CMS Introduces Age-Friendly Hospital Measure to Enhance Geriatric Care

The Centers for Medicare & Medicaid Services (CMS) has finalized a new measure aimed at improving the quality of care for older adults within hospital settings. This initiative, termed the "Age-Friendly Hospital Measure," signifies a significant step towards integrating age-specific considerations into routine hospital operations and quality reporting. The measure, which is not entirely new but has seen its implementation timeline solidified, seeks to encourage hospitals to adopt a more holistic approach to geriatric care, moving beyond a purely disease-centric model.

The Age-Friendly Hospital Measure is built upon the foundational principles of the Age-Friendly Health Systems framework, which centers on the "4Ms": What Matters, Mobility, Mentation, and Medications. While the core framework is established, the measure introduces specific domains and subdomains that hospitals must address, moving towards a more structured and measurable approach. This aligns with a broader national effort to ensure that healthcare systems are better equipped to meet the complex needs of an aging population, which currently constitutes approximately 50% of all hospital admissions.

Evolution of the Age-Friendly Health Systems Framework

The concept of age-friendly healthcare systems has been developing over several years, gaining traction through initiatives like those championed by the Institute for Healthcare Improvement (IHI) and the John A. Hartford Foundation. The initial framework, the 4Ms, was designed to be a guiding principle for healthcare providers to focus on aspects critical to the well-being of older adults beyond their immediate medical conditions.

• What Matters: This domain emphasizes understanding and respecting the individual goals and preferences of older adults. It involves conversations about their values, life goals, and what constitutes a good quality of life for them, ensuring that medical decisions are aligned with these personal aspirations.
• Mobility: Maintaining physical function and independence is crucial for older adults. This domain focuses on ensuring that hospitalized older adults are kept as mobile as possible, with interventions aimed at preventing functional decline during their stay.
• Mentation: Cognitive function and mental well-being are paramount. This domain addresses the assessment and management of cognitive status, including delirium, dementia, and depression, to support optimal mental health throughout the care journey.
• Medications: The appropriate use of medications is a critical aspect of geriatric care. This domain focuses on optimizing medication regimens, identifying and reducing the use of high-risk medications (often guided by frameworks like the Beers Criteria), and ensuring medications are aligned with an individual’s health goals.

While the original framework is comprehensive, the new CMS measure introduces a more defined structure for reporting and assessment. This includes additional domains such as Frailty Screening, Social Determinants of Health, and Leadership and Governance, reflecting a broader understanding of the factors that influence health outcomes in older adults.

The CMS Age-Friendly Hospital Measure: Key Components and Implementation

The Age-Friendly Hospital Measure is designed to be an attestation-based quality measure, meaning hospitals will report whether they meet the requirements rather than submitting detailed clinical data for every patient. This approach allows for a national baseline assessment of age-friendly care practices. The measure’s rollout is phased, with an initial focus on encouraging participation and data collection.

Key Domains of the Age-Friendly Hospital Measure:

1. Eliciting Patient Goals (What Matters): This component requires hospitals to document conversations about care goals at critical junctures: admission, discharge, and during significant changes in clinical status. This moves beyond simple advanced care planning to a more dynamic discussion of patient preferences.
2. Medication Management: Beyond routine medication reconciliation, this domain calls for reviewing high-risk medications (such as those identified by the Beers Criteria) and considering alternatives or discontinuation. This aims to reduce polypharmacy and adverse drug events common in older adults.
3. Frailty Screening and Mobility: This domain integrates the assessment of an older adult’s physical resilience and functional status. While not always prescribing a specific frailty tool, it mandates screening and, importantly, the implementation of actions to address identified needs, particularly concerning mobility. This also includes mentation screening, acknowledging the interconnectedness of cognitive and physical health.
4. Social Determinants of Health: Recognizing that non-medical factors significantly impact health, this domain encourages hospitals to screen for social needs. This includes aspects like caregiver stress, housing instability, and food insecurity, though it acknowledges the challenge for hospitals in directly addressing these complex issues within their operational scope and short lengths of stay.
5. Leadership and Governance: A crucial element for the sustainability of age-friendly initiatives, this domain requires hospitals to designate leaders responsible for age-friendly health system work. This ensures dedicated oversight and strategic direction for implementing and advancing these practices.

Challenges and Opportunities in Implementation

The introduction of the Age-Friendly Hospital Measure presents both challenges and opportunities for healthcare systems.

Challenges:

• Actionability: A primary concern is ensuring that screening leads to meaningful action. For instance, identifying social needs or frailty requires robust referral pathways and resources, which may be limited within the acute care setting.
• Measurement and Documentation: Accurately measuring and documenting adherence to these domains within electronic health records (EHRs) can be complex. Information may be scattered across different notes or require new data fields.
• Defining "Major Change in Clinical Status": The requirement for goal-of-care conversations at specific clinical junctures, including "major change in clinical status," leaves room for interpretation, potentially leading to variations in implementation across institutions.
• Caregiver Stress: While acknowledged, addressing caregiver stress presents a unique challenge for hospitals, as it extends beyond the patient’s immediate care needs.

Opportunities:

• Improved Patient Outcomes: By focusing on what matters to patients, optimizing medications, preserving mobility, and addressing cognitive and social needs, the measure has the potential to significantly improve patient experience and health outcomes.
• System-Wide Transformation: The measure serves as a catalyst for hospitals to critically examine and redesign their processes to be more age-friendly across the entire continuum of care, not just within the inpatient setting.
• Enhanced Care Transitions: The requirement to report mentation and mobility baselines upon discharge to the next care setting highlights the critical importance of smooth and informed transitions, potentially reducing hospital readmissions and post-acute disability.
• Data-Driven Improvement: The attestation-based approach, while initially less prescriptive, will generate valuable national data that can inform future iterations of the measure and guide evidence-based practices.

Expert Perspectives on the Measure

Healthcare professionals involved in geriatric care and health policy have weighed in on the significance and implications of the new measure.

Stephanie Rogers, a geriatrician and Medical Director of UCSF’s Age Friendly Health Systems, emphasizes the measure’s role in revitalizing the age-friendly movement. "This is not just a nice to have; it’s a must-have," Rogers stated, highlighting how the CMS measure provides institutional backing for initiatives that might have previously been considered optional. She also noted the flexibility of the initial phase, allowing hospitals time to develop their strategies.

Julia Adler-Milstein, Chief of the Division of Clinical Informatics and Digital Transformation at UCSF, views the measure as a crucial step towards more integrated care. She points out that while the measure is not entirely prescriptive, it offers significant guidance, particularly regarding the timing and context of goal-of-care conversations. Adler-Milstein also stresses the importance of studying how different hospitals operationalize these domains to identify best practices and ensure that the focus remains on improving outcomes for older adults.

Shari Ling, Deputy Chief Medical Officer for CMS, explained the rationale behind the attestation-based approach, noting that it allows for flexibility while signaling the importance of age-friendly care. "The attestation is a means for us to have said we believe this is important in the care and keeping of the people who we serve," Ling remarked. She also highlighted that the measure is designed to evolve, with future iterations potentially incorporating more specific quality metrics and incentives as the healthcare system becomes more adept at implementing these practices. Ling further emphasized the need for leaders who are both clinically engaged and committed to evidence generation and policy translation.

Future Outlook and Implications

In five years, it is widely anticipated that hospital care for older adults will look different as a direct result of this measure. While achieving perfect implementation across all older adults will likely take time, the increased focus on the specific dimensions of age-friendly care—from understanding patient goals to managing medications and promoting mobility—is expected to lead to more patient-centered and effective care.

The measure’s success will hinge on its ability to move beyond a "checkbox" mentality towards genuine integration into clinical workflows and a demonstrable impact on patient outcomes. Continued collaboration between CMS, healthcare providers, researchers, and advocacy groups will be essential to refine the measure, address implementation challenges, and ensure that age-friendly principles become the standard of care for all hospitalized older adults. The initiative represents a significant commitment to ensuring that the growing population of older adults receives healthcare that is not only effective but also deeply respectful of their individual needs and preferences.