Attention to patients' needs helps fine-tune approach

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center.

I'm your host, Amber Smith.

Upstate is becoming known as an age-friendly health system, dedicated to caring for older adults. Upstate University Hospital received a Level 1 designation over the summer, and recently Upstate Community Hospital's Transitional Care Unit in the Ambulatory University Geriatricians' Office earned a Level 2 designation.

Here to talk about what that means is Quonitra Bullock, nurse manager of the Transitional Care Unit, and Carrie Dickinson, the operational excellence leader for ambulatory services administration at Upstate. Together they led the team that worked to earn the age-friendly system designation for Upstate.

Welcome to "The Informed Patient," both of you.

Quonitra Bullock: Thank you for having us.

Carrie Dickinson, PhD: Yes, thank you for having us, Amber.

Host Amber Smith: This age-friendly health systems designation is an initiative of the John A. Hartford Foundation and the Institute for Healthcare Improvement in partnership with the American Hospital Association and the Catholic Health Association of the United States.

So it's a national effort meant to acknowledge hospitals and health systems that are taking good care of seniors. Is that right?

Quonitra Bullock: That is correct, Amber.

Host Amber Smith: Well, Mrs. Bullock, for people who aren't familiar with the hospital terms, can you explain what the TCU, or Transitional Care Unit, is?

Quonitra Bullock: Absolutely. The transitional care unit, at the Community Hospital location, is actually a short-term rehabilitation unit. It is definitely considered skilled nursing, where you are provided physical therapy, recreational therapy, occupational therapy, as well as nursing care, to get you into a place where you are able to transition back to your home environment.

Host Amber Smith: So how long are patients typically there?

Quonitra Bullock: Patients who frequent the TCU have a general length of stay, that is a hospital term, of approximately 12 days.

Host Amber Smith: And are all of the TCU patients above the age of 65?

Quonitra Bullock: Not exactly. All of the TCU patients are Medicare patients. Most of our patients are 65 and older, but these are the Medicare population for the most part.

Host Amber Smith: Can you give us some examples of things that the TCU has done that are considered age-friendly?

Quonitra Bullock: So there are so many things that any unit could do that are age-friendly, but specifically speaking for the TCU, one of the major things that we recently have done was we have purchased a blanket warmer for our patient population. Many of our clientele complain of being cold, and we want to keep them warm and comfy during their stay.

Other things that the TCU have done to be more age-friendly is we have created documentation in large print as well as in other languages to be able to support the understanding and transferring of that patient education to our patient population.

Host Amber Smith: And Dr. Dickinson, I know you have a doctorate in control system engineering, but I'm not really sure what that is. Can you explain it?

Carrie Dickinson, PhD: Sure. Amber, I'd be happy to. I have a background in engineering. Control systems engineering is a subset of electrical engineering, and prior to my coming to Upstate, I had various experiences working in different manufacturing facilities.

And part of my engineering background is really a process improvement methodology, and that's really what led me to Upstate a few years ago, is applying that lean methodology to our patients here at Upstate, always looking at how we can improve and make things better for our patients.

Host Amber Smith: Can you explain what lean methodology is?

Carrie Dickinson, PhD: Lean methodology, it's really looking at it from a customer perspective, a business process. And that business process can really be anything. So as I mentioned earlier, my background was in engineering, but really here at Upstate, we have many business processes, but really our customer, in this case, is our patient, so really the most important thing.

And in terms of lean, we look at what adds value from a patient perspective. So anything that doesn't add business value to a process we consider to be waste. And we want to make our processes as efficient as possible and certainly also as effective as possible, so we look at things from a big picture. And we really try to focus in on what matters the most and streamline those processes.

Host Amber Smith: Well, for the patients specifically that are part of University Geriatricians, I know they have robotic therapy pets, but how is that going, and how did that come about?

Carrie Dickinson, PhD: Within our ambulatory geriatricians' office, and I believe also in our TCU, we have, the availability of robotic therapy pets, and what those really are is if you imagine a cat or a dog at home, a normal pet that a person may have, you interact with that pet, you pet the cat, for example. The cat responds, meows, purrs, things like that.

But with the robotic pets, you don't have the worry of having to take care of the pet, to feed the pet, to change a litter box, to take the pet to the doctor's, to the veterinarian.

And it really helps the patients, that may have anxiety or really just to have some comfort and some interaction.

Host Amber Smith: So are these robotic pets that they bring home with them?

Carrie Dickinson, PhD: Yes, they do. It's a pet that they take home, and they keep the pet.

Host Amber Smith: Can you also describe how nursing has been collaborating with the pharmacy on behalf of patients who need help, maybe paying for their medications?

Carrie Dickinson, PhD: Sure, Amber. So, some of our patients may have some challenges paying for their medications. We do have a very helpful pharmacy department here at Upstate, and they have ways of looking for financing to help our patients pay for those medications that they need.

Host Amber Smith: This is Upstate's The Informed Patient podcast. I'm your host, Amber Smith, talking with Upstate's Quonitra Bullock, she's the nurse manager of the Transitional Care Unit, and Carrie Dickinson, the Operational Excellence Leader for Ambulatory Services Administration. They led a team that earned the age-friendly system designation for Upstate.

Mrs. Bullock, can you walk us through what was done to obtain this age-friendly designation?

Quonitra Bullock: Absolutely, Amber. Well, to start, we joined the HANYS webinars. HANYS offered webinars about age-friendly health care, speaking about some of the things other facilities in the surrounding areas were doing to be more age-friendly. And in attending some of those webinar series, we found that a lot of these things we are already doing, we're just not as organized and they were not defined as being age-friendly. And so what we did was we came back to our own smaller work groups, work team, and we started to discuss some of the things that we heard during those webinar series.

And we started to discuss some of the things that we were doing and some ideals of things that we could do to create a more age-friendly environment for our patients

One of the major things that we did as a committee was, we included a resident from the community who is 97 years old. She just recently celebrated 97 years of life. She is sharp as a whip, and she has provided us with a wealth of knowledge regarding what she, as an individual, felt was important for residents like herself.

And that is where we were able to look at the blanket warmer. That is where we started looking at making sure that in every room we had chairs with arms, because the elderly patient population could oftentimes get into a chair but would have trouble getting up from that chair.

She asked questions about devices on the unit, if we had things that would help amplify conversations for those that were a little more hard of hearing, but who were too embarrassed to say that they were hard of hearing, who sometimes would seem as if they may have been confused because of the way in which they answered a question.

So just really recognizing those little things that we could do to make this a better stay. When we spoke about pharmacy earlier, one of the major things that pharmacy did on the inpatient side was we began to offer a one-stop shop when it came to vaccinations. And so instead of just offering the flu and the pneumonia vaccine, which were very typical, very routine in the hospital, we began to make sure that we offered Tdap (tetanus, diphtheria and pertussis vaccine), shingles, COVID vaccinations, as well as the COVID booster. So we wanted to make sure that we gave them that, made it convenient, for the patients that we served, and we went from giving maybe 50 vaccinations prior to initiating this process to over 150 vaccinations right on the unit prior to discharge, which is a patient satisfier.

The robotic animals that we use on the unit, we currently have dogs and cats, and we do tend to use them more with those patients who fall under dementia or a delirium protocol. And it is really about providing them with a safe space for themselves and some level of comfort, so they pretty much function as emotional support animals, and we've been very successful in trying to help reorient and calm any anxieties that come to patients who may be experiencing dementia or delirium during their hospital stay.

I spoke about our average length of stay being approximately 12 days. Most of the time, actually 80% of the time, the patients that come into the TCU are discharged back to home, and we are very proud of that, and we want that number to continue to climb. That other 20% at times have to go to more of a longer-term, skilled nursing facility and/or some type of assisted living, but for the most part, our goal is to get people home, and we are really working hard to do that.

Our physical therapists are right on site. Our pharmacists are right on site. They're there for any questions nurses may have. We have recently updated our computer system to allow nursing to document all of the things that we are doing that are considered age-friendly for the patients that we serve.

So we're able to run reports to see how we're doing and looking at surveys and things as such to see how we are doing. And right now our patients are pretty happy with us, so I want to keep that momentum going.

Host Amber Smith: You mentioned HANYS -- I know that's the Hospital Association of New York. It sounds like being age-friendly means that you took the time to kind of look at things through the eyes of someone who's a senior at the surroundings and everything in the hospital environment.

Quonitra Bullock: Absolutely.

Host Amber Smith: Dr. Dickinson, what are the four M's for older adults? I saw that in one of the write-ups about age-friendly designation.

Carrie Dickinson, PhD:

The age-friendly health systems, the key that they talk about are the four M's, and those four M's are what matters, mentation, mobility and medication, and I'll give a brief description of what each of those are.

For what matters, we're really asking the patients, "What's important to you?" For example, maybe in the TCU the patient is there for rehabilitation; just understanding what matters to them every day. Or, you know what, I have a cat at home, and I want to make sure that my cat gets fed. So it could be some simple things like that for the what matters?

In terms of mentation, it's really looking at the patient's mood or memory, so in terms of looking at any screening for depression, dementia, delirium.

And then, mobility is making sure that the patient is, to the best of their ability, moving every day in a safe manner, right? Really being able to stay up and about.

And then, medication: If the patient is on medications, are those medications friendly from an age perspective? Oftentimes our senior patients may be on many medications, so looking at them as a whole to make sure that there's not a lot of interactions, do they need to be on those medications, things like that.

So, really looking at each of these four M's and really the four M's together, so that what matters to the patient, the other three M's are supporting that.

Host Amber Smith: I'd like to talk to both of you for advice that you would give to someone who needs to bring an older relative to the hospital.

Is there anything that they should bring along with them when they come?

Quonitra Bullock: I can answer from the TCU's perspective. One of the things that I think is really important for a family member of an older relative is to ensure that nursing is aware of things that support healthy living for that older adult. If you know that this person has an issue with, let's say for an example, they do not really like oatmeal. Like if that is something that's such a big deal, and nutrition is something that we are working on with that resident, we will want to know that about that resident.

I would also encourage family members to bring something that is very familiar, and that helps sometimes ease the anxiety, that absolutely helps with delirium, just having those familiar items, in their room. Because for a short period of time, we treat it almost as if it's a short-term home, and they are getting dressed every day to go to their therapies in street clothes. They're not wearing hospital gowns. So if you look up, and you see pictures of the family, that's natural to them, and that helps motivate them to get better and get home.

Host Amber Smith: Now what about things like hearing aids or CPAP machines that someone might use when they're sleeping, or even eyeglasses? People use these on a daily or regular basis, but can they bring them to the hospital?

Quonitra Bullock: Absolutely. We highly encourage those items are present with the patient. One thing: We really worry about those items, and so it's something that if you are a family member, bringing your relative who is in need of a CPAP machine, eyeglasses and/or hearing aid, that you make it known that that item is on site with that family member, so we are able to document for it and keep track of its whereabouts.

There are times where patients leave the unit for testing. They may leave the unit to go to another unit at times. And these are what we call life-safety type of items. We want to make sure that they have them, so that their stay is a pleasant stay.

Host Amber Smith: Are there ways in which senior patients are treated differently than other adult patients in a hospital stay?

Quonitra Bullock: For myself, and Carrie may want to jump in at some point, and I will speak from not only experience as the transitional care manager. In relation to personal experience, I think that is just recognizing that their senses are maybe a little more sensitive than someone who may be a little younger.

So maybe they are moving a little slower, maybe they cannot hear as well. Their vision is a little altered. Really taking the time to consider those factors when you are addressing any senior. They may not even share with you that they cannot see as well, due to embarrassment, or they don't want to feel like they are a burden.

Host Amber Smith: So, I'm imagining maybe their room would be put at the end of the hall where maybe it's quieter, or there's less commotion around. Or even thinking about foods, if they need something that's soft to chew, perhaps the menu is adaptable for that?

Quonitra Bullock: The menu is adaptable. As far as room placement, we really look at the overall safety of a patient as an individual.

So we do not look at that as "everyone in this age group needs to be in this certain room type." A lot of times when you're dealing with a patient who is suffering from delirium or dementia, it's best to keep them closer to points of highlight visual contact -- you know, nurses are easily able to peek in and just make sure that they're OK. Unless we feel that that additional stimulation is causing a problem for that particular patient or resident.

Host Amber Smith: Now, Dr. Dickinson, it seems to me that the age-friendly health system designation is important, and it's only going to become even more important in anticipation of the aging population.

Do you have projections for the numbers of seniors in America that are projected to come in the years ahead?

Carrie Dickinson, PhD: Yes, Amber, that's a great question. So according to the U.S. Census Bureau, our last census in 2020, there are about 50 million individuals 65 years and older. And they estimate in the year 2050, so about 30 years, 83 million people, aged 65 and older, so a significant increase in the next 30 years.

Host Amber Smith: Well, I want to thank both of you for taking time for this interview.

Quonitra Bullock: Thank you, Amber, for having us.

Carrie Dickinson, PhD: Yes, thank you very much, Amber. It's been a pleasure.

Host Amber Smith: My guests have been Quonitra Bullock, nurse manager of the Transitional Care Unit, and Carrie Dickinson, the operational excellence leader for ambulatory services administration at Upstate. They were the co-leaders of the team that earned the age-friendly system designation for Upstate.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.