United States. A group of older patients, geriatric health experts, and health care system leaders studied what works to create age-friendly health systems. They evaluated the complex web of issues and honed them down to the 4Ms - manageable, evidence-based factors that can be assessed and acted upon. The 4Ms identify the core issues that should drive all care and decision-making related to the care of older adults, focusing on the person’s wellness and strengths, not just diseases. The initiative’s goal is to spread the 4Ms framework to 20% of U.S. hospitals and medical practices by 2020. This grant will help in that effort.
The COACH 4M grant expands upon a 2015-2018 grant YSM received, which was also part of GWEP. In 2017, Marottoli took over leadership of the original grant from Lisa Walke, MD. The original grant was designed to address the fact that the population of older adults is increasing rapidly in this country—by 2025, 10% of the population will be 65 and older—but the number of geriatricians available to care for them is not. Consequently, GWEP’s mission was to enhance the training of other health professionals to better meet the care needs of older adults, who these health professionals will see in their own practices.
Marottoli explains, “to accomplish this, we partnered with a number of community-based organizations, as well as schools and organizations training health professionals in different disciplines and at different junctures in their careers. We worked closely with these partners to identify what would work best for their organizations and their respective constituencies, crafting programs to incorporate geriatric principles in their training and education modalities.” Specifically, YSM partnered with Yale School of Nursing, Gateway Community College, Fair Haven Community Health Center, Cornell Scott Hill Health Center, VA Connecticut, and Yale New Haven Health System.
When Marottoli took over the original grant, the thought of seeking an extension and expansion was already on his mind. “Once we got word late last fall that there would be another round of funding, we began working in earnest on how the program would evolve from the original version.”
Marottoli continues “our mandate for the new grant is to continue to evolve these relationships and teaching approaches, with extra emphasis on inter-professional education, a focus on primary care settings, and the utilization of the 4Ms as the conceptual underpinning of this teaching.” Additionally, YSM is charged with determining the effect of teaching efforts under the grant on dementia caregiver education and support; advance care planning; fall risk; risk of opioid misuse; and high risk medication use. Coach 4M runs from July 2019 – June 30, 2024.
In the new grant, YSM is continuing with its original partners, and adding Northeast Medical Group, the New Haven Health Consortium, and the YSM Physicians Associate (PA) Program. The inclusion of the Northeast Medical Group, encompassing 100 primary care practices covering nearly 200,000 patients in southern and central Connecticut, Western Rhode Island, and part of New York, means the COACH 4M efforts can have an expansive impact.
One important new initiative is incorporating the 4Ms into the Integrated Longitudinal Clinical Experience (ILCE), which all first-year Yale MD, PA, and APRN nursing students participate in over nine months. As Tinetti points out, regardless of one’s role with patients, medical professionals tend to do the things they first learned. By embedding the 4Ms in the ILCE, students will, from the start of their professional education, be thinking about them, including how to interpret everything else they have and will learn through the lens of what matters to each older patient. Wu, who directs the ILCE clinical coach program, emphasizes the benefits to the students of learning together, across disciplines, since they will be practicing together throughout their careers.
Specifically, MD, PA, and APRN students will learn history-taking skills involved in functional health pattern assessment of older patients, using the 4Ms. Students also will learn that medical studies usually are conducted on participants younger than 65, and so may not apply to older patients. In fact, it can be harmful to apply these studies’ findings to older people because, for example, most individuals in this population have multiple medical conditions and take several medications that may adversely affect each other. Therefore, Wu explains, “the key is to hear what is important to the person in order to provide the best care to the patient” and he hopes “students learn to think more about the person with an illness, than a patient with a disease.”
Tinetti echoes this idea, emphasizing that “what matters most is the most defining of the 4Ms, and what YSM and its partners will focus most on.” Tinetti describes how older individuals were raised thinking the doctor knows best, so part of the paradigm shift is to get people to recognize the patient is the expert in knowing what matters most, and the clinician the expert in knowing what steps to take based on that priority.
Tinetti believes “YSM and its partners are in a unique position to make a difference” by focusing on the 4Ms across all sites in the grant: unlike some of the bigger metropolitan areas which received the grant, the COACH 4M geographic area is small enough to allow for strong relationships between the partners, enabling effective change and creating an age-friendly health environment across the grant’s geographic reach.