According to a recent World Health Organization (WHO) publication, in 2020 the number of people aged 60 years and older outnumbered children younger than 5 years worldwide (asamonitor.pub/3NC2L83). Simultaneous to the rapidly growing older population, their surgical and perioperative needs are also increasing. Minimally invasive surgical techniques and procedures are allowing patients with increasingly complex comorbidities to proceed with intervention, when once this may not have been offered to them given the intrinsic risk. There is an expanding effort to provide comprehensive perioperative care to the older surgical patient. Housing the assessment, risk-stratification, and education of these patients and their caregivers in an outpatient clinic setting is an effective means of meeting this demand and to allowing a standardized process for evaluation. It is also in line with the national efforts of the Geriatric Surgery Verification Program. There are, however, multiple logistical obstacles to achieving effective, streamlined, age-friendly care. In this article, we will address some of the important considerations in the creation, implementation, and sustainability of an age-friendly outpatient perioperative clinic.
“One of the most important considerations in establishing an effective age-friendly clinic is to clearly identify and articulate the goals of the age-friendly pathway at the institutional level. The older adult has unique physiologic, pharmacologic, and psychosocial needs that must be considered when providing high-value, quality perioperative care
One of the most important considerations in establishing an effective age-friendly clinic is to clearly identify and articulate the goals of the age-friendly pathway at the institutional level. The older adult has unique physiologic, pharmacologic, and psychosocial needs that must be considered when providing high-value, quality perioperative care universally. The Institute for Healthcare Improvement (IHI) and the John A. Hartford Foundation have developed a collaborative initiative focused on age-friendly health systems and reliably addressing the “4Ms”: What Matters, Medication, Mentation, and Mobility. Other initiatives that may be helpful in clarifying the goals of the pathway include the Geriatric Surgery Verification Program. This program is a national initiative composed of specific perioperative standards designed to improve surgical care and outcomes for older adults. Once defined and incorporated appropriately at the clinic level, this innovative age-friendly pathway will ensure individualized, safe, and effective care is provided to every aging patient.
Being unified behind a common set of goals will set the stage to work toward achieving “buy-in” from critical stakeholders at the institution. Every institution has a slightly unique infrastructure, and approaching this step with openness will allow the clinic to develop roots and identify champions dedicated to the overall success of this program. Important champions to identify include (but are not limited to) surgeons, anesthesiologists, geriatricians, advanced practice providers, nurses, social workers, physical therapists, nutritionists, senior administration, and patient experience boards, where relevant. These champions will serve as the core group dedicated to the success of the program.
Once the various champions of the clinic are identified, a vital area to explore is funding. There are a broad range of opportunities for funding from local to national levels. Local opportunities at the departmental or institutional level often represent short- to intermediate-term funding that can support pilot or educational projects for gaining traction and data to support further funding endeavors. These opportunities are often found on institutional websites, email updates, and by word of mouth. At the national level, the National Institute on Aging (NIA) supports research and programs dedicated to providing high-quality care to the older population. Securing funding is important to offset the costs of creation, implementation, and maintenance. Matching the age-friendly clinic and program goals with local and national opportunities will increase the success and sustainability of the clinic and program.
An important logistical consideration is the formal creation with outlined expectations of the geriatric optimization program that will be housed in the clinic. There are a wide range of geriatric assessment tools and risk-stratification calculators that can be utilized, such as the Mini-Cog, Edmonton Frail Scale, and the Timed Up and Go test. Leaning on the expertise and enthusiasm of your champions while simultaneously aligning these with best practice guidelines and targeted educational materials will help to formalize the ideal in-clinic process. It may also be advantageous to create a defined clinic council that meets regularly, which will allow those knowledgeable of the day-to-day workings to provide input to ensure a smooth workflow. It is also imperative to identify and define specific staffing needs and to outline roles.
One further consideration is to include institutional information technology (IT) and an electronic medical record (EMR) builder, where relevant, from the beginning. This will allow the core group to become familiar with specific geriatric tools, assessments, and resources that are already built and immediately available as well as to understand the considerations of building others. Another benefit of early IT consultation is an agreement of what can be harvested for data and quality metrics. Collecting and analyzing data and quality metrics are vital to highlighting and monitoring the effectiveness and impact of the program and clinic.
“Setting a clinic-wide expectation that there may be multiple challenges and unforeseen roadblocks is helpful to keep staff invested. Equally important to setting this expectation is to have a clear method of identifying, documenting, and tracking these obstacles so the age-friendly clinic council can collectively think through potential solutions to identified issues.”
Once the program specifications have been created and reviewed, widespread education efforts are crucial. This effort can take a considerable amount of time and will come in many different forms that vary by institution. Education can be in the format of a web-based educational platform, in-person didactics, incorporation of standardized patients or simulation prompts, and even hands-on learning opportunities. Each clinic may require a unique combination of strategies to achieve adequate education for everyone from front desk staff to management. It is imperative to ensure that everyone involved in this program understand the goals of achieving age-friendly, equitable health care.
Another challenge of an age-friendly pathway is spreading awareness and furthering buy-in of the program and clinic offerings. One idea to address this challenge is to create a marketing strategy and awareness platform, or “enthusiasm tour,” that advertises the goals of the age-friendly perioperative clinic to the institution, referring surgeons and primary care physicians, as well as patients. These can take the form of web ads, widespread grand rounds presentations, emails, or individual discussions with key stakeholders. It may be helpful to emphasize that the goals of this clinic are synergistic with efforts such as the Geriatric Surgery Verification Program
Despite a clear plan, champions leading the charge, and spreading the message about the clinic’s offerings, implementation and the inaugural first few patients in the pathway may pose an additional logistical challenge. Setting a clinic-wide expectation that there may be multiple challenges and unforeseen roadblocks is helpful to keep staff invested. Equally important to setting this expectation is to have a clear method of identifying, documenting, and tracking these obstacles so the age-friendly clinic council can collectively think through potential solutions to identified issues. Leaning on the Plan-Do-Study-Act tool will allow the group to make modifications, trial the alteration, observe the impact, and determine what further adjustments should be considered (asamonitor.pub/3h8OK5Q; asamonitor.pub/3sUeeq2). Supporting an environment of open communication and innovation will allow those involved in the day-to-day operations to provide valuable suggestions. It will also set the stage for ensuring the sustainability of the program within the clinic.
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