What Matters Most in Geriatric Care: The 5 M's of Age-Friendly Health Care
In this Better Edge podcast episode, Anna Liggett, MD, and Alexandra Petrakos, MD, both assistant professors of Internal Medicine and of Geriatrics at Northwestern Medicine, discuss the importance of patient-centered care and "What Matters Most" in geriatric medicine. Their conversation focuses on the five M's of age-friendly health care: medications, mentation, mobility, multi-morbidity and what matters most. Dr. Petrakos and Dr. Liggett share their research methods and findings, including survey responses from patients who were in a skilled nursing facility in the last six months.
Featured Speakers:
Learn more about Anna Liggett, MD
Alexandra Petrakos, MD is Assistant Professor of Geriatrics in the Department of Geriatrics.
Learn more about Alexandra Petrakos, MD
Anna Liggett, MD | Alexandra Petrakos, MD
Anna Liggett, MD is an assistant professor of Medicine in the Division of Internal Medicine and Geriatrics. Liggett earned her MD from Ross University in 2015 and completed her residency in family medicine at United Health Services, Upstate Medical University in 2019 before joining as geriatric medicine fellow at McGaw Medical Center of Northwestern University. Her clinical work focuses on home care and using integrative medicine to treat older adults. Her academic focus is on using data to improve post-acute care outcomes and improve efficiency in long-term care facilities.Learn more about Anna Liggett, MD
Alexandra Petrakos, MD is Assistant Professor of Geriatrics in the Department of Geriatrics.
Learn more about Alexandra Petrakos, MD
Transcription:
What Matters Most in Geriatric Care: The 5 M's of Age-Friendly Health Care
Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. And joining me today is Dr. Anna Liggett, she's an Assistant Professor of Medicine in the Division of Internal Medicine and Geriatrics; and Dr. Alexandra Petrakos, she's also an Assistant Professor of Medicine in the Division of Internal Medicine and Geriatrics. They're both with Northwestern Medicine and they are here to tell us about what matters most. Sounds like such an interesting topic. I know it's going to be. And doctors, thank you so much for joining us today,
Dr. Petrakos, I'd like to start with you. What are we talking about when we say what matters most? There's a lot of things that come to mind. Your research is based on the what matters most concept. Can you briefly highlight what this patient-centric topic really is?
Dr Alexandra Petrakos: Yeah. Thank you so much first of all for having me and having us. It's such a pleasure to be here. What matters most is part of the Illinois Institute for Health and Age-Friendly Health Systems Initiative that kind of takes into account the five M's of age-friendly healthcare. Those M's include medications, mentation, mobility, multi-morbidity, and then what matters most. And what matters most is kind of the overarching M, if you will, that brings the other M's together and allows clinicians to practice patient-centered, age-friendly healthcare and it's a concept that we're pretty passionate about in geriatrics.
Melanie Cole, MS: Well, thank you for that. It's really such an important topic. Dr. Liggett, what are the most impactful issues that you see with older patients that affect their quality of life when we're talking about this issue as far as lack of information on what matters most to older adults in the post-acute and skilled nursing facility setting? Why did you decide to apply this model to patients in that post-acute and skilled nursing facility settings recently discharged from hospitals? Tell us a little bit about some of these issues that Dr. Petrakos just mentioned with medication, mentation, mobility, what matters most, multi-modality, multi-complexity. Tell us about those.
Dr Anna Liggett: Exactly. In skilled nursing, we want to focus more on the patients and get it back to the medications and the mobility and what matters most to them specifically. A lot of times, skilled nursing facilities get stuck in a lot of the guidelines and regulations that are imposed on them through the state, and we just wanted to realign what the patient's goals are and what matters most to them and incorporate and target treatment towards them and what matters most to them.
Melanie Cole, MS: Well then, Dr. Petrakos, what are some of those areas that impact that quality care for older adults? I'd like you to expand for other providers that are looking at this type of a model, what that means.
Dr Alexandra Petrakos: No matter what setting of care you're in, whether we're talking about inpatient medicine in the hospital or in the outpatient clinic, which is where I primarily practice, or in the post-acute care setting where Dr. Liggett practices, we have an opportunity to kind of keep in mind these four M's. Medications, for example, making sure that we have an accurate medication list and that we review that all of the medications are appropriate for a patient to be on. We can try to minimize the number of medications a patient is on just in general because taking a lot of medications can be burdensome. We can also try to minimize the number of inappropriate or potentially inappropriate medications patients are on. Especially in older patients, there are certain medications that are not super safe for adults older than age 65.
Thinking about mentation, which is another one of the Ms, we screen for dementia or cognitive impairment in most all of our patients, as well as look for delirium or kind of acute confusion and impaired attention on the inpatient side or in the post-acute setting and also screen for depression in almost all of our patients.
Thinking about mobility, this is something that really comes into play in the post-acute care setting where patients are often going for physical and occupational therapy and rehab to try and get stronger and increase their independence and functionality. And then, of course, the older we get, the more medical problems we accumulate. And so, our patient population of older adults often has a long list of medical problems and some of the treatments for these different problems conflict with one another. And so for me, thinking about what matters most to the patient can help me determine which treatment to pursue, especially if there's conflicting medical problems and conflicting treatments, if that makes sense.
Melanie Cole, MS: Well, it does, and they do have so many comorbidities that go with age and so many medications to keep track of. It really is difficult for some of these older individuals. And Dr. Liggett, I'd like you to tell us about your research into what matters most and tell us about the research methods that you used.
Dr Anna Liggett: Yes. So, we reached out to 110 people who had been in a skilled nursing facility in the last six months, and we got 32 people to respond to the survey of various questions on getting to the bottom of what matters most to them. And once we got all those statements, about 48 statements, we divided them into themes. And we can go into those a little bit more. But I think Dr. Petrakos was going to go into more of the analysis we used as well.
Dr Alexandra Petrakos: Yeah. So once we had kind of our list of responses and phrases from patients about what they had stated they valued most, three different coders, we call them, analyzed those responses using the constant comparative method or constant comparative analysis. This is the method that we use typically for thematic analysis. And the way it works is you start reading through your list of responses and, in your mind, you're categorizing the different responses into buckets or themes. And as you go further down the list, you see, "Oh, well this one is kind of similar to that one that I saw first, and so if I just modify my bucket." And so by the time you get to the bottom of the list, you've constantly been comparing the responses that you're continuing to read the responses that you've already read. And it allows you to develop these themes or I always call it buckets to fit different responses into. And so Anna, you can talk about the different responses and the different themes that we identified.
Dr Anna Liggett: So, the three main themes related around their personal health goals and restoring their own health and getting back to where they were before they were hospitalized and generalized safety, so that was under the personal theme. And then, the most prevalent theme was the staff's competence and professionalism and just being overall kind and explaining their therapies and medications, that was taking place in the skilled nursing facility. And then, a third theme we saw was the facility itself. Just overall cleanliness and quality and even the food affects what matters most to them were some of the major themes that we teased out from the surveys,
Melanie Cole, MS: And all of that makes sense for the quality of life of these older individuals. I saw that with my dad too. Food's important and the staff is important, all of these things. Dr. Petrakos, did any of the responses or values of the residents surprise you at all?
Dr Alexandra Petrakos: I will just say that I love reading about what matters most to patients. I feel like most of the time I'm delighted by what people say. And then also, like you said, it makes sense, a lot of these responses make sense. I think for me, the one that I was most, I guess, it is surprised by, was the comment about cleanliness and quality of food just because I wasn't really expecting that I suppose, that diet affects the care. But thinking about my own family and, yes, my own father, it's kind of a more personal thing. What you eat and the food that they present to you, if you're interested in having that nutrition, it's going to affect your ability to participate in rehab. So, that one surprised me and delighted me and struck a personal chord.
Melanie Cole, MS: Well, it does for me too. And when you think about their energy levels, if the food is not appealing, they may not want to eat it. And we know that older individuals, especially in nursing facilities, can suffer from malnutrition. And if the food is unappetizing and physical therapy is going to be more difficult, I mean, it does all spiral and domino effects on each other. So, it does make a lot of sense. But how interesting is this study that you doctors did? So Dr. Liggett, how are you incorporating this research into your work at Northwestern Medicine? Take us from bench to bedside because this is really such an applicable study. I mean it absolutely can transfer so easily to the things that we see and this caregiving model.
Dr Anna Liggett: Yes. It's very good to refocus what matters most to the patients because we can get caught up in their complex comorbidities and their medications, and just focusing on what their goals are and what matters to them and how they're being treated in the nursing facility is very important to hone in on because you can't be there 24/7. And it is a theme that we identified is the most important to them. So even checking in with the facility and the director of nursing to make sure that everyone is trying to be as polite and professional as possible. Especially with the COVID-19 pandemic and the nurse shortages we saw, I think patients were running into, unfortunately, staff that was burnt out or overworked and it had a big impact on their stay at the skilled nursing facility and it's an important time when they're in rehab because they're really working on their own strength and getting back to their baseline. And there's not a certain medication that can get them back to the baseline they have to put in the work. So, it's important that they're in an environment that supports that healing and restorative process.
Melanie Cole, MS: Well, I think it also does tie this all together because they're not just comorbidities or separate ailments that they have for a medication with each. It's all one person and all of these things that you doctors studied come together to make that better quality of life. And we did see during COVID, especially in the nursing facilities, this disconnect. And it was heartbreaking to see that some of these services, some of the staff, as you said, were so overworked and exhausted all the time. So bringing this all around is really uplifting and it's interesting to see these results. Dr. Petrakos, can you leave us with one bit of information or advice for other providers listening that want to look to the what matters most model for caregiving because it is so important for the quality of life for these individuals.
Dr Alexandra Petrakos: Anna, I just love what you said. You kind of gave me goosebumps. Obviously, in my work, I think it's important to kind of have these conversations with every patient. Practicing patient-centered and goal-directed care based on what is important to patients, that is the most important thing I understand though that taking the time to have these conversations and determine. That it does take time to do this, but I guess I just urge other providers to take the time because I think the information that you'll glean from your patients and the deeper relationship that you can develop with your patients by learning what matters most to them is going to fuel your fire and your passion for practicing medicine and also gives you the opportunity, especially for patients that you're not sure what the best thing to do is let the patient tell you what matters to them and it will make it so much easier to know what the next best step is from a medical perspective as well in my experience.
Melanie Cole, MS: Very well said. And Dr. Liggett, any final thoughts that you'd like to add to this really important study?
Dr Anna Liggett: I think Dr. Petrakos said it very well, and just getting back to what the patients, really care about will really help guide the provider with their treatment is perfect.
Melanie Cole, MS: Well, it is such a patient-centric model, and I think that that's where we're moving to in the future with medicine. And these kinds of studies are just that important for other providers to see because it can make us all better healthcare providers in the long run and help our patients with their quality of life. Thank you doctors both so much for joining us today.
And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.com. That wraps up this episode of Better Edge, a Northwestern Medicine Podcast for physicians. Please remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.
What Matters Most in Geriatric Care: The 5 M's of Age-Friendly Health Care
Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. And joining me today is Dr. Anna Liggett, she's an Assistant Professor of Medicine in the Division of Internal Medicine and Geriatrics; and Dr. Alexandra Petrakos, she's also an Assistant Professor of Medicine in the Division of Internal Medicine and Geriatrics. They're both with Northwestern Medicine and they are here to tell us about what matters most. Sounds like such an interesting topic. I know it's going to be. And doctors, thank you so much for joining us today,
Dr. Petrakos, I'd like to start with you. What are we talking about when we say what matters most? There's a lot of things that come to mind. Your research is based on the what matters most concept. Can you briefly highlight what this patient-centric topic really is?
Dr Alexandra Petrakos: Yeah. Thank you so much first of all for having me and having us. It's such a pleasure to be here. What matters most is part of the Illinois Institute for Health and Age-Friendly Health Systems Initiative that kind of takes into account the five M's of age-friendly healthcare. Those M's include medications, mentation, mobility, multi-morbidity, and then what matters most. And what matters most is kind of the overarching M, if you will, that brings the other M's together and allows clinicians to practice patient-centered, age-friendly healthcare and it's a concept that we're pretty passionate about in geriatrics.
Melanie Cole, MS: Well, thank you for that. It's really such an important topic. Dr. Liggett, what are the most impactful issues that you see with older patients that affect their quality of life when we're talking about this issue as far as lack of information on what matters most to older adults in the post-acute and skilled nursing facility setting? Why did you decide to apply this model to patients in that post-acute and skilled nursing facility settings recently discharged from hospitals? Tell us a little bit about some of these issues that Dr. Petrakos just mentioned with medication, mentation, mobility, what matters most, multi-modality, multi-complexity. Tell us about those.
Dr Anna Liggett: Exactly. In skilled nursing, we want to focus more on the patients and get it back to the medications and the mobility and what matters most to them specifically. A lot of times, skilled nursing facilities get stuck in a lot of the guidelines and regulations that are imposed on them through the state, and we just wanted to realign what the patient's goals are and what matters most to them and incorporate and target treatment towards them and what matters most to them.
Melanie Cole, MS: Well then, Dr. Petrakos, what are some of those areas that impact that quality care for older adults? I'd like you to expand for other providers that are looking at this type of a model, what that means.
Dr Alexandra Petrakos: No matter what setting of care you're in, whether we're talking about inpatient medicine in the hospital or in the outpatient clinic, which is where I primarily practice, or in the post-acute care setting where Dr. Liggett practices, we have an opportunity to kind of keep in mind these four M's. Medications, for example, making sure that we have an accurate medication list and that we review that all of the medications are appropriate for a patient to be on. We can try to minimize the number of medications a patient is on just in general because taking a lot of medications can be burdensome. We can also try to minimize the number of inappropriate or potentially inappropriate medications patients are on. Especially in older patients, there are certain medications that are not super safe for adults older than age 65.
Thinking about mentation, which is another one of the Ms, we screen for dementia or cognitive impairment in most all of our patients, as well as look for delirium or kind of acute confusion and impaired attention on the inpatient side or in the post-acute setting and also screen for depression in almost all of our patients.
Thinking about mobility, this is something that really comes into play in the post-acute care setting where patients are often going for physical and occupational therapy and rehab to try and get stronger and increase their independence and functionality. And then, of course, the older we get, the more medical problems we accumulate. And so, our patient population of older adults often has a long list of medical problems and some of the treatments for these different problems conflict with one another. And so for me, thinking about what matters most to the patient can help me determine which treatment to pursue, especially if there's conflicting medical problems and conflicting treatments, if that makes sense.
Melanie Cole, MS: Well, it does, and they do have so many comorbidities that go with age and so many medications to keep track of. It really is difficult for some of these older individuals. And Dr. Liggett, I'd like you to tell us about your research into what matters most and tell us about the research methods that you used.
Dr Anna Liggett: Yes. So, we reached out to 110 people who had been in a skilled nursing facility in the last six months, and we got 32 people to respond to the survey of various questions on getting to the bottom of what matters most to them. And once we got all those statements, about 48 statements, we divided them into themes. And we can go into those a little bit more. But I think Dr. Petrakos was going to go into more of the analysis we used as well.
Dr Alexandra Petrakos: Yeah. So once we had kind of our list of responses and phrases from patients about what they had stated they valued most, three different coders, we call them, analyzed those responses using the constant comparative method or constant comparative analysis. This is the method that we use typically for thematic analysis. And the way it works is you start reading through your list of responses and, in your mind, you're categorizing the different responses into buckets or themes. And as you go further down the list, you see, "Oh, well this one is kind of similar to that one that I saw first, and so if I just modify my bucket." And so by the time you get to the bottom of the list, you've constantly been comparing the responses that you're continuing to read the responses that you've already read. And it allows you to develop these themes or I always call it buckets to fit different responses into. And so Anna, you can talk about the different responses and the different themes that we identified.
Dr Anna Liggett: So, the three main themes related around their personal health goals and restoring their own health and getting back to where they were before they were hospitalized and generalized safety, so that was under the personal theme. And then, the most prevalent theme was the staff's competence and professionalism and just being overall kind and explaining their therapies and medications, that was taking place in the skilled nursing facility. And then, a third theme we saw was the facility itself. Just overall cleanliness and quality and even the food affects what matters most to them were some of the major themes that we teased out from the surveys,
Melanie Cole, MS: And all of that makes sense for the quality of life of these older individuals. I saw that with my dad too. Food's important and the staff is important, all of these things. Dr. Petrakos, did any of the responses or values of the residents surprise you at all?
Dr Alexandra Petrakos: I will just say that I love reading about what matters most to patients. I feel like most of the time I'm delighted by what people say. And then also, like you said, it makes sense, a lot of these responses make sense. I think for me, the one that I was most, I guess, it is surprised by, was the comment about cleanliness and quality of food just because I wasn't really expecting that I suppose, that diet affects the care. But thinking about my own family and, yes, my own father, it's kind of a more personal thing. What you eat and the food that they present to you, if you're interested in having that nutrition, it's going to affect your ability to participate in rehab. So, that one surprised me and delighted me and struck a personal chord.
Melanie Cole, MS: Well, it does for me too. And when you think about their energy levels, if the food is not appealing, they may not want to eat it. And we know that older individuals, especially in nursing facilities, can suffer from malnutrition. And if the food is unappetizing and physical therapy is going to be more difficult, I mean, it does all spiral and domino effects on each other. So, it does make a lot of sense. But how interesting is this study that you doctors did? So Dr. Liggett, how are you incorporating this research into your work at Northwestern Medicine? Take us from bench to bedside because this is really such an applicable study. I mean it absolutely can transfer so easily to the things that we see and this caregiving model.
Dr Anna Liggett: Yes. It's very good to refocus what matters most to the patients because we can get caught up in their complex comorbidities and their medications, and just focusing on what their goals are and what matters to them and how they're being treated in the nursing facility is very important to hone in on because you can't be there 24/7. And it is a theme that we identified is the most important to them. So even checking in with the facility and the director of nursing to make sure that everyone is trying to be as polite and professional as possible. Especially with the COVID-19 pandemic and the nurse shortages we saw, I think patients were running into, unfortunately, staff that was burnt out or overworked and it had a big impact on their stay at the skilled nursing facility and it's an important time when they're in rehab because they're really working on their own strength and getting back to their baseline. And there's not a certain medication that can get them back to the baseline they have to put in the work. So, it's important that they're in an environment that supports that healing and restorative process.
Melanie Cole, MS: Well, I think it also does tie this all together because they're not just comorbidities or separate ailments that they have for a medication with each. It's all one person and all of these things that you doctors studied come together to make that better quality of life. And we did see during COVID, especially in the nursing facilities, this disconnect. And it was heartbreaking to see that some of these services, some of the staff, as you said, were so overworked and exhausted all the time. So bringing this all around is really uplifting and it's interesting to see these results. Dr. Petrakos, can you leave us with one bit of information or advice for other providers listening that want to look to the what matters most model for caregiving because it is so important for the quality of life for these individuals.
Dr Alexandra Petrakos: Anna, I just love what you said. You kind of gave me goosebumps. Obviously, in my work, I think it's important to kind of have these conversations with every patient. Practicing patient-centered and goal-directed care based on what is important to patients, that is the most important thing I understand though that taking the time to have these conversations and determine. That it does take time to do this, but I guess I just urge other providers to take the time because I think the information that you'll glean from your patients and the deeper relationship that you can develop with your patients by learning what matters most to them is going to fuel your fire and your passion for practicing medicine and also gives you the opportunity, especially for patients that you're not sure what the best thing to do is let the patient tell you what matters to them and it will make it so much easier to know what the next best step is from a medical perspective as well in my experience.
Melanie Cole, MS: Very well said. And Dr. Liggett, any final thoughts that you'd like to add to this really important study?
Dr Anna Liggett: I think Dr. Petrakos said it very well, and just getting back to what the patients, really care about will really help guide the provider with their treatment is perfect.
Melanie Cole, MS: Well, it is such a patient-centric model, and I think that that's where we're moving to in the future with medicine. And these kinds of studies are just that important for other providers to see because it can make us all better healthcare providers in the long run and help our patients with their quality of life. Thank you doctors both so much for joining us today.
And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.com. That wraps up this episode of Better Edge, a Northwestern Medicine Podcast for physicians. Please remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.