Helen Osborne: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and author of the book Health Literacy from A to Z. I also produce and host this Health Literacy Out Loud podcast that focuses on many aspects of health communication, patient education and health literacy.

Today’s guest is Leslie J. Pelton, who is a senior program officer at The John A. Hartford Foundation, where she oversees grants that are transforming care for older adults and family caregivers through the Age-Friendly Health Systems movement.

Prior to this, Leslie was vice president at the Institute for Healthcare Improvement, where she collaborated with funders, national partners and leading health systems to design and spread Age-Friendly Health Systems.

Now with more than 5,000 hospitals, medical practices, nursing homes, clinics and home healthcare agencies, this movement is committed to delivering evidence-based care to reduce harm and align with what matters to older patients and their caregivers.

Leslie, welcome to Health Literacy Out Loud.

Leslie J. Pelton: It is an absolute pleasure and an honor to be here with you, Helen.

Helen Osborne: I am so eager to learn more about these Age-Friendly Health Systems. I was at a conference a while ago. It was the first time I heard about it, and immediately I’m thinking, “Wow, that’s health literacy in action.”

Please, tell us all, what are Age-Friendly Health Systems?

Leslie J. Pelton: Age-Friendly Health Systems are really about ensuring that every place that an older adult and a family caregiver show up to receive care, they receive evidence-based care, that care causes no harm to older adults and also that it is centered and focused on what really matters to older adults and their family caregivers.

Helen Osborne: We’re all special. At whatever age, we all want care that’s just right for us. What prompted the thinking about age-friendly care, particularly with seniors in mind, that’s specific to that generation of people?

Leslie J. Pelton: At The John A. Hartford Foundation, we looked at the half a billion dollars that we have invested in models of care that improved the health of older adults, of which we’re incredibly proud.

What we noticed was that those models of care that were distinctly designed to address the health and healthcare needs of older adults were actually not reaching enough older adults.

We reached out to the Institute for Healthcare Improvement, and we said, “Let’s partner and make sure that what we know is the right care for older adults actually gets out into the world.”

Helen Osborne: I was curious about it. Can you just tell a little story? I love hearing stories and examples. What about it wasn’t working?

Leslie J. Pelton: For example, my mother, Suzanne, is 86 years old young, or 86 years old old, and she has very specific ideas about what kinds of tests and screenings she actually wants done at this point in her life. She’s made some choices about the quality of her life and there’s certain healthcare that she’s not interested in right now.

To ensure that the care that she receives is age-friendly care, her care team would begin with asking her, “What matters to you? What makes a good day? What makes a good year? What brings joy into your life?”

In doing so, they get to know her. They get to know her at that point in time, which is different than how she may have felt or what she may have wanted a year ago, and they’re able to organize the care around that.

For example, she likes to go to the Council on Aging four days a week, and her bus leaves at 11:30 a.m. There was a time when she was really tired at 11:30 a.m. When she had an appointment with her doctor, she said, “I really want to go to the Council on Aging. It’s when I get to be with my friends. I have a good meal. I’m so tired at 11:30 a.m.”

The fact that her care team could have that conversation with her meant that they could open up a conversation about, in this case, adjusting her medications so that she could be less tired at 11:30 a.m. It was fine that she was tired at 4:00 p.m. when she was home and relaxing.

They realized that just with a medication timing shift, they could enable her to have the quality life and live the days that brought her joy.

That’s a very specific example of how an Age-Friendly Health System might care differently for a person.

Helen Osborne: Thank you, Suzanne, for letting your daughter share your story. That’s a great example.

She’s much more than her blood levels, her titration of this or her medication schedule that some doctor or somebody thinks just would work for everybody. It’s really putting your mom at the center of her treatment and care. That’s what kind of brings a dose of humanity into this care. We all need that in healthcare.

What are components of these Age-Friendly Health Systems?

Leslie J. Pelton: The centerpiece of an Age-Friendly Health System is four essential evidence-based elements. I can tell you the story later, but these are all built on deeply evidenced models.

We said for an Age-Friendly Health System to deliver age-friendly care, it needs to do four aspects of care reliably with every older adult in every place that an older adult and their family caregiver show up.

They need to begin with asking what matters. They need to understand what medications an older adult is on and avoid medications that interfere with what matters to the older adult.

Helen Osborne: Like for your mom.

Leslie J. Pelton: Like for my mom, for Suzanne.

The third M is mentation, or the health of the mind. Again, this is making sure we know when an older adult might be experiencing depression, cognitive impairment, delirium, and that we put practices in place to address it when it exists and to prevent it if it’s not there.

The fourth element is mobility, making sure that an older adult can move every day in a way that allows them to act on what matters.

In case you didn’t catch it, that’s the 4Ms.

Helen Osborne: The 4Ms. I’m a fan of alliteration. I want to get into each of those but just give us a heads up. This sounds so neat. Did you just simply come up with, “M is a good letter. We’ll come up with four key components,” or was this a big project to make it seem so simple? How did this whole system come up with the 4Ms of age-friendly healthcare?

Leslie J. Pelton: I told you that the motivation behind this was that The John A. Hartford Foundation had invested deeply in models of care that were evidenced and provided the best outcomes for older adults. The challenge was that those weren’t getting out into healthcare delivery sites and reaching older adults and their family caregivers.

The Institute for Healthcare Improvement said, “We’re going to go back to school.” We took 19 models that The John A. Hartford Foundation had invested in and really grown and nurtured that were delivering great results, and said, “Let’s take them apart. Let’s look at what the elements are of each of those different models.”

I think there were 90 different elements across those different models. We said, “That’s great, but can we narrow that down at all?”

The Institute for Healthcare Improvement was able to narrow those down to about 17 different elements of care, and we said, “That’s great. There is not a primary care practice, a nursing home, a hospital that could actually integrate 17 new ways of caring for people. There’s no way. We see how stressed people are.”

We convened a group of experts, and when I say experts, I mean policymakers, older adults, family caregivers, nurses, physicians, social workers, people who ran healthcare systems, and we said, “Here are 17. Nobody is going to adopt all 17. Go away and bring us back the five that are going to have the greatest impact on older adults and family caregivers.”

They did one better. They came back with four, and it was what matters, medication, mentation and mobility.

Helen Osborne: Wow.

Leslie J. Pelton: That’s why I can say with a high degree of confidence that they are based in what the evidence tells us is the right care for older adults.

Helen Osborne: I am wowed by that. Also, you do what we try to do in health literacy specifically, which is try to communicate clearly in ways that really matter to the other person and find out what they value.

You talked about your expert panel. I’m so glad that your expert panel crosses such a wide swath of folks, including the older adults and their caregivers, along with community members, community organizations and health professionals. You kept it simple.

Do you want to go through and give an example of some of these? You’ve got the four. It’s pretty easy to remember now. Is “what matters” the story of your mom, or is there another example you want to give of what matters and how that can play out in healthcare?

Leslie J. Pelton: Healthcare systems, I would say, more often than care teams even want to, look at somebody as an amalgam of a disease state or their physical challenges. We make assumptions about people. We make assumptions about people if they have a particular disease, if they’re a particular age or their body is able to move in a particular way.

What matters is about stepping back and saying, “No. I’m going to actually pause and I’m going to allow space for the older adult and the family caregiver to tell me what matters to them,” which allows the care team to prioritize the care around what the older adult wants and needs.

We call it the keys to the kingdom at The John A. Hartford Foundation. What matters is the keys to the kingdom.

Helen Osborne: More alliteration. You’ve got another job ahead of you.

Leslie J. Pelton: For medication, most older adults are on eight or 10 medications. They start to have what’s called polypharmacy, which is when the medications are interfering and creating side effects with each other.

The medication M is about pausing and saying, “Which of these medications might be actually causing harm to the older adult? Which of these medications might be interfering with their ability to act on what matters?”

Let’s stop and know what medications people are on, and in a very safe way, start to consider deprescribing medications that might be causing some inadvertent harm, and not prescribe the medications that we know cause harm to older adults.

As our bodies age, we metabolize medications differently. For somebody at 40, what their body can take is very different than what somebody at 85 might be able to manage.

Looking at the medication through the evidence-based lens of what actually happens to a body at 65, 75 or 85 is also a critical part of the medication M.

Helen Osborne: I assume at that point you’re also asking the person him or herself, “How does this medicine make you feel?” and all of that.

Leslie J. Pelton: That’s right.

Helen Osborne: You’re also looking not just for the deficit model of what’s wrong, but are you looking for, “Is that helpful?” You’re looking for the positives of it, too.

Leslie J. Pelton: Right, because there’s a circle that we have the 4Ms be around. None of the 4Ms are particularly an innovation in and of themselves, although some might argue that asking, “What matters?” doesn’t happen enough.

But the innovation is the set. The innovation is understanding medications and how they’re impacting somebody’s ability to act on what matters to them.

The innovation is using what matters to somebody to help them continue to stay mobile and active in their lives.

The innovation is the connection between the 4Ms and the 4Ms as a set. That’s the innovation. That’s what’s different about an Age-Friendly Health System. It’s the 4Ms being practiced as a set.

Helen Osborne: That’s interesting. I was looking at some of the things I’ve read about the system, and it uses that term “practice this as a set.”

You’ve covered a couple: what matters and medication. The other ones are mentation and mobility. Tell us a little story about each of those, please.

Leslie J. Pelton: Mentation is about the health of the mind. What we know can happen to people that shows up more often in older adults and/or suggests a different intervention than maybe when we’re 20 years old is around depression, cognitive impairment and delirium.

Too often, we don’t stop and find out, for example, if somebody is suffering from depression. We don’t stop and ask, and there are very accessible tools that care teams can use and engage older adults with to understand if somebody is depressed. The only way we can help somebody if they’re depressed is to first find out if they are.

A really critical part of mentation is getting people comfortable talking about the health of our brain just like we talk about the health of our heart or our lungs. It’s another organ. There’s no shame in having a conversation with our care team about the health of our mind.

It is shameful for some people, and so we’re really trying to debunk any concerns or shame that might show up for a family caregiver or older adult to talk about the health of their mind by making it just a standard part of the practice and the care.

We know when somebody is depressed or when somebody is cognitively impaired, what matters or their ability to act on what matters may look different.

Again, we have to know first, “Is this something that you’re facing in your life?” That’s mentation.

Helen Osborne: Mentation wasn’t a term I have known before. I used to work in psychiatry. But it seems as though you’re covering the thought disorders or the major mental illnesses, such as depression or anxiety.

You’re also looking at cognition that might be changing and diminishing over time, and you’re also looking at delirium that can be just episodic and maybe is a result of some health intervention that might get better. That’s a nice term that covers of range of factors there.

Leslie J. Pelton: Sometimes we call it the health of the mind. Mentation we’ll sometimes call mind, because it doesn’t have to be major mental illness. It can be a low-grade depression that somebody is suffering from.

Helen Osborne: Or pain.

Leslie J. Pelton: Yes. But it’s really the health of the mind.

Then the fourth is mobility. If you’ve worked in the healthcare field for a long time or for any of us who have had a stay in the hospital or even just showing up for our annual wellness visit or visiting our primary care, they’ll often ask you about falling. “Have you fallen in the last six months? Have you fallen in the last six weeks?”

Helen Osborne: I get that question all the time. When I get that question “Are you afraid of falling?” I just want to say “I don’t know anybody my age who isn’t afraid of falling.”

Leslie J. Pelton: That’s right. Our healthcare systems and our communities have done a really good job of trying to keep us safe by preventing falls, but what we actually know is that one of the greatest risks for falling is not moving around.

As part of the Age-Friendly Health Systems movement, we wanted to augment the incredible work that’s been done around falls in our hospitals, our health systems and our society to recognize that what impacts health positively is moving, being able to safely get around and move in a way that allows you . . . Now we’re doing a circle. We’re coming back to what matters. It allows you to act on what matters.

I hear the story very often of an older adult, for example, who is in the hospital and we ask about what matters. Very often, for us, what matters is that we have a beloved pet or a beloved family member at home, but often it’s a beloved pet that people want to get home to. That’s what matters.

But getting out of bed when you’re in the hospital and you’re recovering from some sort of episode is really hard. It’s really hard work. What we hear is care teams in hospitals using what matters and the understanding of what matters to encourage people to mobilize and get up out of bed.

“You said you wanted to get home to your dog by next Tuesday, to be able to take care of your dog. If you can take 10 steps today in the hallway, that is going to get you closer to your Tuesday goal of being home and taking care of your dog.”

Again, you’re linking mobility with what matters because it’s the set and it’s the connection between them.

Helen Osborne: I love that. In the spirit of alliteration, I have some questions I am going to cluster as C questions.

My reaction to listening to yours is this seems to be about the continuum of care, because you’re talking about health systems. You’re not just talking about hospitals or outpatient clinics. You talked about nursing homes, so it seems to be that continuum.

I also hear you referencing community. It’s not just when someone is ill and in a healthcare situation, but also when they’re well and going to their senior center.

You also talk about care teams, so it’s not just a specific doctor or nurse or certain professionals.

Am I onto something there, that the essence of this really comes away with those Cs? It’s the whole continuity of who we are as people.

Leslie J. Pelton: Indeed. Thankfully, the vast majority of most of our lives are spent outside of the healthcare system, and some of the greatest harms can be when we are in the healthcare system and if we’re in the healthcare system and move between settings of care.

If I have a really good conversation with my care team in primary care about what matters to me and I end up in the emergency department for some reason and they don’t know what matters to me, the choices that are made there or the way my options are framed to me might be very different than if the 4Ms are used as a common language between sites of care and brought in across sites of care.

We know at The John A. Hartford Foundation, as part of the Age-Friendly Health Systems movement, that part of allowing the 4Ms to work for family caregivers and older adults across settings of care is making sure that it’s a language that older adults have.

We’ve created a toolkit called My Health Checklist that is really a tool for older adults and family caregivers to get clear around the 4Ms with them, and a tool for them to help bring the 4Ms into their interactions with the healthcare system.

Unfortunately, healthcare is still pretty fragmented between settings of care, and so empowering the older adult and the family caregiver to be ready and talk about the 4Ms and demand the 4Ms helps them be spread across the continuum of care, across a nursing home and hospital, and also into the community.

Helen Osborne: That’s wonderful. Leslie, we’re going to have space on your Health Literacy Out Loud web page to list a lot of resources. But in this podcast itself, was there some primary way you’d like listeners to know that they could just click on and learn more about this model of care?

Leslie J. Pelton: www.IHI.org/agefriendly and www.IHI.org/myhealthchecklist are two places that people can go to learn more about Age-Friendly Health Systems and the 4Ms.

We have over 5,000 sites of care now that are recognized as Age-Friendly Health Systems by the Institute for Healthcare Improvement.

The Center for Medicaid and Medicare, which is the part of the federal government that regulates and pays healthcare systems for care of older adults, has recently put a requirement in for hospitals to adopt age-friendly care, and to report on how they’ve adopted on age-friendly care.

I think you’re going to see a lot more healthcare systems getting involved in the movement with that. That’s a lot of engagement.

I want to tell people that you can find out about health systems and what they have reported to CMS on their age-friendly measures on Care Compare, which is a publicly available website. You’ll be able to see information there as well about the age-friendliness of your hospital.

Helen Osborne: That is amazing. Leslie, you started with a story of your mom Suzanne, but as we bring this to a close, I want you to close with another little view, or if you can think of what your mom would be saying. What do you think might matter to her most about these Age-Friendly Health Systems? What might your mom say?

Leslie J. Pelton: Suzanne is a belovedly feisty and independent woman, and the fact that she has a tool like My Health Checklist where she is learning about how to demand the right and evidence-based care from her care teams is incredibly impactful for her.

She is and wants to continue to be independent and be able to advocate for what she needs, and here is a tool. The 4Ms are an accessible framework that enables her to do that.

I would say the My Health Checklist is essential for all of us becoming more literate in understanding what age-friendly care is and then demanding that.

Helen Osborne: Leslie, I thank you for all your work to make this happen, to go from thousands of policies and studies down to four memorable Ms, for bringing in the humanity, for making your mom the center of what this is all about and for sharing it with all of us on Health Literacy Out Loud. Thank you so much for being a guest on this podcast,

Leslie J. Pelton: Thank you for asking about Age-Friendly Health Systems. Thank you for getting the word out so that we can be sure that the care for older adults is centered on what matters and that it’s evidence-based every place that we show up.

Helen Osborne: As we just heard from Leslie Pelton, it’s important to think about Age-Friendly Health Systems, what matters to a person, putting them at the center of all their treatment and care wherever they are.

But doing something like this is not always easy. For help clearly communicating your health message, please take a look at my book, Health Literacy from A to Z. Feel free to also explore my website, www.HealthLiteracy.com, or contact me directly at helen@healthliteracy.com.

New Health Literacy Out Loud interviews come out the first of every month. Get them all for free by subscribing at www.HealthLiteracyOutLoud.com, or wherever you get your podcasts.

Please help spread the word about Health Literacy Out Loud. Together, let’s tell the whole world why health literacy matters.

Until next time, I’m Helen Osborne.

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