Our program uses a Comprehensive Geriatric Assessment to assess frailty, functional status, sensory assessment, delirium, cognition, fall risk, pain, high-risk medications, mood/depression, social isolation/support, elder abuse, nutrition and advance care plan. Choose the evidence-based assessments or tools best suited to your patient population. Links to evidence-based resources include: • Try This: Series | Hartford Institute for Geriatric Nursing (hign.org) • Resource Algorithm for Fall Risk Screening, Assessment, and Intervention (cdc.gov) • Health Care Professionals’ Information | National Institute on Aging (nia.nih.gov) Dashboard — Developing a dashboard to track processes and outcomes is essential to change management. A program coordinator or other designated staff member should use this to provide feedback to individual units on their implementation. See Appendixes G and H for an example dashboard and outcome tracker. Healthy aging worklist — A list of program participants that is integrated into your EMR can help you organize your work and prioritize patients, for example by age or FRAIL score. At Sharp, this list includes everyone who is enrolled in the various program components and uses an algorithm to prioritize patients based on several factors. The EMR should be designed to include components for appropriate patient identification to ensure capturing of patients who may not have been identified at admission. For example, at Sharp, the patient list includes identifiers, such as name and age, but also imports the FRAIL score (or a blank space that identifies when the scale has not been completed), BMI, attending physician and other critical information for the team. Patients with a high FRAIL score may be prioritized, as well as patients with a low FRAIL score who are at risk due to other factors. Education — Develop a plan to ensure staff receive the education needed to be successful. At Sharp, staff were educated on the 4Ms Framework with annual education and training updates, as needed. The need for training updates can be informed by your process measures. A plan to provide education for new staff is also important. At Sharp, we have developed a specific curriculum for each phase of the program. Communication — Develop a plan to provide feedback to units in your Generational Health program. See Appendixes G and H for an example. A program coordinator or designated staff member can fill this role. The frequency of feedback may decrease over time as the program becomes more ingrained in each unit’s workflow. This designated person should also hold check-ins with each unit leader, or other designated point person, on a regular basis. If capacity allows, develop an automatic report to be sent to each unit leader. Setting the stage for culture change Sharp Memorial Hospital had an ideal culture to launch an innovation like Generational Health. The fundamental heart of the organization is The Sharp Experience. Since 2001, Sharp has been on a journey to transform the health care experience and make Sharp the best place to work, the best place to practice medicine and the best place to receive care. Our dedicated team members bring The Sharp Experience to life with the foundational elements of Everyday Actions, “must-have” respectful interaction standards, and a focus on responsive, compassionate service recovery. We use storytelling to connect with our patients and team members, and to convey The Sharp Experience in action. Important tenets of this collaborative culture are that every stakeholder group has an important role and an expert voice to share. Patients do not benefit from siloed clinical interventions. Generational Health provides a platform for a universal assessment of an older adult’s individual needs; links clinical experts to proactively create a plan with the patient; and communicates the plan and progress across the entire team. The patient and family experience is designed to be one of efficient, coordinated interventions focused on maximizing wellness based on the goals of the individual. All team members are empowered to ask questions and speak up to improve safety. Outcomes are reviewed and shared with team members. During case reviews, opportunities for improvement are approached with a sense of inquiry and focus on process improvement. Successes are shared with storytelling and provide evidence of purpose-driven daily work. All these factors continuously build a team culture of excellence. 6
