The Veterans Health Administration (VHA) is the largest integrated health care system in the US, providing care to more than 9 million enrolled veterans at 1298 facilities.1 In February 2019, the VHA identified key action steps to become a high reliability organization (HRO), transforming how employees think about patient safety and care quality.2 The VHA is also working toward becoming the largest age-friendly health system in the US to be recognized by the Institute for Healthcare Improvement (IHI) for its commitment to providing care guided by the 4Ms (what matters, medication, mentation, and mobility), causing no harm, and aligning care with what matters to older veterans.3 In this article, we describe how the Age-Friendly Health Systems (AFHS) movement supports the culture shift observed in HROs.
Age-Friendly Veteran Care
By 2060, the US population of adults aged ≥ 65 years is projected to increase to about 95 million.3 In the VHA, nearly half of veteran enrollees are aged ≥ 65 years, necessitating evidence-based models of care, such as the 4Ms, to meet their complex care needs.3 Historically, the VHA has been a leader in caring for older adults, recognizing the value of age-friendly care for veterans.4 In 1975, the VHA established the Geriatric Research, Education, and Clinical Centers (GRECCs) to serve as catalysts for developing, implementing, and refining enduring models of geriatric care.4 For 5 decades, GRECCs have driven innovations related to the 4Ms.
The VHA is well positioned to be a leader in the AFHS movement, building on decades of GRECC innovations and geriatric programs that align with the 4Ms and providing specialized geriatric training for health care professionals to expand age-friendly care to new settings and health systems.4 The AFHS movement organizes the 4Ms into a simple framework for frontline staff, and the VHA has recently begun tracking 4Ms care in the electronic health record (EHR) to facilitate evaluation and continuous improvement.
AFHS use the 4Ms as a framework to be implemented in every care setting, from the emergency department to inpatient units, outpatient settings, and postacute and long-term care. By assessing and acting on each M and practicing the 4Ms collectively, all members of the care team work to improve health outcomes and prevent avoidable harm.5
The 4Ms
What matters, is the driver of this person-centered approach. Any member of the care team may initiate a what matters conversation with the older adult to understand their personal values, health goals, and care preferences. When compared with usual care, care aligned with the older adult’s health priorities has been shown to decrease the use of high-risk medications and reduce treatment burden.6 The VHA has adopted Whole Health principles of care and the Patient Priorities Care approach to identify and support what matters to veterans.7,8
Addressing polypharmacy and identifying and deprescribing potentially inappropriate medications are essential in preventing adverse drug events, drug-drug interactions, and medication nonadherence.9 In the VHA, VIONE (Vital, Important, Optional, Not indicated, Every medication has an indication) is a rapidly expanding medication deprescribing program that exemplifies HRO principles.9 VIONE provides medication management that supports shared decision making, reducing risk and improving patient safety and quality of life.9 As of June 2023, > 600,000 unique veterans have benefited from VIONE, with an average of 2.2 medications deprescribed per patient with an annual cost avoidance of > $100 million.10
Assessing and acting on mentation includes preventing, identifying, and managing depression and dementia in outpatient settings and delirium in hospital and long-term care settings.5 There are many tools and clinical reminders available in the EHR so that interdisciplinary teams can document changes to mentation and identify opportunities for continuous improvement.
Closely aligned with mentation is mobility, with evidence suggesting that regular physical activity reduces the risk of falls (preventing associated complications), maintains physical functioning, and lowers the risk of cognitive impairment and depression.5 Ensuring early, frequent, and safe mobility helps patients achieve better health outcomes and prevent injury.5 Mobility programs within the VHA include the STRIDE program for the inpatient setting and Gerofit for outpatient settings.11,12