WHAT WE’RE LEARNING

Dear Colleagues—

“What matters to you?” It’s a powerful question that should guide health care decisions for everyone. The question becomes even more important as people age and consider procedures like surgery that carry risks along with benefits. An 85-year-old woman who develops a heart condition wouldn’t want a surgeon assuming she should – or should not – have an operation without trying to understand her life, goals and preferences.

Yet, in a world where cost savings, reimbursements, and billing take priority, how do we ensure that asking and acting on what matters to each patient is feasible for everyone involved in their care, including for those hospitals that may already be lacking resources?

That’s what we wanted to learn when developing the standards for the new Geriatric Surgery Verification Program, which launched last week as another way to help health systems become more age-friendly.

In 2015, the American College of Surgeons (ACS) and The John A. Hartford Foundation (JAHF) set out to create evidence-based standards that can be applied to foster optimal care for older adults undergoing surgery, guiding everything from pre-operative decisions and planning to post-operative care. To draft these standards, we created the Coalition for Quality in Geriatric Surgery, a group that included a wide diversity of experts and stakeholders—including patient and family caregiver groups. The results provide guidance on how best to respect and honor what matters to each patient—while still providing enough flexibility and customization to be feasible for health systems of any size or budget to adopt.

To ensure that the standards consistently center on what matters, we considered everything we knew about the unique needs of older adults. They are more likely to have multiple chronic, complex health conditions, limited mobility, or cognitive issues that must be factored into decision-making about surgery and any treatment plan. They are also more likely to need the support of a caregiver—often a friend or family member. Most importantly, what matters to a person may be very different at different stages of life. A younger person with cancer may want aggressive treatment focused on living as long as possible. The same person in later life may instead want less intensive care focused on relieving pain and symptoms. None of that can be assumed. We must ask the question.

Creating standards to ensure we align care with what matters to older patients also involved gathering input from those responsible for their care at every point in the process. That’s why, to create the standards, we brought together such a diverse group of stakeholders and experts. In addition to patient and family caregivers, we included representatives from nursing, social work, physical therapy, emergency medicine, anesthesiology and a host of other disciplines, along with regulators and payers. The goal was to create a set of standards that addressed every aspect of the process surrounding surgery for older adults, not just the surgical procedure itself.

By opening the conversation to those on the other side of the operating room door, we were able to think through the real-life, lived situations of older adults undergoing surgery and the impact on their families. With the perspectives of different providers, we were able to create practical, realistic standards that would both lead to age-friendly care and be broadly applicable. Most importantly, the diversity of input ensured that the standards never, at any point deprioritize what matters most to patients.

Perhaps not surprisingly, bringing together so many stakeholders resulted in no shortage of ideas for “what matters”-based standards. In fact, the initial set of standards approached a total of 300, which the stakeholders and project team then prioritized to 30. Next came the critical part: making sure that those standards put forth were both meaningful and manageable for every kind of hospital and could be adapted according to each system’s resources and capacity. To do this, ACS tested the standards in two phases, beginning with a survey. Next, eight hospitals deployed the standards to determine whether they were feasible. This was where the real-world applicability came into better focus.

For example, while one hospital may have the resources to adapt their electronic health records (EHR) to document “what matters,” we learned that low-tech options work, too, such as an orange piece of paper that goes everywhere with a patient listing that person’s goals. Since clinicians know the settings in which they practice better than anyone else, rather than opting for prescriptive, directive rules, we intentionally designed adaptable standards that can be customized according to the resources of every care setting.

All of the stakeholders involved in developing these standards are excited about what we learned along the way: that we truly can make what matters more pragmatic and realistic for hospitals and health systems. And in the process, we learned that making respecting what matters more feasible for everyone involved—not just the patient—also has broad applications across our work at The John A. Hartford Foundation, whether it’s increasing access to home-based primary care or spreading geriatric care best practices in emergency departments.

Bringing together a wide, diverse array of stakeholders when formulating standards or best practices results in more complete, holistic guidance that details what age-friendly care looks like at every point in a care plan. Opening the conversation ensures that specialists and caregivers involved in the care of older adults can share their points of view and that standards will be considered from every angle, at every point in the process. Importantly, it also ensures that standards can, and should, be tested in a variety of settings and revised to ensure they are adaptable and scalable for every health system. After all, prioritizing what matters for everyone is the first important step in ensuring we all do our part to transform care for older adults.

Sincerely,


Marcus Escobedo, MPA
Vice President, Communications and Senior Program Officer, The John A. Hartford Foundation