Partnership with Trellis Leads to a New Way to Serve Older Patients
Author: Courtney Grace-Anderson, MS
For a healthcare provider, it can be challenging to know which community resources to offer older adult patients. From accessibility to respite care to dementia-related services, older people and their caregivers may ask for this information during a routine clinic visit.
To improve clinical care, the Minnesota Northstar GWEP partnered with Trellis, formerly known as the Metropolitan Area Agency on Aging, to create an after-visit summary (AVS) that specifically addresses vital areas that older adults care about. The benefits are twofold: Clinicians have an easier job of making appropriate, need-based recommendations while older adult patients receive more comprehensive care.
Trellis provides partnership and expertise in care of older adults
Trellis serves as a clearinghouse for virtually any service related to aging. In addition, President and CEO Dawn Simonson, MPA, and the Trellis team run other programs like Dementia Friends and the Senior LinkAge Line.
“As an organization that helps people optimize well-being as they age, we value MN GWEP’s collaboration with Trellis to create a streamlined process that connects people to community resources,” said Simonson. “Trellis brings knowledge of social care, public benefits and locally delivered support options that help older patients achieve their health goals. We are a conduit to statewide information systems like the Senior Linkage Line and to services that support family caregivers and older, diverse individuals. We appreciated the opportunity to partner in this important initiative.”
With their boundless knowledge, quality connections, and a deep understanding of policy implications, Trellis has served as a trusted member of the MN GWEP Community Advisory Board since 2019.
"Trellis has been indispensable for linking our clinical work to the outstanding array of community services for older adults and their caregivers," said MN GWEP Director James Pacala, MD, MS.
Trellis' expertise made them an ideal partner in co-authoring the AVS for use in select M Health Fairview clinics in the Twin Cities for primary care visits of adults age 65+. This is an age-friendly tool that had not existed before, but which has been sorely needed to connect patients and families with quality community resources.
Understanding What Matters
During traditional clinic visits before use of the Age-Friendly model, the clinician and the patient are guided through a brief visit that might not touch on what matters to the patient. Sometimes the standardized questions, especially in an annual wellness visit, do not adequately capture the patient's priorities for their own care.
For example, one patient’s biggest priority could be to avoid pain. Consequently, the care team might prioritize medications or rest. Another patient’s top priority might be to increase mobility so they can play actively with their grandchildren. In this case, the care team might prioritize physical therapy or other mobility supports.
Those are different goals based on the patient's priorities of what matters. But if the provider and the patient haven't had that conversation, then they might not come upon a care plan that recognizes what the patient really wants. The patient’s caregiver may not have known the wishes of their loved one until a provider asked those questions.
At the end of a usual visit, the patient receives an after-visit summary showing things like recommended vaccinations, follow-up instructions, and other appropriate information. But if certain questions are not asked—about things that matter most to the patient—then the AVS is not as useful as it could be.
Having a conversation about what matters to a patient doesn’t often occur during a clinical visit. That realization helped spark the creation of the “What Matters” educational toolkit, developed by Edward Ratner, MD, associate professor of medicine in the Division of Geriatrics, Palliative and Primary Care at the University of Minnesota.
The 4Ms: Toward greater care for older adults
The Age-Friendly 4Ms Smart Set, which is the framework accompanying the improved After Visit Summary, is for anyone aged 65 and over. The implementation of it is designed to offer a comprehensive conversation between the provider and the patient around the 4Ms. It is evidence-based and draws from the Age-Friendly Health System or the 4Ms: What Matters, Medication, Mentation, and Medication.
Medical practitioners, particularly family medicine physicians, cover a wide range of health needs and may not have deep expertise in geriatric care. Having easy access to the Age-Friendly clinical tool and AVS helps to bridge that gap.
“Previously, the annual wellness visit was not getting at ‘what matters’ and was also lagging in the medication component, which are two critical pieces to the population of those 65 and over,” explains Rhiannon Williams, PhD, evaluator for the Minnesota Northstar GWEP. “This 4Ms Smart Set is making sure that the primary care visit has a comprehensive and holistic view of the care needed for those older patients.”
Over half of the number of providers within four Twin Cities clinics have piloted the new 4Ms Smart Set. Nearly 500 patients have received this care, which is improved and Age-Friendly. The goal now is to educate more clinicians and raise awareness of this helpful, evidence-based tool. By focusing on clinics where students and residents learn, it is possible to improve care while evolving the practice of the next generation of healthcare professionals.
“It's available in the M Health Fairview health system in the electronic medical record as a smart set that clinicians can utilize, and we are in the process of training more providers to use that,” Williams said.
The design of the Age-Friendly tool in the electronic medical record was led by Drs. Jim Pacala, Christine Arenson and Rhiannon Williams. This was in collaboration with the National Center for Interprofessional Practice and Education, which is based at the University of Minnesota, with interprofessional clinicians and the Minnesota Northstar GWEP.
Highlighting What Matters for patients and clinicians
For patients who are 65 years old and better—along with their healthcare providers—the 4Ms Smart Set provides significant benefits. The predesigned tool guides the clinical care team through medical workup and aids a conversation with older adult patients. During a clinic visit, a medical assistant and provider can quickly access the set of medication questions to identify potentially dangerous medications, possible duplications, and any contraindications.
Christine Arenson, MD, professor at the Department of Family Medicine and Community Health and director of the National Center for Interprofessional Practice and Education, summarizes the goals of the 4Ms Smart Set:
"Healthcare practitioners of all backgrounds (physicians, nurses, pharmacists, MAs and many others) all want to provide the best, most patient-centered care to older adults. But in the context of busy clinical practice, it is challenging to cover all pertinent topics and make sure that the older adult, their family, and their practice team all understand the patient's current health status, treatment plan, and goals for what matters most for that individual. Using the 4Ms framework and building tools that fit with daily practice flows make it much more practical for the whole team to cover these important domains and have that information at their fingertips for future visits. We've seen the difference it makes for our patients and our colleagues."
Providers, patients, and caregivers can be more thoughtful about what their goals are for their own health and well being. Together, the provider and the patient can make intentional and well-informed decisions about care.
Looking ahead to more collaboration and positive change
The MN GWEP team and its partners plan to continue building awareness around the 4Ms Smart Set that is available to clinical providers. Whether direct or indirect, the impact on clinicians, patients, and others has been overwhelmingly positive thanks to the partnership with Trellis.
Age-Friendly Health Systems are part of a larger effort to enhance livability in our state to be dementia friendly, age friendly, and connected. Many other organizations continue to do great work to benefit older adults and their caregivers—and for the MN GWEP team, it is exciting to see the work become reality.