Establishing First Age-Friendly Health System Tele-Palliative Care Clinic – Facilitators,Challenges,Lessons Learned to Improve Care for Rural,Older Veterans

Abstract

Age Friendly Health Systems (AFHS) promote geriatric best practices to improve healthcare quality, minimize harms and support older adults’ care preferences. AFHS-designated clinics consistently address the Geriatric 4Ms: Mentation, Mobility, Medication, and What Matters Most. The VA Eastern Colorado Health Care System tele-Palliative Care clinic achieved AFHS Level 1 and 2 recognition in 2021, becoming the first AFHS-designated telemedicine clinic in the nation. An interprofessional team and older Veterans guided planning and implementation. Using existing staff and clinic workflows, we consistently addressed the Geriatric 4Ms during visits. Specific metrics include: (1) AFHS Level 1 and 2 recognition, (2) maintenance in addressing Geriatric 4Ms in tele-Palliative Care, (3) number of patients served, (4) travel-miles saved. FY23-24, we conducted 192 AFHS tele-Palliative Care visits, 81% with rural/highly rural Veterans. We served 108 unique patients (FY23:57; FY24:51; percent decrease = 10.5%). Compared to Colorado’s Veteran population, Veterans from racial/ethnic minority backgrounds and women were underrepresented; older Veterans were overrepresented. In FY23/FY24, the majority of patients were White (82%/73%), not Hispanic/Latino (83%/73%), male (100%/98%), and ≥65 (90%/89%). All 4Ms were addressed for 86% (FY23) and 76% (FY24) of unique patients. AFHS tele-Palliative Care saved Veterans/caregivers 23 622 (FY23) and 18 632 (FY24) miles of travel. Congruent with AFHS, Palliative Care focuses on physical, emotional, and psychosocial aspects of serious illness. AFHS designation in a tele-Palliative Care clinic is novel nationally. We demonstrated that evidence-based care can be provided to every older adult, regardless of care modality, without expanding staff or changing clinical workflows.

Keywords

age-friendly health systems telemedicine Palliative Care Veterans

Highlights

Telemedicine programs that are completely virtual are not currently recognized as Age-Friendly Health Systems by the Institute for Healthcare Improvement.

Veterans Health Administration (VHA) Eastern Colorado Geriatric Research Education and Clinical Center (GRECC) Connect’s experience demonstrated that is it feasible to achieve fidelity to AFHS guidelines and standards within a telemedicine context – tele-Palliative Care, specifically.

Our clinical demonstration project supports AFHS recognition for telemedicine clinics and allowing clinical programs with virtual components to report the number of older adults served in their Level 2 program monitoring metrics.

Applying AFHS standards and requirements to telemedicine helps ensure that care, regardless of modality, reflects geriatric best practices and is consistently aligned with What Matters Most to older patients.

Introduction

The US Census Bureau projected that the US population aged ≥65 years will double from 43.1M in 2012 to approximately 83.7M in 2050.¹ A parallel demographic shift is occurring among patients, yet the healthcare system is not designed to provide evidence-based care consistently to older adults.¹ This has implications in terms of the ability of the current healthcare system to deliver quality healthcare and achieve positive health outcomes for older adults. This stark reality extends to the Veterans Health Administration (VHA), which cares for US Veterans, 48.5% of whom are ≥65;² further, over half (54%) of rural Veterans enrolled in the VHA are ≥65 (Figure 1). (Supplemental Appendix A features acronyms used throughout manuscript.)

Figure 1.

FY23 US Veteran demographics (courtesy of VHA Office of Rural Health).

“Age-Friendly Health Systems” (AFHS) are designed to meet this 21st century challenge. AFHS is an initiative of The John A. Hartford Foundation and Institute for Healthcare Improvement (IHI), in partnership with the American Hospital Association and the Catholic Health Association of the United States. AFHSs aim to provide care to older adults aligned with geriatric best practices to maximize healthcare quality, minimize harms and support older adults’ goals of care.¹ Evidence-based practices refer to the Geriatric 4Ms: Mentation, Mobility, Medication, and Matters Most. Mentation refers to maintaining mental activity, managing dementia (decline in memory/mental abilities that makes daily living difficult), and helping treat/prevent delirium. Depression, another facet of the mentation domain, is a mood disorder that can interfere with all aspects of life and is important to evaluate routinely and treat in a timely manner to optimize healthy brain aging. Mobility focuses on balance, strength and flexibility to maintain physical function, including the ability to walk and prevent falls/injuries. Medication focuses on reducing polypharmacy through de-prescribing (discontinuing unnecessary medications), building awareness of harmful medication effects, and patient-centered prescribing. Matters Most seeks to align care with a person’s individual, personally meaningful health outcomes, goals and preferences that should inform, and be documented in, their treatment plan.³ This domain includes discussions of values and life-sustaining treatments. Aligning the treatment plan with what matters most to the older patient and caregivers can help maintain functional independence, optimize quality of life and uphold beneficence. Figure 2 presents the Geriatric 4Ms and their importance to addressing multiple chronic conditions and complex care needs (ie, multicomplexity – a fifth M recognized in the Geriatric 5Ms framework endorsed by the American Geriatrics Society).⁴ (Figure reproduced with permission from authors.)

Figure 2.

The 4Ms framework guides evidence-based care of older adults to support comprehensive assessment and care for managing multiple chronic conditions and complex care needs (reproduced with permission).

IHI confers AFHS recognition for clinical units that complete a formal application process and 2 sequential levels of achievement: Level 1 (Participant) and Level 2 (Committed to Care Excellence – the highest AFHS designation). For Level 1 recognition, interprofessional teams at the clinical site successfully develop a feasible plan to address the 4Ms within a specified clinic. The site plan is documented in the 4Ms Care Description worksheet, which incorporates site-specific assessments/tools using the 4Ms framework. After IHI confirms Level 1 recognition, these care teams work toward Level 2 recognition, comparing previous practice to newly-adopted AFHS standards. AFHS Level 1 teams use 1 of 3 methods to study site performance in providing geriatric care aligned with the 4Ms: (1) real-time observations, (2) chart review, or (3) electronic medical record (EMR) report for at least 3 months; teams submit the results to IHI for AFHS Committed to Care Excellence (Level 2) review and recognition. No actions are required to sustain recognition. However, AFHS-designated sites continuously monitor quality and effectiveness, and identify and implement needed improvements. They also promote dissemination and implementation of the 4Ms within their healthcare ecosystem.⁵

VHA’s Office of Geriatrics and Extended Care has joined the AFHS movement as a national enterprise-wide initiative to deliver safe, reliable, high-quality health care in every setting based on what matters most to older Veterans.⁶ As of October 1, 2024, 401 VHA care settings had earned Level 1 Participant recognition across 157 VHA medical facilities. Over half (57%; 228/401) of these care settings had earned Level 2 Committed to Care Excellence recognition. The 157 VHA facilities represent nearly all (96%; 133/139) of VHA parent stations, defined as an urban-based VHA medical center and affiliated community-based outpatient clinics (CBOCs), the latter of which are located closer to small communities.

GRECC Connect is a national VHA initiative to increase access to geriatric specialty care via telemedicine for rural, older Veterans with multiple chronic conditions and complex care needs. The 20 sites are each connected to a Geriatric Research Education and Clinical Center (GRECC), which are VHA centers of excellence focused on aging.⁷ The national GRECC Connect program has become the nexus of the VHA AFHS movement. The GRECC Connect site within the VHA Eastern Colorado Health Care System (ECHCS; Figure 3) offers rural tele-geriatrics/dementia and tele-Palliative Care across a catchment area of approximately 44,914 square miles. (“This area includes a mix of urban centers, suburban areas, and extensive rural regions. While exact figures are unavailable, considering that Eastern Colorado is predominantly rural outside of major urban hubs, it is reasonable to estimate that approximately 70 to 80% of the [VHA] Eastern Colorado Health Care System’s coverage area serves rural populations.” (Chat GPT query October 8, 2024).). The VHA Eastern Colorado GRECC Connect tele-Palliative care clinic achieved AFHS Level 1 (Participant) recognition in September 2021 and, subsequently, Level 2 Committed to Care Excellence recognition in December 2021.

Figure 3.

VHA Eastern Colorado Health Care System catchment area (VHA Eastern Colorado Health Care System 2023 Annual Report⁸).

A systematic review of articles published between January 2010-June 2022 documented that tele-Palliative Care supported the patient-provider therapeutic alliance for more responsive/timely symptom management (Matters Most).⁹ A broader systematic review, inclusive of telehealth articles with relevance to tele-Palliative Care and published 1986 to March 2024, showed telemedicine supported medication review and adherence (Medication), management of pain and depression (Mobility and Mentation), and improved quality of life (Matters Most).¹⁰ In both reviews, tele-Palliative Care increased access to care for patients with disabling symptoms and reduced burdens (Matters Most), as well as stress/anxiety (eg, Mentation).^9,10

Our goal with the Eastern Colorado GRECC Connect tele-Palliative Care clinic was to reach rural/highly rural Veterans residing within our healthcare catchment area that had uncontrolled symptoms, frequent hospitalizations/emergency department visits, or needed care coordination for managing complex medical conditions like cancer or multiple chronic conditions. (Highly rural Veterans live in “sparsely populated areas, [defined as areas where] less than 10% of the working population commutes to any community larger than an urbanized cluster, which is typically a town of no more than 2500 people.” (Source: https://www.ruralhealth.va.gov/aboutus/ruralvets.asp)) The tele-Palliative Care team included a Palliative Care provider, social worker, pharmacist and Palliative Care psychologist. This interprofessional team, located at the VHA medical center outside Denver, Colorado (indicated with a star in Figure 3), provides care via telemedicine to rural CBOCs (the circles in Figure 3). Clinical video telehealth (CVT) capabilities of CBOCs allow Veterans to access specialty services closer to home and have telehealth technicians present for support. Telehealth technicians take vitals, weight and support telemedicine providers at the medical center; they also address Veteran needs (eg, providing technology support, if needed). If a Veteran is unable to travel to a CBOC for a CVT visit, VA Video Connect (VVC) – VHA’s secure videoconferencing application – is an option for completing secure video visits from the VHA to the Veteran’s home, using a VHA-issued, Wi-Fi-enabled tablet, if needed. VHA has invested in efforts to bridge the digital divide (ie, disparities in access to adequate broadband infrastructure, reliable internet connectivity, up-to-date technology equipment, and computer literacy)¹¹ to improve access to telemedicine services. These structural supports address well-documented barriers to telemedicine adoption and acceptance by patients and providers. VVC is a convenient option when there is inclement weather, Veterans are feeling unwell, or an on-demand visual assessment from a provider is necessary.

The purpose of this paper is to detail our experience achieving AFHS recognition for tele-Palliative Care. We were the first nationally to achieve AFHS recognition for a telemedicine clinic. This paper addresses an existing gap in the literature on telemedicine clinics as AFHS-designated sites to advance the AFHS field and support policies recognizing the importance of telemedicine in the AFHS national movement.

Methods

VHA ECHCS’ success in achieving AFHS Level 1 and 2 recognition in 2021 was the culmination of (1) initial planning involving the interprofessional tele-Palliative Care team and a workgroup that included older Veterans; (2) implementing and maintaining AFHS practices; and, (3) adopting standardized templates to track the delivery of care aligned with the Geriatric 4Ms. These milestones are presented in Figure 4. We followed the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guidelines in developing this manuscript (see Supplemental File). The Colorado Multiple Institutional Review Board of the University of Colorado Anschutz Medical Campus, the IRB of record for the Rocky Mountain Regional VA Medical Center, advised that applying for and achieving AFHS recognition for an existing tele-Palliative Care clinic did not constitute research or warrant human subjects review.

Figure 4.

Process flow diagram depicting process of achieving Level 1 and Level 2 AFHS designations.

Planning

Tele-Palliative Care Team

The first step in achieving AFHS recognition was to engage the robust and high-performing interprofessional team. Our telemedicine Palliative Care team was well-established with (1) weekly pre-clinic huddles to review Veterans’ charts and share updates, (2) open lines of communication regarding Veterans’ health status changes, and (3) monthly Palliative Care team meetings with all medical providers and support staff. We also invested in teambuilding opportunities throughout the year and leveraged routine meetings to discuss AFHS practices to advance this change initiative. Dedicated time outside of patient care allowed staff to focus on accomplishing required AFHS documentation. Our team reflected on current practices and recognized that the 4M questions are often asked during new Palliative Care consultations (eg, what are your goals, how is your mood, are you safe at home/falling), along with medication review. We also identified the following needed changes/adaptations to meet AFHS guidelines: highlighting each of the 4Ms with their own section at the top of provider notes while adding treatment plans and assessment for ease of access by other providers/specialties, and the need to designate which provider would complete the required Age-Friendly Whole Health template for data tracking and reporting. In response to these needed changes, we updated language and delineated team member roles to ensure that AFHS questions were asked and sufficiently documented.

Throughout this process, we utilized the VHA’s Age-Friendly Community of Practice as a resource for questions, guidance and support (Age-Friendly Action Community (sharepoint.com)). For those outside the VHA, IHI has established its own community of practice, which includes opportunities and tools for teams to connect with others around the world in their efforts to improve health care and health for older adults. (https://community.ihi.org/home)

VHA Workgroup

In addition to the regular meetings of the interprofessional tele-Palliative Care team, a workgroup was created to assist in the planning, implementation, and tracking of the 4Ms. The workgroup included a physician, physical therapist, social worker, clinical pharmacist, nurse practitioner, project manager, research fellow, research social worker, research nurse practitioner, and 2 older Veterans. This group therefore brought together individuals with varied perspectives and diverse areas of expertise. The workgroup began to meet during the planning phase and continued to meet monthly until Level 2 recognition was received. Workgroup tasks included (1) discussing outcomes aligned with the 4Ms and the frequency they should be assessed, (2) identifying strategies for 4Ms documentation and tracking based on national note template examples, (3) completing Level 1 and Level 2 recognition worksheets, and (4) disseminating information (eg, AFHS best practices). Following receipt of Level 2 recognition, the group continued to meet biannually to discuss the current state of AFHS practice within the tele-Palliative Care clinic and other clinics interested in achieving AFHS designation.

Implementation

Here we describe how AFHS practices were implemented by the tele-Palliative Care team in caring for patients. For the initial patient consultation, the VHA telemedicine Palliative Care provider and social worker jointly participated in the telemedicine visit with each Veteran and their family member and/or caregiver. We encouraged having a caregiver or collateral person involved to ensure (1) there was a person in a Veteran’s life that also heard their wishes and values during conversations with VHA staff, and (2) someone was present who could relay information pertinent to the Veteran’s care and help ensure that what Mattered Most to the Veteran remained at the center of their care, should a Veteran have memory issues related to their treatment or dementia.

During the initial visit, both the provider and social worker completed a 4Ms assessment for their respective profession. Before the visit, the pharmacist updated the electronic medical record to reflect Medication regime from a phone call reconciliation and alerted the medical provider to review associated notes before the Veteran’s appointment. During the visit, the provider discussed medication changes and recommendations with the Veteran to ensure they aligned with their wishes (Matters Most). Either the provider or social worker documented the Mentation and Mobility sections of the note template during the visit. Generally, the social worker was responsible for completing the Patient Health Questionnaire-2 (PHQ-2) and assessed mood as part of their clinical evaluation, as situational depression related to disease or treatment is common. If deemed appropriate, a social worker recommended visiting with the team psychologist, while the Palliative Care practitioner provided education on antidepressants or other medication to address mood. Palliative Care psychologists provided support and counseling to help Veteran’s process their experience of coping with chronic comorbidities; explore changes in role and function; address the interaction of PTSD and/or military experience with their current situation; and engage in work around anticipatory grief and issues of legacy. Either the Palliative Care practitioner or social worker was able to assess for Mobility/falls using the Stopping Elderly Accidents, Deaths & Injuries (STEADI)¹² screening tool and either inquired about physical therapy and ordered a life alert device or home safety evaluation for adaptations. (A link to each profession-specific template is provided in Appendix B for reference.) Figure 5 details the patient experience starting from initial referral to the tele-Palliative Care clinic.

Figure 5.

Veterans’ experience with Age-Friendly tele-Palliative Care at the VHA Eastern Colorado Health Care System.

Each team member updated their Palliative Care intake assessment to reflect 4Ms charting as outlined in the Level 1 application. We learned that creating a saved template in the EMR was a best practice for efficient documentation – an aspect we describe in further detail in a later section of the paper.

Workflow and Staffing

During the implementation phase, the interprofessional team’s cohesion supported a flexible approach, as each discipline felt comfortable asking the 4M questions. Here we provide an example by detailing how our team worked together in relation to medication review and reconciliation.

A key facilitator for Age-Friendly care within the context of our GRECC Connect tele-Palliative Care clinic was the fact that our pharmacist completed medication reconciliation prior to the first visit as standard of care. The Veteran/caregiver was contacted via telephone, allowing the Veteran to remain at home where they were near their medications to review pill bottles and locate any supplements or over-the-counter medications, which Veterans might not consider to be “medication.” This also precluded the need for the Veteran and caregiver to travel to a CBOC with their medications. The pharmacist started asking “What Matters to you?” during their call to elicit the Veteran’s initial thoughts as a starting point for the Age-Friendly conversation during the subsequent tele-Palliative Care visit. The pharmacist completed a comprehensive medication review based on evaluation of the medical record and alerted providers to recommendations. Medication management was assessed, and pill boxes were provided, if needed, to assist with medication adherence. During subsequent tele-Palliative Care visits with the provider and social worker, the social worker asked Veterans/their care partner how medications were administered and overseen. This interprofessional approach and communication across visits using multiple modalities allowed the team to provide Veteran-centered care and successfully complete Level 2 requirements with existing staffing levels.

Documentation

To achieve AFHS Level 2 Committed to Care recognition, we tracked the number of visits in which all 4Ms are addressed. We began tracking immediately upon submitting the Level 1 application. In 2021, the VHA had not yet established data visualization software or “PowerBI” dashboards to support tracking at a national level; for this reason, we initially relied on individual chart reviews. Our GRECC Connect program utilized a research assistant experienced in conducting chart reviews to manage data requirements, including reporting. Each team member updated their Palliative Care assessment to reflect 4Ms charting as outlined in the Level 1 application and created a saved template in the EMR as a best practice to support documentation.

As Palliative Care has no age requirement for care, we decided we would ask all Veterans for whom we provided care the same Age-Friendly questions. However, we only documented the responses of Veterans ≥65 years in the medical chart. This strategy ensured that other ECHCS primary care/specialty care providers had the same medical information for Veterans seen by the tele-Palliative Care team, with Age-Friendly criteria being highlighted for those ≥65 years of age.

The VHA created a national Age-Friendly Whole Health template to support tracking each of the 4Ms in FY22 Q4; associated data populates PowerBI data visualization software. Our team adopted the Age-Friendly 4Ms Note Template (Version 1.2) in FY23 Q4. The template can be inserted into a provider’s note or included as an addendum after each member of the care team has met with the Veteran. Each of the 4Ms has a designated radio button for the provider/designee to click and, when “yes,” add pertinent information to a textbox (eg, documenting What Matters/goals of care, number of falls, brief cognitive screen score and date completed, or information on medications). The date a radio button is checked auto populates the next Age-Friendly template, thus helping track the information over time and alerting providers when they need to ask or update AFHS questions. The establishment and adoption of the Whole Health national boiler plate template for workload documentation simplified tracking metrics for our team and automated the process of generating standardized reports for the team’s review.

Results

The VHA ECHCS achieved Level 1 and 2 AFHS recognition in September and December 2021, respectively, becoming the first telemedicine clinic nationally (in the VHA or other healthcare system) to achieve this designation. Further, we were the first clinical site in the ECHCS and the third clinical site within our VHA region¹³ to achieve this designation. Initially, our data tracking efforts focused on confirming that the interprofessional care team was consistently addressing the Geriatric 4Ms across tele-Palliative Care visits. During the maintenance phase (ie, FY23 and FY24), when processes were well established and the 4Ms were reliably addressed, we expanded data tracking efforts to include demographics of unique Veterans served (including rurality) and travel miles saved (ie, miles that Veterans or caregivers did not have to travel to receive Palliative Care services at the main VHA medical center). We continued to track the proportion of tele-Palliative Care visits in which the 4Ms were addressed.

Results reported here focus on FY23 and FY24 – the maintenance phase of our AFHS work and the 2 most recent years for which data are available. Over that period, we conducted a total of 192 AFHS tele-Palliative Care visits, an average of 81% of which were conducted with rural/highly rural Veterans. There was a general trend of increased rural visits over time, with the lowest percentage of rural visits (65%) in Q1 of FY23 and the highest percentages (92% and 100%) achieved in the second and third quarters of FY24, respectively. While the proportion of rural AFHS tele-Palliative Care visits increased over time, the total number of AFHS tele-Palliative Care visits decreased from a high of 35 total visits in Q2 of FY23 to a low of 14 total visits in Q2 of FY24. Figure 6 compares the number of rural visits to the total number of AFHS tele-Palliative Care visits by quarter. The ability to provide comprehensive Palliative Care, aligned with the 4Ms, via telemedicine saved Veterans and caregivers from having to travel a total of 23 622 mi in FY23 and 18,632 mi in FY24.

Figure 6.

Absolute number of AFHS tele-Palliative Care visits (total and rural) by quarter during maintenance phase (FY23 and 24).

AFHS status requires that all 4Ms are addressed consistently within a 30-day period. This can be achieved by addressing all 4Ms during a single visit or across multiple visits involving a patient that occur within a month. Within our clinical workflow, the 4Ms were most often addressed across multiple visits with our interprofessional team over the course of 30 days. Applying the AFHS criteria, all 4Ms were addressed for 86% of unique patients in FY23 and 76% of unique patients in FY24.

In FY23 and FY24, we served a total of 108 unique patients (FY23: 57; FY24: 51). The demographics of these AFHS tele-Palliative Care Veterans are presented in Table 1, which compares patient demographics with the demographics of Colorado Veterans – a geographic area that best approximates the ECHCS and for which the most complete demographic information is available; Colorado Veteran demographics are reported for 2023. The majority of AFHS tele-Palliative care patients in FY23 and 24, respectively, were White (82% and 73%), not Hispanic/Latino (83% and 73%), male (100% and 98%), and ≥65 (90% and 89%). Compared to Colorado’s Veteran population, Veterans from racial/ethnic minority backgrounds and women were underrepresented, while Veterans of Hispanic/Latino ethnicity and older Veterans were overrepresented among AFHS tele-Palliative Care patients. Only 8% (FY23) and 6% (FY24) of AFHS tele-Palliative care patients reported being from racial/ethnic minority backgrounds compared to 16% of Colorado Veterans; however, 10% and 22% of Veterans served by our AFHS tele-Palliative Care clinic in these fiscal years, respectively, had missing data or explicitly declined to answer this demographic question. There is incomplete demographic data available as VHA relies on self-reporting upon enrollment; Veterans have the option to disclose based on preference. Highly rural Veterans comprised the largest percentage of Veterans served. Specifically, highly rural Veterans comprised just over two-thirds (67%) of Veterans served in FY23 and just under three-fourths (71%) of Veterans served in FY24.

Table 1.

Demographics of Unique AFHS Tele-Palliative Care Patients (FY23 Through third Quarter of FY24).

Demographics	FY23	FY24	Colorado (2023)¹⁴
Race
• White	82% (47/57)	73% (37/51)	81.0% (297 339/368 109)
• African American/Black	2% (1/57)	2% (1/51)	6.3% (23 153/ 368 109)
• American Indian or Alaska Native	4% (2/57)	-	1.0% (3503/368 109)
• Native Hawaiian/Pacific Islander	2% (1/57)	2% (1/51)	0.2% (914/368 109)
• Multiple races (Black/African American and White)	-	2% (1/51)	7.0% (25 901/368 109)
• Asian	-	-	1.6% (5903/368 109)
• Unanswered (missing)	5% (3/57)	12% (6/51)	-
• Declined to answer	5% (3/57)	10% (5/51)	-
Ethnicity
• Not Hispanic or Latino	83% (47/57)	73% (37/51)	75.3% (277 099/368 109)
• Hispanic or Latino	12% (7/57)	16% (8/51)	12.6% (46 445/368 109)
• Unanswered (missing)	2% (1/57)	8% (4/51)	-
• Declined to answer	2% (1/57)	4% (2/51)	-
• Unknown by patient	2% (1/57)	-	-
Gender
• Male	100% (57/57)	98% (50/51)	87.3% (321 235/368 109)
• Female	-	2% (1/51)	12.7% (46 874/368 109)
Rurality
• Urban	28% (16/57)	16% (8/51)	-
• Rural	5% (3/57)	14% (7/51)	-
• Highly rural	67% (38/57)	71% (36/51)	-
Age
• 45-49	-	2% (1/51)	6.4% (23 691/368 109)
• 50-54	2% (1/57)	2% (1/51)	8.0% (29 623/368 109)
• 55-59	4% (2/57)	6% (3/51)	9.0% (32 739/368 109)
• 60-64	5% (3/57)	2% (1/51)	9.4% (34 736/368 109)
• 65-69	19% (11/57)	14% (7/51)	9.0% (32 974/368 109)
• 70-74	26% (15/57)	24% (12/51)	9.2% (33 756/368 109)
• 75-79	23% (13/57)	25% (13/51)	11.1% (41 029/368 109)
• 80-84	9% (5/57)	10% (5/51)	5.3% (19 661/368 109)
• 85-89	11% (6/57)	8% (4/51)	85+ 6.1% (22 294/368 109)
• 90-94	2% (1/57)	6% (3/51)
• 95-99	-	-
• 100-104	-	2% (1/51)

To complement these quantitative metrics, we present a case example to illustrate qualitatively how we worked together as an interprofessional care team to address the 4Ms and provide patient-centered, holistic care for a Veteran with serious illness.

Case Example – Age Friendly Health System tele-Palliative Care in Practice

A 70-year-old male Veteran residing in a rural town with his wife/caregiver has a medical history of IB esophageal adenocarcinoma s/p resection and radiation in 2009 on pembrolizumab, mental health diagnosis of bipolar disorder. He presented to the VHA emergency department with worsening rash over his right orbit and face from herpes zoster opthalmicus. His spouse requested Palliative Care consultation during Veteran’s hospitalization. Couple met with the rural tele-Palliative Care nurse practitioner bedside as an introduction, with plan to follow-up for continuing care, pain management, and support. The couple lived 2 h (just over 100 mi) from medical center. Telemedicine allowed them to meet the tele-Palliative Care team from their home without the burden of travel. In addition to the uncontrolled pain, having esophageal cancer with a jejunostomy tube negatively impacted Veteran’s quality of life. He was unable to physically prepare, cook or take food by mouth. Veteran had worked as a professional chef for 40 years. What mattered most to him was his spouse. He met with the Oncology Clinic Psychologist for support around psychosocial factors related to the medical management of esophageal cancer and Behavioral Health Interdisciplinary Program for mood.

The provider started working with this couple on symptoms of nausea and pain. They worked closely with spouse to educate on medication administration (crushed via tube vs by mouth). Simultaneously, advance care planning and life-sustaining treatment preferences were reviewed and documented in the medical record for other VHA specialty care team members to have available for routine care in oncology, mental health and primary care. Monthly telemedicine appointments were conducted; Veteran and/or wife could call the provider as needed between visits. Veteran’s spouse was enrolled in the Veteran Directed Care program and paid to help with patient’s activities of daily living and assist with his mobility, transfers, and wheelchair use. The social worker provided case management support and information. As the Veteran’s condition progressed and his initial plan to continue living at home with care from his spouse changed, there was already a specialty social worker involved and familiar with the couple. This facilitated the discussion about placement based on Veteran’s functional decline and increased need for nursing care. During follow-up visits, the provider discussed hospice care as another layer of support for the Veteran and spouse with the goal of avoiding a crisis situation at home without a VHA Palliative Care team member available or that might require non-VA hospitalization.

Discussion

Achieving AFHS recognition for a tele-Palliative Care setting is novel nationally and positions us to contribute unique insights to advance the AFHS movement in the VHA and other healthcare systems. Quantitative metrics document implementation and success in reaching rural/highly rural older Veterans. We saw 6 fewer patients in FY24 compared to FY23. We attribute this decrease to the establishment and implementation of more precise referral criteria. Initially, the tele-Palliative Care team saw any Veteran outside the Denver metro area. As areas of southern Colorado grew in population, we refined the process of identifying rural/highly rural Veterans. Using the VA Office of Rural Health’s Rurality calculator, the social worker was able to better distinguish between urban and rural Veteran consultation requests, referring the former to other outpatient Palliative Care provider teams who see urban Veterans in their respective areas. This contributed to seeing fewer Veterans overall in FY24 compared to FY23.

Lower referral rates in FY24 underscore the importance of continuous outreach to CBOC staff to educate about our AFHS tele-Palliative Care service, particularly given the persistently high turn-over rates of CBOC staff. During periods in which we received relatively fewer rural/highly rural Veteran referrals in FY24, the tele-Palliative Care provider and social worker traveled to rural CBOCs to provide education on VHA tele-Palliative Care and AFHS services to increase awareness. This helped rural clinic staff identify Veterans that could benefit from AFHS tele-Palliative Care consultation based on unmet needs and fostered open communication between CBOC staff and the tele-Palliative Care team at the main medical center >100 mi away. For the tele-Palliative Care team, we learned more about local community resources that could be engaged for Palliative Care and hospice support.

AFHS-related planning and implementation challenges were minimal for the tele-Palliative Care team. Our workgroup discovered that Palliative Care providers within the service were using individually personalized templates for documentation and organization. Outpatient providers have now adopted a standardized AFHS template; this standardized approach prepares the urban team well for their 2025 Level 1 AFHS application.

Other key lessons learned from implementing AFHS core practices in a tele-Palliative Care setting are presented below, organized by feasibility considerations at the level of the Palliative Care team, medical facility, and telemedicine modality.

Feasibility of Integrating AFHS Practices Within Palliative Care

Palliative Care’s philosophy naturally aligns with AFHS principles/goals, as Palliative Care is focused on supporting the physical, emotional, and psychosocial aspects of advanced illness, which is congruent with AFHS’s whole health approach. AFHS processes are commonly used by interprofessional Palliative Care teams without “Age-Friendly” labels. For example, Age-Friendly questions support advance care planning. AFHS processes are optimized by interprofessional collaboration, which is typical in Palliative Care.

Feasibility of Pursuing AFHS Recognition for Facilities

Currently, IHI does not recognize 100% virtual programs as AFHS sites. Further, if a hybrid program (ie, part face-to-face, part virtual) receives AFHS recognition, older adults seen virtually must be excluded from Level 2 counts.¹⁵ Our experience demonstrates it is possible to deliver evidence-based care to every older patient and across multiple care modalities. We also demonstrated that AFHS practices can be implemented without expanding staff or changing clinical workflows. Key facilitators included an established, robust, well-functioning interprofessional team that leveraged existing structures to support communication and collaboration across visits. We also benefited from an established national community of practice that shared best practices and templates so that we, as a new implementation site, could adopt and integrate existing resources, including data infrastructure to streamline data tracking and reporting.

AFHS practices are aligned with the VHA mission of providing Veteran-centered and value-driven care. Our experience suggests that AFHS practices can support compliance with quality standards for healthcare systems (eg, using medicines safely), can help avoid/alleviate moral injury among staff, and are responsive to patient-centered care principles.¹⁶

Implications for AFHS Recognition for Telemedicine

We demonstrated that the Geriatric 4Ms can be addressed consistently in telemedicine, thus helping to extend AFHS practices to patients who cannot leave home or travel to an urban-based medical facility to receive care. Integrating the 4Ms into an expanded array of care modalities to provide Veteran-centered, value-driven care decreases travel time, cost and burden, and provides the best care possible closer to home. On demand access to Veterans in their home with VVC to support what matters most to Veterans and caregivers advances health equity, particularly within the VHA, which has programs/services designed to bridge the digital divide. GRECC Connect has been a national leader in establishing and expanding such supports, which include one-page tipsheets to help Veterans and caregivers set up their VHA-issued tablet, get logged into their first telemedicine appointment, and get the most out of such appointments, for example, by bringing their list of questions and concerns and having a caregiver present to help record and recall information shared.¹¹ Further, for Veterans who access AFHS tele-Palliative Care at CBOCs, these community-based clinics are staffed with telehealth technicians or other support staff who assist with the technological aspects of accessing telemedicine.

Prior to the COVID 19 pandemic, in-person care was the gold standard and the context for AFHS work. Face-to-face appointments were considered important for establishing rapport and building trust – the therapeutic alliance with an interprofessional care team necessary to address the 4Ms, including exploring/identifying what matters most (ie, Veteran’s goals of care). The COVID 19 pandemic accelerated the adoption of telemedicine in the VHA and other healthcare systems, with GRECC Connect well positioned to lead efforts nationally to move AFHS work into this care modality within the VHA.

Currently, IHI does not recognize virtual telemedicine programs as AFHS sites. We hope that our AFHS tele-Palliative Care experience will stimulate a national conversation that informs the future expansion of AFHS. We pose the following questions to promote further discussion in the field: should IHI consider telemedicine clinics as eligible for IHI AFHS designation, given the potential to expand geriatric best practices of care to rural older Veterans and older Veterans who cannot travel to medical facilities/clinics due to debilitating conditions? As a corollary, should IHI exclude older adults seen virtually from Level 2 counts? We hope that our experience serves as an illustrative case example that will support IHI as it considers a policy shift to make AFHS recognition available to telemedicine programs.

Limitations

Given the unique clinical context in which we implemented AFHS tools and practices, our AFHS tele-Palliative Care methods and results may not be generalizable to other AFHS sites. However, our work demonstrates both feasibility and acceptability by the interprofessional care team, Veterans and caregivers of a comprehensive, whole health/whole person approach to delivering geriatric best practices by consistently addressing the 4Ms in tele-Palliative care. Further, we demonstrated effectiveness in achieving positive outcomes aligned with the mission of the VHA, honoring what matters most to Veterans experiencing serious illness and reducing burdens associated with receiving care, thereby enhancing quality of care and quality of life.

A second limitation is the underrepresentation of Veterans from racial/ethnic minority backgrounds, such as African Americans and Asians, as well as lack of gender diversity. Data on racial identity was not available/reported for 10% (FY23) and 22% (FY24) of our patients; VHA relies on Veterans self-reporting demographic information upon enrollment. Women were underrepresented, underscoring the need to develop tailored outreach/education strategies to reach women Veterans in rural areas who are experiencing life-limiting conditions. The underrepresentation of Veterans from racial/ethnic minority backgrounds and women Veterans may reflect the intersectionality of rurality, other identities associated with social disadvantage and related health disparities, with lack of digital access being a salient social determinant of health.⁹ Researchers at our academic affiliate found lack of access to information and poor communication by medical professionals negatively affected utilization and acceptance of Palliative and hospice care among patients from racial/ethnic minority backgrounds.¹⁷ Research is needed to explore factors influencing use of AFHS tele-Palliative Care among these subpopulations of rural Colorado Veterans.

Conclusion

IHI does not yet recognize telemedicine programs that are completely virtual as AFHS sites. We hope our experience catalyzes policy change that supports AFHS recognition for telemedicine clinics and allows programs with virtual components to report the number of older adults served in their Level 2 program monitoring metrics. VHA Eastern Colorado GRECC Connect’s experience indicates it is feasible to achieve fidelity to AFHS guidelines and standards within a telemedicine context. Consistent with the published literature on tele-Palliative Care, benefits to Veterans and caregivers include the ability to provide Veteran-centered, value-driven care close to/at home. Applying AFHS standards and requirements to telemedicine helps ensure that this care modality is available to expand access to whole health/whole person care for social/emotional support, symptom management and advance care planning and that care, regardless of modality, reflects geriatric best practices and is consistently aligned with What Matters Most to Veterans.

Supplemental Material

sj-docx-1-inq-10.1177_00469580251352727 – Supplemental material for Establishing First Age-Friendly Health System Tele-Palliative Care Clinic – Facilitators, Challenges, Lessons Learned to Improve Care for Rural, Older Veterans

Supplemental material, sj-docx-1-inq-10.1177_00469580251352727 for Establishing First Age-Friendly Health System Tele-Palliative Care Clinic – Facilitators, Challenges, Lessons Learned to Improve Care for Rural, Older Veterans by Stephanie Hartz, Alexander Garbin, Courtney McGuire, Jill Steagall, Jocelyn McCauliff and Kathryn Allen Nearing in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Footnotes

Acknowledgements

We would like to thank all members of the VHA working group including Ruth (Lisa) Plaza, Hillary Lum, Lauren Abbate, Sarah Beck, Spring Wright, Elizabeth Ellis, Lynette Kelley, Susie Kim, Jennifer Stevens-Lapsley, Michael Bade, Andrea Wershof Schwartz, Hannah Schara, as well as our Veteran partners, Serena Douglas and Susan Martin-Sanders. Additionally, we would like to thank the VHA Eastern Colorado Geriatric Research, Education, and Clinical Center (GRECC) for ongoing support and leadership. In particular, we wish to acknowledge Dr. Josh Yarrow PhD, director, VHA Eastern Colorado GRECC, for his review of earlier drafts of this paper and the critical feedback he provided, which strengthened the presentation of information and salience to a national audience. We would also like to thank Kimberly Wozneak for national support of this VA initiative.

ORCID iDs

Stephanie Hartz

Jocelyn McCauliff

Kathryn Allen Nearing

Ethical Considerations

The Colorado Multiple Institutional Review Board of the University of Colorado Anschutz Medical Campus, the IRB of record for the Rocky Mountain Regional VA Medical Center, advised that this work does not constitute research or warrant human subjects review.

Author Contributions

Hartz, Garbin, McGuire and Nearing contributed to the conception and design of the work, collection of data, conduct and interpretation of analysis and drafting of the manuscript. Authors Hartz, Garbin, Steagall and McCauliff contributed to achieving Level 1 and 2 AFHS designations at the VHA Eastern Colorado Health Care System. The corresponding author, Stephanie Hartz, takes responsibility for the manuscript as a whole.

Tracked Changes or Comments where the poster’s name is listed

Kathryn Nearing – red tracking

Stephanie Hartz – blue tracking

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was funded by the Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health, NOMAD PROJFY-010196. The contents do not represent the views of Department of Veterans Affairs or the United States government.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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