In 2022, Heyi Li, MD, assistant professor in the division of pulmonary medicine at Montefiore Einstein, had a procedure that required sedation. “I'm a person who can’t see anything if I don't have my eyeglasses,” says Dr. Li. “Waking up in the recovery area, in a totally different room, was quite stressful. I had never thought about this in my role as a doctor. From the patient's perspective, it can feel very confusing.”

Heyi Li, MD

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This experience gave Dr. Li, an otherwise healthy 30-something, a palpable sense of what many older adults face during a hospital stay, especially in the intensive care unit, which is where she cares for patients as a critical care physician. “These patients are so vulnerable,” she says. “We as care providers need to really be proactive and identify their needs, because they may not be able to tell us themselves. That's our goal.”

Dr. Li is among the dozens of physicians, nurses, and leaders who have attained an important milestone in ICU care at Montefiore Einstein. The ICUs at Moses and Wakefield hospitals have now been officially designated as “Age-Friendly” by the Institute for Healthcare Improvement (IHI), a nonprofit that supports healthcare organizations worldwide in implementing scientifically based, quality improvement practices.

“Critical illness—being on a ventilator, under sedation, having their day-night cycle completely disrupted because of necessary monitoring—these are all particularly disruptive to our older patients and put them at risk for delirium, for falls, for getting weaker,” explains Michelle Ng Gong, MD, professor and chief of the divisions of critical care and pulmonary medicine. “It's a particularly big issue in the ICU. And it requires a multidisciplinary approach.”

Age-friendly care as defined by the IHI must address four components that it has dubbed the four M’s: mentation, or a patient’s mental awareness; mobility, or a patient’s ability to move; medication, which means taking into account a patient’s age when prescribing medications; and what matters, which means finding out from the patient and their family what is most important to them in regard to their health and course of treatment.

With the number of people in the U.S. over age 65 expected to nearly double between 2010 and 2050, to over 83 million people, providing age-friendly care is an increasing priority for health systems nationwide. One sign of this is new age-related quality measures recently mandated by the Centers for Medicare and Medicaid Services (CMS), one of the federal agencies that governs healthcare safety and effectiveness.

In terms of the care provided in Montefiore Einstein’s ICUs, the good news was that we were well ahead of the curve. Melba Garcia, BSN, MA, nurse manager for the ICU at Moses Hospital, oversees a team of 40 nurses who are the main engines of providing age-friendly care at the bedside there. “The more we learned about the IHI designation,” Garcia says, “the more we realized how much we were already doing right.”

Part of a wider effort

In 2023 Montefiore Einstein launched a multidisciplinary Age-Friendly Governance Committee and Learning Collaborative, led by the division of geriatrics under chief Amy Ehrlich, MD, professor of medicine, and Allison Stark, MD, vice president and chief medical officer, Montefiore Care Management Organization and Office of Community and Population Health, and an associate professor in the division of geriatrics. Montefiore Einstein also joined the Healthcare Association of New York State (HANYS) Age-Friendly cohort, a statewide group of hospitals and health systems. Dr. Ehrlich and Dr. Stark obtained funding from the Fan Fox and Leslie R. Samuels Foundation to create a project director role for the Age-Friendly care initiative throughout Montefiore Einstein. Rachel Brody, RN, MSN, also an assistant director of nursing, took on that role in August.

With the ultimate goal of obtaining a new system-wide IHI Age-Friendly designation, “We've been going for the ripple effect,” explains Dr. Ehrlich. “We started with people who were engaged and interested in this work. We found a core group in our ICUs that wanted to work with us.”

“Both the recent designation and our committee’s future work are building on a strong foundation,” adds Dr. Stark. “The IHI criteria pull it together into a framework and make sure that we're really hitting on each and every age-friendly area, and doing it in a coordinated way.”

Members of the Wakefield Hospital ICU team.

Developing new standards of care

One of those core people is Dr. Li. Based on her own experience of waking up in the recovery room without her eyeglasses, and at the suggestion of her mentor, Dr. Gong, she has been working to ensure patients get their glasses, as well as hearing aids, walkers, and other assistive devices. “You just cannot take good care of your patients if they cannot hear you or see you,” she says. When a patient has their glasses with them, this can be as simple as placing them on the patient’s face when they wake up, without the patient having to ask. Dr. Li has been leading this effort at Wakefield, enlisting the support of nursing staff.

She recounts the story of one patient who had woken up from being intubated. “We thought she was delirious because she wasn’t making sense. And then we realized that she was actually very nearsighted, and also someone who spends a lot of time reading at home. The nurses got her eyeglasses on, and all of a sudden she just looked like a different person.”

The Wakefield ICU’s effort around assistive devices goes above and beyond what’s required for IHI Age-Friendly status. It’s one of a number of examples of how Montefiore Einstein is in the vanguard when it comes to providing best-in-class care for our older patients.

Another example is the white boards developed by the Wakefield ICU team, led by Daniel Fein, MD, director of intensive care at Wakefield. While it’s common to have white boards where providers can make notes about a patient’s condition, the new boards instead display a patient’s hobbies, interests, what kind of music they like, and other personal information.

“We want any provider walking into the room to be able to look at the board and immediately get a sense of the patient as a person,” says Dr. Li. “Initially I wanted to call it the ‘get to know me’ board, because that's what it's about.” The boards have been such a success at the Wakefield campus that they are also being rolled out at the Moses and Weiler Hospital ICUs.

Making the 4Ms a bedrock of care

Dr. Gong’s research includes studies on the how early mobilization of patients in the ICU improves outcomes. Montefiore Einstein was an early adopter of ensuring that even patients who are intubated receive passive movement with the help of nurses and physical therapists. Sheryl Levine, MD,  director of the physical medicine and rehabilitation consult service, has been an instrumental collaborator and has led efforts to train nursing staff and physical therapists. Every patient, regardless of how sick they are, gets a movement goal every day, along with support to ensure those goals are met.

Older adults are more likely than others to have multiple medications, and because as people age their bodies metabolize medications differently, there are also different considerations when prescribing. This holds especially true for medications commonly given in the ICU. Claudene George, MD, MS, PharmD, is leading a system-wide effort to develop a “geriatric context” in Epic, that would help guide physicians in selecting age-appropriate medications. When it’s rolled out, clinicians in both the hospital and ambulatory settings will see only appropriate medications based on their patient’s date of birth.

The ICU’s have long done delirium screenings twice daily for patients, in line with the IHI recommendations. As part of the IHI designation, part of the standard of care in the ICU is also making sure to talk with the patient and their family about what matters most to them. “Now this is part of our history taking and physical exam, speaking with the patient, if they are able, or with the family,” says Ari Moskowitz, MD, director of the medical intensive care unit at the Moses campus. “The physician is prompted to ask about what matters most in the guides we’ve created, and the answers become part of the patient’s record.”

The committee led by Dr. Ehrlich and Dr. Stark is getting ready to roll out an Age-Friendly dashboard that will allow locations to track their progress in addressing the 4Ms. It’s also part of obtaining the next level of IHI recognition. “The second level is to be able to share data about the population that you serve,” says Dr. Ehrlich. This in turn contributes to continuous improvement efforts nationwide.

The ICU physicians and nurses will be leading the way in knowledge sharing and teaching providers in other areas of the hospital. Brody is also working with senior nursing leadership on the hospital-wide rollout, including developing strategies for education. In another area of focus, the Age-Friendly team will be working with Montefiore Medical Group to meet IHI recommendations in the ambulatory setting.

“Combined with the new CMS goals, our current momentum on this will continue to propel us forward,” says Dr. Stark. “It’s a big win for everyone, especially our older patients.”