Our health and social systems are ill-equipped to meet the needs of the growing population of older adults with chronic conditions and their family caregivers. We are living longer, but are we living better? A new invitational “Think Tank,” led by Mary Naylor, PhD, RN and Nancy Hodgson, PhD, RN and sponsored by Penn’s School of Nursing, is looking to address these needs through the leadership and skills of the largest and most trusted segment of the health care workforce: nurses.

For the past few months, a multidisciplinary group of about 50 experts has been teleconferencing to prepare for a day and a half meeting on May 2-3, 2018. After a public event at 9:00 am on May 2, they will convene for closed sessions to develop actionable recommendations.

In this blog post, we peek behind the curtain to highlight the deliberations of the Think Tank prior to the meeting. Three workgroups were tasked with identifying “Big Ideas” that could use the talents and skills of nurses to promote the health and quality of life of vulnerable older adults, while making the most of increasingly finite resources. In keeping with the design thinking process, the Think Tank also conducted two focus groups with community-dwelling older adults to understand their goals and ascertain their needs, and to get feedback on potential recommendations.

Advancing innovation

The group has considered the kinds of innovations that would bridge gaps at different levels, between chronically ill older adults and their family caregivers, their health data, and social and community services. At the home/bedside, a nurse could directly provide the services and supports needed, or facilitate connections by using other caregivers and technology. Within a learning health system level, nurses trained in informatics could help develop systems to identify and prevent the consequences of social isolation through better use of data.  And in the community, nurses could use their position as capable and trusted health professionals to sustain and scale evidence-based interventions to leverage existing resources.

Promoting person-centered care

Another workgroup focused on ways to partner with older adults to co-design a more seamless care system that places the person at its center. Strategies include ways to provide people with access to their own data, to elicit and use preferences in care planning, to help make transparent the costs and benefits of treatment options, and to advocate for person-directed outcome measures and incentives. The group stated its goal directly: to capture what matters most to patients, and to measure whether their objectives for care are being met.

The group has considered how to leverage the role of nurses as providers, leaders, and advocates toward this goal. As providers, nurses can help older adults navigate and act on health data. As leaders, they can provide a much-need “voice at the table” for person-centered care as health systems and payers make decisions. And as advocates, nurses can create or participate in community coalitions at local and national levels to accelerate the pace of change.

Implementing proven care models

The third workgroup took on the challenge of accelerating widespread implementation of proven, cost-effective care models that promote high value, seamless care for older adults and maximize the contributions of nurses. They examined the barriers to uptake and scaling of such models, focusing on concrete steps to advance the adoption and adaptation of proven models of care.

The group has discussed the potential utility of partnerships between care model architects and health systems or communities, the need to involve public and private payers and employers, and the opportunity to engage the proprietary sector. As change agents, nurses are well-positioned to develop targeted information on proven care models to key stakeholders, to promote metrics that “measure what matters,” and advance the national dialogue on care models that address what older adults want from their care.

Focus groups and next steps

The two focus groups were instructive and set the stage for the Think Tank’s upcoming meeting. Overall, participants stressed that their health concerns were just a small part of who they are; their primary goals centered around quality of life, emotional well-being, and the need for social connections. Nurses were seen as trusted providers who “get it” and can see the big picture of older adults’ lives. In response to some of these preliminary recommendations, participants were open to new technologies that could reduce social isolation, interested in telehealth to overcome mobility limitations, and eager to seek care from advanced practice nurses who could help them manage their chronic conditions.

The Think Tank will consider and refine workgroup recommendations at its in-person meeting, and lay the groundwork for subsequent implementation efforts. In effect, the meeting is the start of a conversation, rather than a conclusion, about ways to “move the needle” on high value care for older adults with chronic conditions. For each recommendation, the Think Tank will define the goal (with a compelling rationale), identify target audiences (who benefits and who implements), lay out a reasonable time frame, delineate measures of success, and develop milestones for monitoring progress. The work is just beginning.