Every month, the leadership team at the Gerontological Advanced Practice Nurses Association (GAPNA) highlights the most important published literature that impacts geriatric practice. This month, GAPNA President Sherry A. Greenberg, PhD, RN, GNP-BC, FGSA, FAANP, FAAN, reviews 3 studies that aim to improve the quality of life of older adults by making the most of Medicare’s annual wellness visits, preventing falls, and focusing on the 4Ms — what matters, medication, mentation, and mobility.

Conversations about wellness: a qualitative analysis of patient narratives post annual wellness visits

Geriatric Nursing. 2021;42(3):681-686.

Summary: The aim of this study was to provide ongoing support for health promotion efforts and explore factors playing a role in meeting Medicare’s annual wellness visit (AWV) recommendations, which are currently not be used to the fullest extent. Nurse-led monthly follow-up calls between AWVs offer the opportunity to both provide support and collect data that can inform development of effective health promotion strategies, including personalizing health promotion.


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Commentary by Dr. Greenberg: Advanced practice providers are in an excellent position to promote health, safety, and well-being practices. This is commonly accomplished with older adults, families, and caregivers during AWVs.  The Medicare AWV, covered by Medicare without a copayment or deductible, focuses on wellness, health risk, and lifestyle behavior assessment, health promotion, screening, and disease prevention, as opposed to managing conditions.

This qualitative descriptive study provides insight into factors that influence health promotion behaviors and efforts among older adults after annual wellness visits. Participants were recruited using simple random sampling and researchers used a structured script for phone visits. Narrative analysis focused on stories told by the older adults and inductive thematic analysis was used to identify, analyze, and report themes that emerged from the narratives.

A total of 144 phone visits were made with 47 community-dwelling older adults 65 years and older. Seven themes emerged: mental health, social support, stress, community/environment, motivation, health promotion behaviors, and health care access.

Advanced practice providers and all health care professionals caring for older adults, their families, and caregivers should provide person-centered care, listen, collaborate with interprofessionals, and purposefully address these identified themes during visits.

These important aspects of care promote good health outcomes, address patient needs, promote health equity, ensure access for patients to accomplish goals, encourage health promotion behaviors, and provide crucial ongoing motivation and support.

On the Move clinic: a fall prevention nurse practitioner-driven model of care

Geriatric Nursing. 2021;42(4):850-854.

Summary: Every second of every day an older adult falls, according to the Centers for Disease Control and Prevention (CDC). In 2018, 1 in 4 older adults (36 million) reported falling, more than 8 million falls required medical attention, and more than 32,000 older adults died from their fall (Figure). This article describes a clinic designed to provide person-centered recommendations to decrease fall risk. On the Move, a nurse practitioner-led model of care, is adapted from the CDC’s Stopping Elderly Accidents, Deaths & Injuries (STEADI) Initiative.

Source: CDC/STEADI.a

Commentary by Dr. Greenberg: Using a team approach, a nurse practitioner certified as a gerontologic specialist and a physical therapist received referrals from primary care and emergency department providers for community-dwelling participants 60 years and older with a history of falls or identified as at high risk for falls, ambulatory with or without an assistive device, and cognitively able to follow recommendations.

Participants received individualized intervention plans, motivation, and education to decrease physical, pharmacologic, behavioral, and environmental fall risk factors and a follow-up call after 6 weeks to reinforce recommendations.

Strength, gait speed, and balance as well as evidence-based assessment tools were used to measure changes over 12 weeks. The intervention was associated with significant improvements in the following tests: 30-second chair stands (P<.0001), Timed Up & Go Test (P=.0051), 4-item Dynamic Gait Index (P=.0004), and Activities-Specific Balance Confidence Scale (P=.0006).

Participants self-reported behavior changes included improving balance and endurance (93%); increasing fluid intake (43%); being more observant of the environment (43%); using sleep hygiene techniques (36%); implementing changes to home environment (21%); engaging in more exercise and activity (21%); making medication changes, carrying a phone, and adjusting mood (each 7%).

Advanced practice providers and interprofessional team members should promote person-centered fall risk factor modification, mobility, and exercise plans. Clinics such as On the Move are sustainable programs that meet a crucial need in the health care of older adults.

Evidence for the 4Ms: Interactions and outcomes across the care continuum

Journal of Aging and Health. 2021;33(7-8): 469-481.

Summary: This article delineates the evidence for the 4Ms — what matters, medication, mentation, and mobility — in providing age-friendly care to older adults across care settings. The 4Ms framework forms the basis of age-friendly care and guides health care providers in assessment and action steps when providing care to older adults. The authors argue “that the simplicity and focus for the 4Ms set is starting with what’s most important to the older adult, with the concomitant intersection of all 4Ms driving quality and safety in the plan of care.”

Commentary by Dr. Greenberg: In 2017, The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI), in partnership with the American Hospital Association and the Catholic Health Association of the United States, set out to significantly change the care received by older adults by beginning the Age-Friendly Health System initiative. The partnership created a care model to integrate in a variety of health care settings, allowing for ease of use and reliability.

The Age-Friendly Health System evidence-based initiative was developed by researchers, clinical geriatric specialists, and health system leaders. A convening of geriatric experts reviewed 17 geriatric care models with level 1 or 2a evidence of impact and identified 90 care elements. Redundancies were removed and 13 discrete features were found by the IHI team. An expert meeting led to the selection of the vital set of 4Ms: what matters, medication, mentation, and mobility.

© Age-Friendly Health Systems an initiative of The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI) in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA).

For what matters, know and align care with each older adult’s specific health outcome goals and care preferences. If medication is necessary, use an age-friendly medication that does not interfere with what matters to the older adult’s mentation or mobility. Prevent identify, treat, and manage dementia and delirium; ensure older adults move safely; and set mobility goals to maintain function and do what matters.

Advanced practice providers in all care settings are instrumental in implementing age-friendly care for older adults, their families, and caregivers to promote positive clinical outcomes and meet individualized goals.

aReference to specific commercial products, manufacturers, companies, or trademarks does not constitute its endorsement or recommendation by the US Government, Department of Health and Human Services, or Centers for Disease Control and Prevention.

References

1. Simpson V, Edwards N, Kovich M. Conversations about wellness: a qualitative analysis of patient narratives post annual wellness visits. Geriatr Nurs. 2021;42(3):681-686. doi:10.1016/j.gerinurse.2021.03.001

2. Kanne GE, Sabol VK, Pierson D, Corcoran MW, Silva SG, White HK. On the Move clinic: a fall prevention nurse practitioner-driven model of care. Geriatr Nurs. 2021;42(4):850-854. doi:10.1016/j.gerinurse.2021.03.019

3. Mate K, Fulmer T, Pelton L, et al. Evidence for the 4Ms: Interactions and outcomes across the care continuum. J Aging Health. 2021;33(7-8): 469-481.doi:10.1177%2F0898264321991658