Bill Klaproth (Host): Welcome to Today in Nursing Leadership, a podcast from the American Organization for Nursing Leadership. I'm Bill Klaproth. And today, we're looking at how Advocate Health is advancing age-friendly care across its organization and what other nursing leaders can learn from its experience. Joining me are Amy Margeson, Vice President of Clinical Quality, Safety, and Experience Operations; and Johanna Lemke, Vice President of Nursing Practice Transformation, both with Advocate Health. Amy and Johanna, welcome.

Amy Margeson, MBA, BSN, RN: Thanks for having us, Bill.

Johanna Lemke, BSN, MA, RN, NEA-BC, PhD(c): Thanks, Bill. Pleasure to be here.

Host: Absolutely. Amy, let me start with you with a couple of questions first. So, let's start with the big picture. Why is age-friendly care becoming such an important strategic priority for health systems, and what's driving this increased focus, and why should nurse leaders be paying attention?

Amy Margeson, MBA, BSN, RN: Yeah, such a great question. You know, age-friendly, we have found that has ended up being one of the most important strategies for the future of healthcare because our older adults are representing just our largest and most complex patient population. They occupy, as you know, a significant portion of our inpatient beds, and they're driving many of the health outcomes that we're working to fix, we're working to improve, including mortality and readmissions, length of stay or capacity management, and patient experience as well.

So, the population's continuing to grow while the complexity of care too increases, which directly, right, impacts nursing and those providing direct care. So at Advocate Health, you know, age-friendly is more than just meeting the CMS requirement, right? CMS kind of came out with this IQR kind of program requirements. And for us, we wanted to develop a framework for providing person-centered care that's aligned with what matters most to patients, and of course, while preserving mobility and cognition, independence, and overall quality of life. We're viewing this work as really just critical quality, safety, and experience strategy just to help shape the future of healthcare and across the continuum. So, it continue to be a strategic priority, yeah, just, across all sectors of the healthcare organization.

Host: So, Advocate Health has been recognized as an exemplar organization in age-friendly care. So Amy, what do you think has contributed most to that success, and what leadership decisions or strategies help move this from a concept into everyday practice?

Amy Margeson, MBA, BSN, RN: Yeah, great question. You know, I think one of the most important decisions that we made was treating age-friendly care as an enterprise transformation. It wasn't just this compliance project or check the box. And we've been embedding the principles of age-friendly care into workflows, into quality in nursing and operation also, leadership structures too, and who's part of this. And we've been able to standardize workflows and our IT support, which has been critical, I would say, in developing not just workflows, but data insights as well, in addition to developing our education, our measurement framework and accountability. So, this has become part of daily practice rather than a separate initiative, right? Not just one more thing to do, right, if you're in nursing.

So additionally, I would say, which I find to be a bit of a differentiator, is that we pulled in also our academic learning health system, where how do we learn from this, the research components? And this has really been a game-changer with that leadership in place.

And I think what's really, truly distinguishing us, which I'm so excited about, is of course going above and beyond the CMS requirements by establishing the Senior Care Collective, which Johanna and I have the privilege of being part of. And this is really bringing together service lines and nursing and physicians and quality, safety, analytics experience, just folks across the board, just other stakeholders to identify what are the priorities. And that way, we can develop the next generation of best practices. That's what it's about. We recognize this population. It is not just our greatest opportunity, but our greatest responsibility as well. And so, I would say CMS started with, "Hey, here's a target we go after." And we're like, "You know what? We need to transform healthcare and how we deliver care with this population." And so, we're going to design this around the needs of that population

Host: I like how you said this has become a daily practice rather than initiative. That's really important. So, I'm thinking one of the interesting aspects of this whole approach is then your partnership between nursing and leadership, if you will. Can you talk about that collaboration to advance age-friendly care and why that relationship between nursing and leadership has been so important?

Amy Margeson, MBA, BSN, RN: Yeah. Nursing being at the table too. So to your point, you raise how just embedding into the workflow is important, that we don't want things to necessarily feel like another initiative or another workflow or a different workflow versus how do we embed it into that daily practice. And nursing is usually the number one team to raise their hand and just say, "How do we include this, right, into that daily practice?"

Nursing and leadership, and I would say quality, of course, coming from the quality background, has been foundational to the success. I think, Johanna, we're so lucky to work for an organization with such strong leadership, including yourself, who have been key partners for leaders across all disciplines.

And nursing leaders across Advocate Health have been driving practice transformation, engaging staff especially with workflow design and ensuring, you know, with bedside implementation. So, I think, you know, from quality, we're able to bring the measurement side and reliability science, improvement expertise while together evidence-based practices are being implemented by nursing at the bedside. But then, we're also ensuring that there's sustainability and continuous improvement as well.

And so, again, I think we're not just focusing on that compliance, but the partnership to keep our focus. And, you know, we ask ourselves just to ensure that a process isn't just completed, but we continue to look at this almost like a PDSA cycle as well. We want to improve overall function and a better experience.

And I think that combination of nursing excellence and overall improvement allows us to scale successful practices across a large integrated health system. And so, there is one standard of practice for nursing. It's not variable, despite, you know, ever-growing organization.

Host: And Amy, another question for you. I'm wondering, was it difficult getting frontline nurses engaged in this? And was it tough helping them to see the value in this?

Amy Margeson, MBA, BSN, RN: Yeah, I think that's so important, just bringing nursing at the forefront to say, "This is what we need to do. This is the population that we want to go after." And for them to be at the table, to be able to design the care, but also say, "Let's take a look at our EHR and how they document and how they interface with the patient and how we record that." And we just obtain their buy-in right up front, just always ensuring that nursing has that seat at the table.

Host: And Johanna, let's bring you into this, speaking of the EHR question for you. Let's talk about technology. How have you leveraged your EHR to support nurses in delivering age-friendly care? And is there anything that's made the biggest difference in helping translate these principles into clinical practice?

Johanna Lemke, BSN, MA, RN, NEA-BC, PhD(c): Yes, 100%. Great, very important question, related to how we leveraged our electronic health record. And Amy really said it best with the guiding principles is that, we really understood these can't be add-on workflows. We have to understand the outcome that we're driving towards, work with our frontline nurses, and build those workflows to get those outcomes and deliver the best care to older adults.

So, the EHR really makes the care easier to see and easier to improve. In our environments, it's allowed us to standardize those 4 Ms, assessments, clinical prompts, decision support, and workflows into the nurse's work instead of being a separate process.

So, one example that has been really powerful is we built an age-friendly 4M audit tool that gives patient-level visibility so our nurses can see if they have a missing assessment or a missing documentation and address those gaps before a patient's discharge. And then, the data rolls up to dashboards that allow our leaders visibility to see how we're doing with the program as a whole, both at the unit, the site, and even the enterprise level.

So, the EHR really makes the age-friendly care visible to us. It makes it actionable, and it makes it measurable. And one of the things in the design, that we were really looking for is duplicate documentation. So, sometimes when there is compliance measures, what's done is to just, okay, we'll create another form or another row to make sure that this documentation gets included because it's regulatory compliance.

We really work with our nurses to see—because we knew this is the care that they're providing, you know, related to mental capacity, medications, mobility, and what matters to them. So, where would it be natural for them to chart this, and then building that into our workflows.

Host: So, has the EHR helped reduce the burden on nurse leaders?

Johanna Lemke, BSN, MA, RN, NEA-BC, PhD(c): That is the definite intention is not to add burden certainly. But yes, of course, ultimately we want our electronic health record, to be providing us insights, to be delivering impact, and to be reducing clicks and time in the chart without a doubt.

Host: Absolutely. So, Advocate Health provides care across a variety of settings. So, what does age-friendly care look like in hospitals compared to ambulatory care or home health? And what have you learned about scaling this approach across the continuum?

Johanna Lemke, BSN, MA, RN, NEA-BC, PhD(c): Yeah, this is such an important question because, as Amy mentioned, our older adult population is growing and they're mostly out in the community. Their time in acute care hospitals is episodic and hopefully short. So, the CMS framework of these domains gives us a structure that we can apply no matter where the patient is.

So in the hospital, we're focusing on identifying what matters early on in the stay so we can use it to guide treatment. Medication management is a lot about reducing medication-related harm. We're screening for frailty, looking at mobility limitations, functional decline, assessing social, vulnerability at admission and discharge. And then, leadership is, of course, supporting all those practices.

Once the patient moves to ambulatory, it's really the same domains. It's understanding what matters, but medication management might be more about, you know, managing the medication in the home, managing chronic conditions, preserving their function, and addressing any kind of social issues before they were to become a crisis.

And then, in home health and continuing health, these domains really become to life for our nurses because they are in a care environment where they can see how the patient actually lives. So, they really understand what matters. It might be, you know, maintaining independence. They can do a close analysis of medication safety because they can really do a true reconciliation, not just of hospital medications, but all those home medications.

So, a real meaningful example is our continuing health, being included together with our Wisconsin inpatient hospitals in the IHI Age-Friendly Health System Excellence in System-Wide Spread recognition. So, that recognition was one of the first for home health, continuing health. And we're really excited because this is about the patient, not about the program. So, the age-friendly care, then that'll be one of the, you know, future of where we're going to, is to continue to spread it across the continuum.

Host: So Johanna, for nurse executives listening who want to get started with age-friendly care, what's your advice? Where should they begin and are there common mistakes or challenges they should try to avoid?

Johanna Lemke, BSN, MA, RN, NEA-BC, PhD(c): Yeah, definitely. I think it can seem overwhelming, but like we've been saying, the important thing is to begin with your why, your purpose, which is the care of older adults. Identify one clearly stated population to focus on, and then assess what your organization already does across the five domains because most organizations are going to find that you're not starting from zero. You probably already have strong practices around setting goals for your patients, medication safety, social needs, but the efforts might not be connected.

So, another key is to establish an interdisciplinary leadership team and make sure you have the voice of the nurse at the table, as we talked about before, embedding the nurse's perspective as you build those clinical workflows is going to be a key to success. We recommend having a strong governance structure, because the idea is that you're going to spread and scale, but start small, maybe even with one unit where you have buy-in, engagement, a population of older adults that's going to make the impact meaningful for your teammates.

And then, common pitfalls, I'll circle back to something Amy mentioned, and that is treating it as a compliance requirement. I would say, in terms of implementation, sustainability, and spread, you know, if you treat age-friendly like it's a checkbox, a compliance requirement, and try to implement everything at once without changing the workflow, it just feels like a separate program, and you're going to lose right from the get-go the connection to the meaningfulness of the work.

So, the leadership sponsorship, it was also mentioned before, the physician partnership, nursing executive partnership, and quality that has been tremendous paired with the academic learning health system so that we can study ourselves in terms of the way we implement and sustain.

So, I would say keys to success would be build with nurses. Nurses are going to be definitely a key to success. Start small, but start structured so when you do go to scale and spread, you have that structure and framework to lean on.

Host: So, those are some really good tips that you gave us. So, really important stuff. Make sure you build it with nurses and then start small, but start with structure. Great stuff, Johanna. So as we wrap up, I want to thank you both for your time today. I would love to get your perspectives on this question, each of you. So Amy, let me start with you. What's next for age-friendly care at Advocate Health, and where do you see the greatest opportunities to build on the progress that you've already made?

Amy Margeson, MBA, BSN, RN: Yeah, such a great question. I think this is where we're really excited about the momentum and really creating this senior care collective to see where this is going to go. And it's just a really progressive look at how we pull together all those disciplines.

So when we mention service lines for our enterprise across the whole organization, we know that everyone is touching senior care, right? Whether or not it's cardiology or geriatricians or oncology, and we know that we want to be able to build those best practices. Johanna said it great as far as how we study ourselves and bringing in the academic learning health system as well. But ultimately, we want to create the future of senior care and how we do this with the multidisciplinary approach. Couldn't do it without nursing. But as I mentioned, nursing and physicians and service line and quality, but also with the patient's voice. And I think it's really important as we design the care we're doing that with the patient and the caregiver's voice as well, just to ultimately improve outcomes and the experience for this population that we serve the most across our organization.

Host: Amy, thank you for that. Fantastic. Johanna, I would love to hear from you next. So, what do you think is next for age-friendly care at Advocate Health, and where do you see the greatest opportunities to build on the progress that you've already made?

Johanna Lemke, BSN, MA, RN, NEA-BC, PhD(c): Yeah, absolutely. As, you know, we've talked about, we're going to continue to spread and scale and refine our workflows, so that we can achieve even greater outcomes and impacts with the domains and the 4 Ms. Definitely moving across the continuum, into continuing health, home health, and ambulatory care.

But one of the key things that we're reminded of among our work group in our leadership meetings too, is that we really need to push workflows and our analytics to move beyond whether or not we're just doing an assessment, for example, or a screening tool, to actually what was the improved outcome for that older adult and for these older adult populations. So, I know we will get there and we will be leading the way.

Host: That is wonderful. Well, Amy and Johanna, this has been a great discussion. Thank you so much for sharing all the good work you're doing at Advocate Health. Thank you again.

Amy Margeson, MBA, BSN, RN: Thanks for having us.

Johanna Lemke, BSN, MA, RN, NEA-BC, PhD(c): Thanks, Bill.

Host: You bet. And once again, that is Amy Margeson and Johanna Lemke. And for more information, just go over to our website and check out aonl.org to check out our podcast page to see all of our podcasts right there. And thank you for listening to Today in Nursing Leadership, a podcast from the American Organization for Nursing Leadership. Thanks for listening.