SCCMPod-557: Building Age-Friendly Health Systems in Critical Care

Dr. Bulloch: Hello and welcome to the Society of Critical Care Medicine podcast. I'm your host, Marilyn Bulloch. Today, I'm joined by Terry Fulmer, PhD, RN, FAAN, to discuss her Norma Shemaker Honorary Lecture, Why the 4Ms Approach to Critical Care Improves Quality, Lessons from the Age-Friendly Health Systems Movement. Dr. Fulmer is a president of the John A. Hartford Foundation and a member of the National Academy of Medicine. She is also the former president of the Gerontological Society of America and an experienced critical care nurse.

Welcome, Dr. Fulmer. Before we start, do you have any disclosures to report?

Dr. Fulmer: I have no disclosures and I am just delighted to be with you, Marilyn. It's a huge honor for me and to be able to give the Norma J. Shemaker lecture is especially awesome for me.

I read about her and it sounds like she made such an incredible difference to the founding of this organization, she and her husband. So, reading about her makes me want to do a better job every day.

Dr. Bulloch: You know, that was going to lead into my first question. You know, this is a big award that we give every year to a nurse who has just really had a huge impact on critical care nursing. And so, it is an extraordinary honor that you are well deserving of.

What does it mean to you to receive this award?

Dr. Fulmer: Oh, it's sort of a culmination of so many things I care about. Expert care in the critical care arena is essential for older adults. Without it, they have bad outcomes.

And so, to be able to have read about her, her passion, and to be able to speak to this very august audience and talk to them about ways in which they can do the essential work they do, and at the same time, work with all of us at the John A. Hartford Foundation and IHI and AHA on Age Friendly is just a great opportunity.

Dr. Bulloch: We are so excited to have you. Your CV is extremely impressive. And for our listeners out there, I encourage you to look at what Dr. Former has accomplished. Can you share with our listeners, many of which were probably you when you were much younger, tell us about your journey. How did you get to where you are today?

Dr. Fulmer: I love to talk about that because I do think that it's useful to everybody who is emerging in their leadership. And let me just say, they're going to do it. They're going to be successful.

It's wonderful. And by the way, I also want to thank my friend, Nancy Lundebroe, who's the CEO of the American Geriatric Society. It was her generosity that connected me for this lecture.

So really want to give her a shout out. So when I began my nursing career, it was a time when there was, in fact, a book by a surgeon. His name was John Skillman.

And in his book on surgery in older adults, he wrote that an exclusion criteria for surgery in ICUs was being over 70 years old. So imagine that.

Dr. Bulloch: That was 1975. That's so young. Yeah.

Dr. Fulmer: But it was, there it was. And of course, we know the story now. But just to give you a snapshot in time, and remember that critical care was begun as a unique discipline in order to provide excellent nurse-patient ratios.

So that was the main reason to begin with. And then of course, the science of critical care has just quadrupled, quintupled every single year since then. And it's been a real pleasure to watch everything that has really emerged.

If you didn't follow the science every day, like all of you do, it would seem like a miracle was happening. So it's really terrific. So I started my career.

And what I saw was older people coming in through the emergency room, being admitted. I was on a general unit at that time. And there was a phenomenon where we love to save people, but we don't necessarily like to take care of them.

And here's what I mean by that. If an older person came in and they had cardiac disease, and they had an arrhythmia, and maybe they had a cardiac arrest, which would be horrible. But if they did, we might bring them back, resuscitate them.

But then, as they moved to that next phase where they had trouble eating, and they couldn't get out of bed, and they were incontinent, and began to have pressure ulcers, that then it was no longer very interesting to a lot of people in acute care. And so that was a real sore point for me. And I found my calling.

And that's what I've done ever since that time. And so I remember writing in a chart one time, this very diminutive older woman came in and she had renal failure. But in addition, as far as I was concerned, she was starving.

And I wanted to really have people pay attention to that with me. And I wrote a note that said that this particular patient had a voracious appetite. And I got mocked for that.

They were like, Oh, listen to her voracious appetite. And I said, No, it's true. And you should be worried about this with me.

So I also learned they have to be strong in your convictions and state what you're seeing and make sure that people are listening and taking things seriously with you. I learned I was at the Beth Israel Hospital, now called BIDMC, Beth Israel Deaconess Medical Center in Boston. And it was in the midst of Harvard Medical School.

And I learned very quickly that if I had evidence for what I was purporting for care, I would be fine. But if I ever had a feeling about something, it wasn't going to go very far. Now today, you could say, you know, my instincts are and no one would walk away from you.

But at that time, if you could cite a paper, then you could really get people's attention. So I learned that really fast. And I know that today's critical care nurses are always evidence based.

All of the team is, you know, my friends in pharmacy, and I know that you are a very esteemed pharmacy leader in critical care, Marilyn. And so when I look at the advancements and knowledge and how critical care would never begin their daily rounds without the pharmacy person with them, so.

Dr. Bulloch: Well, that's what I love about you. For our listeners, I have a background in geriatrics as well. And I love the complexity of older adults.

And when you think about each person is so very different, and you cannot have a cookie cutter approach to this patient population. It's interesting, you said you were at Beth Israel, at the time you started, and we think about this patient population, I think about the book, The House of God, and just the way that they approached the care to older adults is very dismissive, and lots of stereotypes in the way that very painful, very painful. So I think that that was very interesting.

Was that really the approach that you were dealing with? Yes. Okay, that's very interesting.

Dr. Fulmer: I've always wondered who haven't read it, that book is 50 years old plus, and it was the most insulting book you would ever read about caring for older adults and also just the whole interdisciplinary team and how diminished other team members were compared to the medicine team.

Dr. Bulloch: And we certainly have grown a long way. And what I personally love about both geriatrics and critical care is these are two specialties that do interprofessional collaboration, and they do it well. There's not a lot of territory that you might see in other disciplines.

We want to work with each other. We want to have the whole team there. The Society of Critical Care Medicine was fortunate on Saturday to do an aging sensitivity in critical care for students in the Orlando area, and we had students from all disciplines, medicine, nursing, pharmacy, we had speech there.

And I was so excited to see the collaboration and some of these simulation trainings that we were doing for them. So I think that this really does intersect because these are who our patients are in critical care. You are here to talk about age-friendly care, which we need to be focused on.

We have the silver tsunami, right, with the baby boomers that is not just trickling anymore. That wave is crashing. And the millennials, and I'm a geriatric millennial, we're bigger than the baby boomers.

So this is going to be a demographic that we in health care, especially in critical care, we have to be comfortable with. We just absolutely do. So tell us what is age-friendly care and how can we make health care better for older adults using these age-friendly practices?

Dr. Fulmer: I'd love to. And just as an overview, I want to remind people that the greatest success story of the 20th century is longevity. All the science, all the advances in public health, all the pharmaceuticals and the technology, pacemakers, antibiotics, renal dialysis, we have a lot of older people.

And that's an amazing success story. So we work with a group called Reframing Aging in order to talk about this longevity as a success story and as a dividend, like it's the only growing natural resource on the planet. So think about that as we think about this incredible group of people.

And the age-friendly health system really came to us when I came to the foundation 10 years ago. And the trustees said to me, you know, Terry, what's your big idea? And I said, creating age-friendly health systems because there's no such thing.

I'm very proud today there is such a thing and that we are now in almost 5,000 locations of care throughout the country. We have a research center for age-friendly at UCSF under the direction of Julia Adler-Milstein. So let me roll back and comment on what is an age-friendly health system.

So through our work with the Institute for Health Care Improvement in Boston, Massachusetts, most of you all know about that, IHI, and our partnership with the American Hospital Association and the Catholic Health Association, we came together to say, what is it that is uniquely important in care of older adults? And so we had a group of geriatric experts and healthcare administrators and leading experts in health systems. And we looked at the evidence and found that there were a number of documented successful care models, like the ACE unit, for example, acute care for the elderly, like the HOPE model, hospital outcomes for patients who are elderly, and the NICHE model, nurses improving care for health systems.

So there were a number of models, but they weren't sticking and they weren't globally adopted. And they were very academic. They were academic to a greater and lesser degree.

The question became, what do we know from those models? And so when we did an analysis of the models, and I'm grateful again to IHI for this work, we found that there were about probably 20 care features, and then no one is going to work with 20 care features, actually. They had started with even more, a higher number than that.

But we distilled it down to about 13 and finally got it to the 4Ms, the vital 4Ms, because everybody in the room agreed that if you had an approach for age-friendly care that followed the 4M approach, you could improve care for older people. What are the 4Ms? They are as follows, and in this order, what matters to the older adult in their family.

If you know what the goals and preferences are for an older adult, that's going to be absolutely critical when you're thinking about intensive care. So what matters to the older person and their family, their goals, what they are willing to tolerate in terms of therapy and their expected outcomes. Medications.

We know that there are a lot of life-saving medications that can have very negative sequelae for older adults. Mobility. The ability to be as mobile as you can be in the context of your underlying health conditions and in the context of the care you're receiving.

So mobility, and I'll talk more about that in a minute. And then your mind, which we refer to as mentation. So mind, mood, memory, your mentation.

And in ICUs, people usually, thankfully, focus on delirium, but it's more than that. It's your delirium, it's your dementia, it's your delirium superimposed on dementia. Donna Fick at Penn State has done such a great job with that work.

And so, along with Sharon Inouye, a number of experts. But the whole notion that you take those 4Ms, what matters, mentation, medication, mobility, and you roll them into a set and you address them with uniformity, with a common set of measures, common goals, and common outcomes. Now with IHI, they have a tight, loose, tight approach, which I really love.

And that is, you have to be very tight on your goals. Then the way in which you meet your goals, whether you decide you're going to use a confusion assessment method for your screening for mentation or whether you're going to use a Folstein and MMSE, that's up to you. But then your outcomes have to be very tight, and that is your number of cases.

We're talking about right now, mentation, your number of cases of delirium, and whether they've been reduced. So when you uniformly address the 4Ms, what matters, mentation, medication, mobility, you have an approach to your measures, and you look at your outcomes, and you see that the outcomes are moving in a positive direction, you are on the road to being an age-friendly health system.

Dr. Bulloch: I was reading that you started with five health systems, and the goal is really to expand it, probably in your mind, to every health system.

Dr. Fulmer: Every health system.

Dr. Bulloch: I have the opportunity to work in a large community teaching hospital, and I love it because that is where I feel like most hospitals are in this country. How can hospitals like mine, that are large, they serve big chunks of their state, some of their outlying rural areas, they don't necessarily have the resources of the big academic medical centers, but they want to provide this care. How can they get involved?

Dr. Fulmer: So you have the resources. They're in front of you. It's how you deploy them reliably.

And as you mentioned, we started with five health systems. That's our pioneering health systems to test. IHI has a model where you plan, do a study act, test, check your outcomes.

Dr. Bulloch: Very strategic. Yes, yes.

Dr. Fulmer: And so one of our original pioneers was Anne Arundel. It's now called Meredith, am I right? It has a different name, but it was Anne Arundel Health System in Maryland, and they're a large community hospital.

And so we did a test with a group probably like yours. So what we've learned is that it doesn't matter whether you're Mass General or whether you're Anne Arundel or whether you're Bassett Medical Center, where I am a trustee. And so that's a community hospital upstate New York and very rural area where we cover 6,000 square miles with a lot of poverty, a lot of people who get their healthcare payments through Medicare, Medicaid, and they're rocking age-friendly.

They're just doing a great job. So what does it take? It takes a will.

As IHI always says, waste no will. If you have one champion who says, I'm interested, go after them and support them and help them and figure out what they need. And so let me pause there and take the next part of your question.

Dr. Bulloch: Because one of the things that I find that with limited resources is there's a lot of things we want to do. We don't always have the budget to do it, but the government tells us you're going to do this. And so accreditation is big for every hospital and every health system in the country.

And so some of the things that we really do have to focus our resources on are the things that CMS tells us to. And so CMS has adopted this cause very recently as of January 1st, 2025. There is a new, for our listeners who are not aware, there is a new CMS hospital measure for an age-friendly hospital that just went into effect.

Got a couple questions around that. One, like what role did you have in advocating for that measure? And then what was that process like?

Because I can't imagine that it is easy to really advocate and get joint commission to adopt because it feels like they have a lot of measures, but they really do just have a few.

Dr. Fulmer: Well, let me unpack some of the things you said, Marilyn, because there's just so much excitement around this. You said that the government tells us to do a lot of things. And when it comes to the age-friendly hospital measure, we know that organizations, ICUs, are already doing these things.

What we're helping people with is reliability and measurement. I don't know an ICU in the world that would say they were not paying attention to goals and preferences.

Dr. Bulloch: Right.

Dr. Fulmer: Or that they were not paying attention to medications or the cognitive status. So, already doing it, but can you do it reliably? Can you do it in a set?

Dr. Bulloch: Can you do it? Can you be consistent?

Dr. Fulmer: Yes. Yeah, that is a real failure. You know, at IHI, they joke about the project-itis that we have going on in our world, which is start-stop things, where you start a project and you don't see it through fruition.

Well, this measure has taken us 10 years, so think about that.

Dr. Bulloch: 10 years.

Dr. Fulmer: Yeah, and it's gone like a blink because we needed to get people on board with us. We needed people to make it better. We needed the literature to start evolving and to show us, and I'll be talking about some really exciting outcomes tomorrow.

But CMS has been a true partner in this work, and especially Sherry Ling, who's at CMS and has such a passion for this work. But it is a hospital inpatient quality reporting program, and that's pay for reporting, and participating hospitals are required to report on eliciting patients' healthcare goals. That's the what matters of the four M's.

They're responsible for, number two, managing medications. So, there's another one of our M's, and doing it reliably with uniform quality. Implementing frailty screening, measurementation and mobility elements, and then assessing social vulnerability, which is so key.

So huge. Yeah, it is huge. It really is.

And, you know, I've heard some doctors say, but I'm not able to do all this.

Dr. Bulloch: I'm not a social worker.

Dr. Fulmer: But you say, but you have a team, and you have the supports throughout your community to help you with social vulnerability. And finally, designating an age-friendly care leader or leaders, and that's where you get back to waste, no will, as Don Berwick likes to say. If somebody has a glimmer in their eye, like I did, you know, grab them and have them be your champion, because when you're passionate, you really stay the course.

And so, that's what we've been doing with so many people. So, this commitment to improving care for older adults, in this case with CMS, those people 65 and older, whether you're in the hospital, the operating room, or the emergency department, really committing. So, those five domains, each addressing essential aspects of clinical care, and making sure that the attestation is met, so that each of the domains receives a point.

And the measure developer here is the American College of Surgeons. So, I'd like to publicly thank the American College of Surgeons for their exceptional work, and the emergency physicians of America, their groups who have done such, the emergency medicine specialty groups who have been right there from day one. But the American College of Surgeons really drove this work, because think about it, they're operating on more and more older people.

Older than 70. Absolutely, and suppose you successfully complete a hip replacement, but the person dies from other reasons, that's what you call tragedy. And so, thank you to the American College of Physicians, and particularly Cliff Cohen, his team, really, Ronnie Rosenthal as well.

So, I think that all of us have this exciting opportunity to think about our work in a uniform and solidified way.

Dr. Bulloch: So, I want to break down the four M's, and maybe just small rabbit holes for each one. So, the first part, and I love that you have what matters at the top, because sometimes medicine can be very parenteral, right? We know what's best for you, and I've run into situations even recently with my team in practice, where as older adults age, and cognition can wax and wane, and sometimes you don't know what a patient's baseline is, you don't know if they have competency, you don't know where capacity comes in.

We run into situations where what the patient wants, and what the family wants, don't always match up, right? But it does seem that both should be considered, and you don't want to neglect one or the other. Sometimes I find this particularly true when we have those patients where cognition, and capacity, and understanding waxes and wanes, right?

So, how should health systems approach those types of situations? Because we see those very often in actual clinical practice.

Dr. Fulmer: Yeah, we do, don't we? First of all, I'll note that that's not an aging issue per se, that you can have that if you have a car accident victim. This is true.

And it's equally painful, and very, very hard to get through from step A to step B, and so think about it as it's a clinical care issue, not just an aging issue, and that people who are in a car accident, for example, may also have cognitive This is true, you're very right. Capacity issues. So again, always thinking about it from a non-ageist lens, but to your point, it happens with older adults.

So the best way to deal with it is to deal with it proactively, and so everybody should have their advanced directives, their health care proxy, they should have had a conversation. You know, Ellen Goodman talks about it as the conversation project in advance, making sure that it starts in your primary care office, and say, do you have an advanced directive? And so you say, but I'm in critical care, but critical care has so much opportunity to talk at conferences like these about, please make sure that you're saying to families, do you have this paperwork completed before you go to surgery?

And there are some times that you can't avoid, but what do we know proactively? And if I were to ask everybody in the audience tomorrow to raise their hand if they had their advanced directive, I guarantee you there would be a number of hands that did not go up. So I'm urging everybody, please get your advanced directive.

You might be 40 years old, please have an advanced directive.

Dr. Bulloch: We like to think we're immortal.

Dr. Fulmer: Well, yeah, it seems like it's not relevant, but it certainly is. Back to your point about a person who has cognitive incapacity that seems to be irregular, take a look at their oxygen, see whether they're hypoxic, see whether they have some other reason that is reversible, and then you can have a conversation with that older person in every case possible. Make sure that the older person is telling you their goals and preferences.

Everybody tells the story about the son who flies from Minnesota or whatever, from New York State, and has an opinion. Of course they do because they're afraid and because they might have had life issues with that person or they might just be absolutely lovingly devastated. So that's where I see critical care do such a beautiful job, really.

You really, really do. And let's just keep thinking about proactive, seeing what we can do piece by piece, giving a reasonable scenario for older people and their families about what they can expect. And it's tough.

Dr. Bulloch: I worry about that. I'm far away from my own mother and she's aging. She's very healthy.

You know, from a physical age, she's probably in her 50s. So we're very, very functional and very blessed. But I do think about that my sister is with her and any decline that might happen, my sister would be more comfortable and I'll be the one flying in and it would be a shock.

And so those are interesting conversations to have with family members. And I do think that it is important not to always just exert our will as clinicians and think that we know because they may not want all the things we think that they need for what they need may be very different.

Dr. Fulmer: And you know, it's funny, but there are so many television shows now where you could watch with your mom and say, what did that mean to you, right? Isn't there an ER show every five minutes and an ICU in the mix? And you could watch it with her and say, what does any of this mean to you?

And see, does she have an advanced directive?

Dr. Bulloch: She does not, but she's made her wishes very clear, very, very clear.

Dr. Fulmer: So would she let you record them? She probably would. Yeah.

Dr. Bulloch: So there you go. That's a good idea. Even if you, someone doesn't want to write them down and put them in a document, even just something simple like that, I think would be great.

You mentioned I'm a pharmacist. So naturally I am drawn to the medication and the framework. We need to be using age-friendly medications in the hospital, meaning that they don't interfere with what matters to the adult.

They don't need to impact mobility or mentation. And following an acute event that our currently ill patients may experience, sometimes it's necessary to use a medication that's not per se age-friendly.

In your experience in research, what's sort of been the best timeline for addressing the continuous need for these medications? And I'll tell you why. I did research years ago on, I call it suboptimal medications in older adults because sometimes it's under prescribing as well as over prescribing.

Sometimes with these measures, and I worry, I do worry about this with the new CMS measure, it gets very prescriptive, almost like the BEERS criteria did with nursing homes. And it's like oh, you can't use any medicine on the BEERS criteria. And that's where BEERS had to reformat, right?

They had to go from just having a long list of medications not to use to no, no, no, no, no, let's provide you some rationale. You can use nitroferantoin in older adults. You just can't use it indefinitely for, you know, for prophylaxis or in people whose kidneys don't work.

The ICU, we're going to need to use some of these temporarily. You have a lot of experience in this setting. What is the best timeline that we really need to start practically applying this to our patients?

Dr. Fulmer: Sure. Before I answer that, I'm going to let you know that I knew Mark BEERS.

Dr. Bulloch: Oh, that's amazing.

Dr. Fulmer: And he was one of the nicest people.

He died way too young. I have heard he was so nice. The nicest guy ever.

He had juvenile onset diabetes and it devoured him. That guy was so dedicated to trying to get people to think about meds in older people. He worked in, Jerry Avorn is another geriatric expert in medication.

So the two of them really got it on the radar of people because prior to that, let's go back to House of God where they talked about vitamin H, meaning it was held off.

Dr. Bulloch: Yes.

Dr. Fulmer: So insulting.

Dr. Bulloch: Yes, exactly.

Dr. Fulmer: But it was, everybody got held off and everybody got a sleeping pill and everybody got a laxative.

Dr. Bulloch: Because you didn't want to have to deal with them.

Dr. Fulmer: And isn't that awful?

Dr. Bulloch: Yes. And that still happens today. It's still, try to tell my residents not to prescribe scheduled things like that.

Make them call you because it may not be appropriate.

Dr. Fulmer: And pretty soon they won't have to call you because they're smart people.

Dr. Bulloch: Right.

Dr. Fulmer: And they understand that convenience medicine is not a good idea. Exactly. So Mark, that was Mark's whole thing and he was awesome.

So with medications, we do take a look there are seven categories within the Bureau's criteria that are particularly important. And I would ask everybody to take a look at that. When we address this, I usually am channeling my inner Nikki Brandt.

So you might know Nicole Brandt. Everybody seems to, who is an expert in geriatrics and pharmacology. She's at the University of Maryland.

So Nikki has been real expert in this and helped us. Todd Semla is another person who's done a lot in helping people think about it. But it's all team all the time and making sure that you have a pharmacology expert, a pharmacy expert with you, or you can just telephone them.

Now we can Google anything and we can AI anything and make sure that we are tapering as fast as we can. The best time to stop medicine is tomorrow. And that's any medicine that you can, because if you can do without it, you're better off for it.

And your liver and your kidneys will thank you. And so I think that, that always having in mind, what can we stop? We were talking earlier about the stop and start criteria and saying to ourselves, what might we stop now?

The patients and families have strong opinions about this. I have one of my high school teachers was telling me that she was on like 20 meds. I said, how could that be Denise?

Don't tell me wrong. And she had a number of over the counter meds that she had added to her already pretty lengthy set of medications. But when I said to her, Denise, I can tell you the seven medications right off the bat that you can stop taking.

She said, oh no, I don't want to stop that one. Oh no, I don't want to stop that one. So you're always weighing pluses and minuses, not only with building trust.

I had to build trust with her before she said, well, I guess I could try it. And also making sure that you are thinking about the organ function that these people have and whether or not you're doing harm.

Dr. Bulloch: And I always look at under prescribing too. Yeah, that's true. And so sometimes when we get people into the ICU, we don't restart their home medicines and you can have certain detrimental effects because you have withdrawal syndromes that can be very painful to our patients.

Dr. Fulmer: Which one comes to mind for you?

Dr. Bulloch: Antidepressants. Venlafaxine all the time is very uncomfortable withdrawal. So, but it's not something that I think as a care provider, it's not one of those medicines is immediately life-saving.

So we don't tend to think about, oh, we've got to restart it, but it can still be very uncomfortable. And that might lead to needing more analgesia in the ICU or even other symptoms that we might mistake for other conditions.

Dr. Fulmer: And some people are on meds they won't tell you about. This is true. And then if they're in the ICU, you can have whopping cases of delirium or other physiologic changes that are very, very serious.

And so it is tricky. And that's why intentionality is so important. Saying what medications are you on at home?

Very often that will get you an incorrect answer also. And sometimes it's because people don't have a careful list and other times because they don't want to tell you. And so it's really being thoughtful and careful and watching the person's symptoms and any signs of distress as you just pointed out.

Dr. Bulloch: So let's move on to our next M, which is mentation. And you've talked a lot about this as well. And that's something that has been on the forefront of ICU professionals for decades, because even one instance of delirium strongly impacts mortality up to a year out.

Dr. Fulmer: And cost of care, by the way.

Dr. Bulloch: And cost of care. And I had an ICU attending one time when I was a resident say being in the ICU is like being in World War III as a patient. That's how they described it to me.

I've never forgotten that. So what are some things that we can do? Because we've done a lot over the years.

But what are our gaps that we still need to grow in to help make it a more pleasant environment that we're not having a negative impact on mentation?

Dr. Fulmer: I think regular measurement of delirium is important in our age-friendly health system. Our approach is to assess for delirium every 12 hours. And people go, oh, I can't do that.

Well, I bet you can. If you were to use even a UB2, which is an ultra-brief screen, and try that. Or use whatever everybody likes the most, whatever they're used to, so that there is a will to make sure that it's getting completed on a regular basis.

That way you'll be able to tell when people are changing. I saw a patient not too long ago on a post-op unit at the hospital where I practice. And it was very clear that 11 o'clock in the morning this person was very, very delirious, dangerously delirious.

And one of the nursing assistants knew enough to get that person up and walk him up and down the hallway. And his oxygen level came up. And he cleared.

And he could tell the story. He said, well, I felt like I was having an out-of-body experience. I knew something was wrong.

And I was there. I saw how delirious he was. And I was afraid.

And what would you do 20 years ago? You'd give somebody Haldol. And you'd look for restraints.

This nursing assistant, who happened to have been quite physically large and strong, got the guy up, walked him around. And there it was. He cleared.

Dr. Bulloch: I love that. And that segues into how these four M's interconnect. That's right.

There was your mobility. And mobility in the ICU and in the hospital, I think, culturally, for so long, there was always, you're sick, you need to be in bed, don't get up. We have ceiling tiles that say, call, don't fall.

But we have a lot of data that show early mobility is huge. You have some of our European colleagues that have exercise machines in their rooms and will walk patients on ventilators.

Dr. Fulmer: And that is the goal, really. When you think about deconditioning and how fast it happens in older adults, I have this hope that we'll get to a point where every team that rounds in an ICU, here comes infectious disease, here comes pulmonary cardiac, that each team who rounds gets a person out of it. And that they are part of the solution in terms of mobility, and that they are also part of the assessment of mobility.

Think about it. Imagine in your mind a team coming through the ICU. Have you ever seen them just get a person up routinely?

Dr. Bulloch: No.

Dr. Fulmer: Of course not. And they could do that. There's no reason not to.

And I was talking to the American Society of Consulting Pharmacists, by the way. And I said to them, you can get the person up. And they said, well, are you sure I'm allowed?

Well, yes, you're allowed. All you have to do is make sure that you're using a safe approach. What is it?

You know, family members get people up. So can't each of us make that commitment to say, how long has it been since Mrs. Fulmer got out of bed? And can we help her today?

Dr. Bulloch: Sometimes it's hard just to get my trainees to wake them up, much less get them out of bed. I think that's going to have to become a culture change.

Dr. Fulmer: That's where we role model. When we need. When a person like you who's senior and revered does that, says, why don't we all help get this person out of bed for a moment, you know?

And a long time ago, we switched and we said only physical therapy. It wasn't a rule. It was just that the culture started to shift to say, well, somebody call physical therapy.

And then somebody would say, well, only nurses get people out of bed. Well, that's not true. That's not true.

It's a team sport. So all of us need to do that. And so to your point about delirium forums, what matters?

Nobody wants to be deconditioned. Medications. Is there anything that this person took?

Well, this person was post-op. And so it was the anesthesia that cleared. Then your mobility, making sure that they're up and moving quickly and that you're really thinking about their mentation all the time.

Dr. Bulloch: And they all connect. They all connect. It's a set.

I want to transition a little bit to discuss caring in critical settings. I don't know how many of our audience members know this. I think you've touched on it a little bit, but you were a critical care nurse at the bedside for a number of years.

And I think that that is so important to have someone leading such an impactful organization as the Hartford Foundation who has those fresh memories of patient care and what it's like in the real world. So when is the best time from your experience as a bedside nurse to address these items in the ICU? And can maybe you share with us some of your real life experiences in the ICU that demonstrate both the difficult but rewarding sides of caring for older adults?

Dr. Fulmer: Sure. Well, for the benefit of the audience, I'm an attending nurse at Mount Sinai in New York City. And that means that I go on service two weeks in January, two weeks in June.

And I have two calls a week with the nursing leadership at Mount Sinai to help them problem solve around some of the clinical conundrums that come up, if you will, and also just observe, support, and celebrate all the good things that go on in any given day. I think that the best time to approach your forums is the minute you walk in the room and say, good morning, or good afternoon, or good evening, whatever shift you're on. And to right there, do your forum baseline.

And once it becomes routine to you, it's second nature. Epic, and soon Cerner, but Epic has a module that can go into your electronic health record on the 4Ms. They've been a great partner, and Cerner's on the way with that as well. The VA has done an amazing job.

They have led the country in age-friendly. And let me say that CVS Minute Clinics has 100% of their CVS Minute Clinics are age-friendly. They have 1,900 advanced practice clinicians, and they have like 2,000 minute clinics.

And every single one of them has, if you're 65 or older, you get screened for your 4Ms. And they will transfer that data to the ICU if you need it.

Dr. Bulloch: Oh, that's fantastic.

Dr. Fulmer: That is good to know.

Dr. Bulloch: Yeah.

Dr. Fulmer: So it's this all-in, all the time, making sure. And I also want to comment on nursing homes. We saw what happened during COVID to nursing homes.

It was horrifying. And our foundation, I'm very proud of the John A. Hartford Foundation, where we pivoted instantly to do daily nursing home huddles and help with some of the tragic events that were going on.

And remember that all the equipment and personnel went to ICUs, and the people in nursing homes were still using garbage bags and cloths for their PPE, right? So how can we anticipate a healthcare system in the future where we are thinking of every location of care in a way that's uniform? And so why do I say that?

The 4Ms are appropriate in a nursing home. You may have an ICU patient who's going to have to go for rehab and will be in a nursing home, and they might need to come back to you if things don't go well there. So having the 4Ms be constant and uniform, whether you're at your kitchen table, the nursing home, or the ICU, is very important.

Dr. Bulloch: That's a very good point. And I'm glad you mentioned that, because I do see a lot of transitions between care. I'm very fortunate.

It was very exciting to me years ago when I could start seeing what medications people picked up. They got them put on insurance. That was really big from a medication reconciliation standpoint.

You're saying that Minute Clinics will do this, the VA is doing that. So to be able to link our computer systems between each other and be able to share that information, I think is big. And we're seeing it the VA.

And that was wonderful. But not just inward, but outward. That's right.

Dr. Fulmer: So continuously sharing that information so that we work smarter, not harder. And how many times have you been in a clinical situation where somebody asked you the same thing twice? Somebody gave you a clipboard and said, please write this down.

And then you walked in, they asked you each of the questions. I know none of us want to do that. And so as we improve, as we constantly improve, thinking about how we can ensure that our data are being recorded in a way that can benefit everybody, no matter where they are.

Dr. Bulloch: We've had such a great conversation today. But I still have so many things to ask you. And one of those is looking at expectations versus reality.

When we look at recent surveys that show a big gap between what older adults expect from health care and what they actually get, why do you think that is? And what can we do about it?

Dr. Fulmer: Well, I think you're referring to the really groundbreaking survey that Age Wave did in partnership with our foundation and with the Harris Bowl, where we surveyed older adults and did a nationally representative survey of more than 2,500 older adults. And really demonstrated, again, that older patients are not feeling heard and respected when they are getting their care. So 82% of the people we surveyed said that they felt the health care system is not prepared for the growing changing needs of our country's aging population.

And they cited personal examples, of course. Only 11% give the health care system an overall A grade. And when I tell you this was a representative sample, it really was.

So we're not talking about a super rich or a super poor. It was everybody. The majority said it's very difficult and stressful to navigate the health care system, particularly for those with multiple health challenges.

And only 19% of older adults said that their providers routinely cover all 4Ms. Only 19%. So low. Yeah, so we can do better.

When you have data, when you have a baseline, you can improve it. And so that's where we are right now. And I think that the opportunity for all of us is to get in the game.

So we ask people to join us. We have our ihi.org backslash age friendly, and we invite people in. We have our website at the John A. Hartford Foundation, where we have lots of ways for people to participate to help us improve. We will not improve unless we have our critical care society membership help guide us in their particular area of expertise. And so I really think that it's a wonderful moment because not only are we in every state in the country in 5,000 locations, but we're also in 12 other countries.

And why is that? It's because our work is about human function. We're not talking about your hemoglobin A1C.

We care about that very, very much. And we know we're going to be following blood sugars and all the other critical elements of our body, our body functions. But at the end of the day, you have to be able to be functional.

And if what matters, mentation, medication, mobility, if those are not in alignment with your goals and preferences, you will have a bad healthcare experience and bad health outcomes. So as we turned around, what we learned is because we've been in Doha, Qatar recently, and we hear that Ireland is age-friendly, Australia, Brazil. Why is it?

It's because these are human functions. And also, it doesn't matter what language you speak. It doesn't matter how you pay.

It doesn't matter what your religion or philosophy is. Everybody wants their function. And so that's why the forum approach is having global resonance.

Dr. Bulloch: Now, one of the things I noticed as I was looking at all of the forums and a lot of the initiatives that have gone into it, even though the focus has initially been older adults, it seems to me, these are very practical things that could apply to everyone, regardless of age. Am I misconstruing that?

Dr. Fulmer: Thanks for saying that. No, we say age-friendly care is good care for everybody. And you make me smile because I love it when people make that immediate logical link.

Yes, age-friendly care is just good care. And people say, well, that's just basic care. It's like, then please do it reliably.

And that's what we aren't doing. So reliability and precision. Here's a little narrative from clinical that makes the point.

I work with great teams. And one of the physicians with whom I was working, I said, well, how do you assess on this floor with all your teams that are here? It's very busy floor.

How do you all assess for cognition? How do you do a cognitive assessment? He said, I don't know.

Let me check. So came back and he said, well, we all do it a little differently, but we all do it. I said, then you don't do it.

Then you don't do it. Pick one. Just test it.

When people say to me, I can't, I say, well, would you do it for one week? If we just keep dialing it back and say, would you do it for one day? Would you do it for five patients?

Would you do it for one week? And then they begin to see the value and they begin to solidify their approach to the care. And so I'm asking everybody in the society, would you do it for one week?

Would you do it for one year? Would you join us in the age-friendly health system movement?

Dr. Bulloch: I feel like this needs to be, as an educator in healthcare education, I really feel this needs to start at the ground level with our trainees in the classrooms. Get them while they're young. And I say that metaphorically, but get them when they're young in their careers and make it just the expectation.

Like this is just the normal of what you will do when you get out there.

Dr. Fulmer: We've learned that the medical school at Yale now has it as a part of their curriculum. And we're seeing that at the University of Utah, there is a medical director for age-friendly health systems. Imagine that.

So we're starting to see all these pop-ups of empowerment for this work. And so imagine your own empowerment. Name the way that you want to address age-friendly.

We know that the American Society of Consulting Pharmacists is just doing an amazing job.

Dr. Bulloch: They have an age-friendly certification course.

Dr. Fulmer: Yes, they do.

Dr. Bulloch: That I was looking at.

Dr. Fulmer: And they just said, oh, that makes sense. And they did it. So sometimes don't overthink it.

Just get in the game. We have friends of age-friendly group that meets. And that's if you're not sure you want to start, just join friends of age-friendly.

And how could our listeners do that? Go right to ihi.org backslash age-friendly. And you'll be able to sign on to all the different action communities we have.

We have an action community every fall with IHI, every spring with AHA. We invite systems to join in. And currently there is no cost for this because the foundation is supporting all of the work through our grants.
Seems like a win-win. It is a win-win. We wrote a book called Age-Friendly.

If people prefer to read material, we have a variety of manuals that are available. And if there's something we're missing, let us know and we'll do it. That's wonderful.

Dr. Bulloch: Well, we're about out of time today. This has been such a great conversation. Before we close, I just want to give you an opportunity to maybe address or say anything I didn't get a chance to ask you about.

Dr. Fulmer: You've done a great job and made it so easy for me. I guess I want to thank everybody out there in age-friendly health system community, the age-friendly public health system community that's working so hard. Our age-friendly ecosystem and say, what you're doing is making a difference to this longevity boom that we're having that we're so grateful to have.

We want to make sure that we use all the science and all the compassion we have to do a great job for all of them. Thank you.

Dr. Bulloch: We have enjoyed having you today. Thank you so much for being our guest and thank you for speaking at our Critical Care Congress. This concludes another episode of the Society of Critical Care Medicine podcast.

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Announcer: Marilyn N. Bulloch, PharmD, BCPS, FCCM, is an associate clinical professor and director of strategic operations at Auburn University Harrison School of Pharmacy. She is also an adjunct associate professor in the Department of Family, Internal and Rural Medicine at the University of Alabama in Tuscaloosa, Alabama, USA and the University of Alabama Birmingham School of Medicine.

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