LeadingAge Magazine · May-June 2019 • Volume 09 • Number 03

Residents Living Their Best Lives

May 20, 2019 | by Gene Mitchell

This provider is working to align its work with the values and preferences of residents and clients—an effort that has also given its constituent parts a common purpose.

In aging services, the growing emphasis on person-centeredness has made dramatic inroads into the way LeadingAge members operate and serve their residents and clients. A prerequisite for meeting that challenge is gaining a real understanding of what the person at the center needs and wants—or what matters most to the person.

One LeadingAge member, Boston-based Hebrew SeniorLife (HSL), which is affiliated with Harvard Medical School, has made an organization-wide commitment to do just that, shifting from asking “what’s the matter” to "what matters most.”

HSL’s program was partly inspired by a broader effort in Massachusetts, which it has joined, to encourage adults of all ages to communicate their wishes regarding medical decisions at all stages of life and points of care, with an emphasis on end-of-life care.

The Massachusetts Coalition for Serious Illness Care

In Massachusetts, recent surveys have demonstrated what many health care professionals know all too well: that most people have never made known their wishes regarding end-of-life care to those who would most need that information.

Surveys by research firm SSRS and the University of Massachusetts Medical School, performed in 2016, 2017, and 2018, included interviews with hundreds of Massachusetts residents aged 18 and older. Participants were asked if they had discussed their wishes regarding who would make medical decisions for them if they became seriously ill. Even among older adults with serious health conditions—the group most likely to have made their wishes known—barely more than 1 in 4 of those surveyed had ever had such conversations with doctors or family members.

The Massachusetts Coalition for Serious Illness Care is dedicated to ensuring that more Bay State residents think about their own wishes and make those preferences known. The organization, first organized by Blue Cross Blue Shield of Massachusetts, says its mission is “to ensure that health care for everyone in Massachusetts is in accordance with their goals, values, and preferences at all stages of life and in all steps of their care.”

Getting to What Matters Most

LeadingAge spoke with 3 representatives of Orchard Cove, a life plan community in Canton, MA, that is part of the Hebrew SeniorLife system: Aline Russotto, executive director; Susan Flashner-Fineman, Vitalize 360 master coach; and Dr. Jennifer Brinkerhoff, medical director.

Orchard Cove photo
Photo courtesy of Hebrew SeniorLife.

 

Much of this interview was done at the 2018 LeadingAge Annual Meeting & EXPO in Philadelphia, where Russotto, Flashner-Fineman, and Brinkerhoff presented an education session on their program.

LeadingAge: Why was the Massachusetts Coalition for Serious Illness Care created, and how did you get involved?

Aline Russotto: Massachusetts spends a lot of energy and resources on innovation in health care. We have 2 outstanding leaders who live here: Dr. Maureen Bisognano [president emerita and senior fellow at the Institute for Healthcare Improvement], and Dr. Atul Gawande, a renowned physician, author, and teacher. They came together in 2016 to launch the coalition. Its framework was inspired by the coalition that eradicated polio in the United States: a group of organizations came together to rally around a common goal, eradicating polio, with each trying to reach the goal following different paths, learning from each other, and measuring outcomes.

The coalition has an overall goal of aligning the delivery of care with values and preferences at all stages of life and in all points of care. To do so, it offers a roadmap to members, with 6 goals:

  • That everyone over 18 in Massachusetts has completed a health care proxy.
  • That everyone has had a conversation with their health care agent about what matters most to them.
  • That everyone has had the same talk with their physician.
  • That physicians are trained in asking the right questions and documenting wishes.
  • That systems are in place to make sure wishes are respected and that care is aligned with wishes at all points
  • That preferences can be shared across settings.

There are now 100-plus organizations that have joined the coalition, from small organizations to large hospital systems.

Editor’s note: a breakdown of the 6 goals is available at the coalition website.

LeadingAge: What role does Hebrew SeniorLife (HSL) play in this and why does it resonate with you?

Aline Russotto: LeadingAge Massachusetts received a call from Dr. Gawande, asking it to become a member of the coalition. Of course it immediately said yes. Who would say no to Dr. Gawande? HSL became a member, therefore, through its membership in LeadingAge. Because resident-directed care is such an important part of HSL’s mission, the proposed work of the coalition really resonated with us. We decided to make our own commitment to the coalition and became a strategic partner.

LeadingAge: What is HSL doing?

Aline Russotto: We’ve actually followed the framework of the coalition. We are dedicated to rethinking, researching, and redefining the possibilities of aging. We serve over 3,000 older adults daily through long-term care, subsidized housing, home and community-based services, assisted living, and 2 life plan communities. We also conduct research into aging, and provide education for geriatric care providers.

Instead of having an organization-wide approach to achieving the goal of the coalition, we decided that each entity within our organization would each find its own way of contributing to the greater goals of the coalition, and that together we’d learn from each other and measure outcomes. This allowed the work of each part of the organization to align its contributions with its own priorities.

We now have 9 active pilots across our organization. Our work is intended to impact the residents, patients, families, and staff we serve. What’s been most fascinating is to see how it has brought this multifaceted and multi-site organization together in a new way. The different parts today have a common project to work toward together.

LeadingAge: What do you mean when you say you are “getting to what matters most” to the people you serve, and how does Vitalize 360 fit into that goal?

Susan Flashner-Fineman: Vitalize 360 is a program that originated at Orchard Cove and has since been further developed through a partnership between Kendal Corporation and HSL. We now have more than 30 organizations across the country that take part in the program, which is very exciting. The intention of Vitalize 360 is for each participant to live their best life by articulating what matters most to them, by developing a plan to achieve what’s important to them, and supporting them in achieving goals. The program uses a coaching model combined with a scientific foundation. Once participants know what’s important to them, coaches and entire communities can be shaped differently, and care provided can align with those values and preferences.

LeadingAge: Can you give examples of the kinds of things residents articulate about what matters most to them?

Susan Flashner-Fineman: Esther, one of our residents, moved in about 5 years ago. Her life-long passion has been teaching. She has a particular interest in teaching Hebrew and other topics related to Judaism. Through teaching in a few of these areas, she found a particular niche in Yiddish and Yiddish culture. Her classes are now well-attended by about 30 residents, who meet twice a month.

Esther also has a passion for working with residents on the skilled nursing floor, and she wasn’t sure how to move that forward. After learning what mattered most to some of the residents on that floor, she began a Jewish literature class and a Jewish holiday class which she continues to this day.

Sally is another example. She moved into Orchard Cove about 2 years ago and had always filled her life with 2 areas that brought out her passions: music and art. Particularly in art, she says, “I don’t just want to take an art class. I want to continue to do art at a very high level and find some new methodologies in art. I also want to mentor someone in art.” She was able to find a class where she learned new art modalities, which she brought back to Orchard Cove. She developed a group of residents who work with her; in fact, she mentors one resident who also mentors her, so it’s working in a beautiful way.

Aline Russotto: What’s fascinating to me in this work is how easily we all agree that the care we deliver or receive should be aligned with values and preferences. It makes sense. And, through this work, I’ve realized how hard it can be to articulate what’s most important in our lives, and what our values and preferences are. As senior living providers, we have a chance to change that, learning how to have a conversation about values and preferences and remembering to start conversations by asking the question of “what matters most.”

Vitalize 360 and the coaching process gives us that moment we can pause, step back, and think about what’s important in life. The reality is that we all have very different things that matter the most in our lives. This practice of learning how to ask the question, and helping every stakeholder get to that essence of values and preferences, is so important. As for our field, once we know what’s most important to a person or a group that we serve, it is our responsibility to make sure that all of our services and care are aligned to match it.

LeadingAge: Once a statement of what matters most is completed, what happens next?

Susan Flashner-Fineman: Vitalize 360 is supported by a team of specialists—an interdisciplinary team that includes Dr. Brinkerhoff, our fitness staff, programming, resident services, social work, and chaplaincy, to name a few. Each learns about what matters most for the resident, and what their goals are. Together the team discusses ways we can support the resident in achieving those goals. Most often residents feel empowered to achieve their goals on their own, yet will turn to us to help with some of them. It takes a team to make Vitalize 360 successful.

Aline Russotto: From a community perspective, what is fantastic is the opportunity for us to allocate resources differently to provide programs and services that are really aligned to what is important to our residents. And, Dr. Brinkerhoff has this incredible opportunity to realign the delivery of care to match those preferences.

Jennifer Brinckerhoff: In health care delivery specifically, knowing what matters most to the patient really shifts the conversation from the treatment of medical illness to the treatment of the entire person. As a physician, you go from someone just trying to fix problems to someone supporting the whole person. This background affects every level of decision-making, from daily care assistance to medication use, treatments, and specialist referrals. It strengthens the relationship and boosts provision of high-quality care when the provider knows what matters most to each patient.

LeadingAge: Why is coaching so important to this, and how do you develop coaching skills in staff?

Susan Flashner-Fineman: Coaching is the opportunity for the participant to develop a relationship based on trust. Through the coaching relationship, the conversation becomes real and meaningful; the coach can really hear what’s important to the participant and help articulate it. We offer coaches within our own community, and in collaboration with other Vitalize 360 organizations, to become part of the coaching training. The 3-day training focuses on how to build coaching skills, learn how to ask the right questions, and how to build a culture that embraces the power of aligning services and care to what matters most.

LeadingAge: What do you mean by the term “mountain climbing”?

Jennifer Brinckerhoff: It’s a pictorial representation of how the complexity of medical care tends to increase as a person ages. In the later decades of life, it is common to find the number of medical issues growing; in fact, a person can expect to add one new medical diagnosis per decade after they hit 40. This often means multiple specialists and multiple medications by the time a person reaches 80 or 90.

At the top of the mountain, where the medical complexity can often be highest, trade-offs across many conditions and treatments become a necessary part of managing care. Our goal is to line up what matters most to an older adult while still providing safe, high-quality care. And it is entirely possible to make these types of health care decisions from an early age, thus avoiding the “mountain climbing” altogether—or at least reducing the slope of the mountain.

LeadingAge: What outcomes have you seen from these efforts? In other words, how do you measure success?

Aline Russotto: HSL’s Hinda and Arthur Marcus Institute for Aging Research provides outcomes management as part of our program. People who participate in Vitalize 360, meaning people who set and are supported in achieving goals, and for whom health care is aligned with what matters most to them, have reported a significant increase in self-reported satisfaction in life. We ask them, “How delighted are you in your life as a whole?” We’ve also seen that many older adults report satisfaction with their overall health. Also, as part of our work with the coalition, we’ve significantly increased the number of residents who have designated a health care proxy, and who are beginning conversations with their family members and doctors about what’s important to them.

Jennifer Brinckerhoff: Success in this program can be seen at all levels. It’s a shift, noticeable in the responses and conversations we have with our residents. Asking “what matters most” instead of “how are you,” for example, adds depth to the conversation. You get to know the people you’re talking to, you know their story, and you can be responsive to that.

The conversations regarding what matters most strengthens the community scaffolding of support. It makes a significant difference when the health system, the entire community, and staff recognize that older individuals vary in what matters most to them and collectively set out daily to meet those needs.

LeadingAge: What is the starting point for other providers who might want to try a program like this?

Aline Russotto: It’s the humbleness of remembering that we often forget to ask the question. If we don’t ask what is important to our residents, we cannot assume we’re doing our best to provide the most supportive environments and care. It’s learning how to ask, remembering to ask, and knowing what to do with the information. Maybe it’s just normalizing the conversation.

If we follow the vision that Bisognano and Gawande have set out, this conversation begins by the age of 18, if not before. Don’t wait until there is a problem to be fixed or something is broken. It’s really an aspiration to learn how to be good listeners and ask the right questions.

This topic has become part of the fabric of who we are at HSL. People really enjoy talking about what’s meaningful to them, and as Dr. Gawande asks, “what makes life worth living?” When we embarked on this, people would say, “I’m OK, I have all my affairs in order. I have a health care proxy.” But the more we talk about this topic, the more people have realized they might have their affairs in order, and that might be pretty easy, but what’s not easy is to start this meaningful conversation about what matters most and think about what makes their lives worth living.

Part of the success we see is that the more we talk about it, the easier it becomes to talk about it, and the easier it is to shape care and services to it.

Editor’s note: Susan Flashner-Fineman is featured in one of LeadingAge’s Aging Unmasked podcasts, which includes other Vitalize 360 coaches.

Gene Mitchell is editor of LeadingAge magazine.