Using The 4Ms Framework To Teach Geriatric Competencies In .

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Received: 12 July 2020 Revised: 15 August 2020 Accepted: 9 September 2020DOI: 10.1111/nuf.12511GENERAL ARTICLEUsing the 4Ms framework to teach geriatric competencies in acommunity clinical experienceMargaret Avallone DNP, RN, CCRN‐K, CNE1Staci Pacetti PharmD11Rutgers University School of Nursing‐Camden, Camden, New Jersey, USA Elyse Perweiler MA, MPP, RN2 Abstract2Background: As the population of older adults in the US steadily increases andDepartment of Geriatrics and Gerontology,Rowan School of Osteopathic Medicine,Stratford, New Jersey, USAbecomes more diverse, there is an urgent need to integrate geriatric competenciesinto baccalaureate nursing education.CorrespondencePurpose: To integrate the Institute for Healthcare Improvement 4 Ms FrameworkMargaret Avallone, DNP, RN, CCRN‐K, CNE,Rutgers University‐Camden, 530 Federal St.,Camden, NJ 08102.Email: Margaret.avallone@rutgers.eduinto an existing baccalaureate nursing community clinical experience to build geriatric and interprofessional competencies and promote positive health outcomes.Methods: As part of the Geriatric Workforce Enhancement Program, 15 studentsFunding informationworked with bilingual social workers and community health workers in an afford-Health Resources and ServicesAdministration, Grant/Award Numbers:T1MHP39061, U1QHP28714able housing urban highrise, assessed building residents and implemented personalized plans of care using the 4Ms framework (what matters to the individual,medications, mentation, and mobility).Results: Students demonstrated competence conducting cognition and depressionscreening, medication review, and functional and fall risk assessments. Studentself‐rated achievement of learning objectives ranged from 4.3 to 4.8 (1–5 scale).A retrospective pretest–posttest survey suggested learning about the importance ofinterprofessional teamwork, and integration of person‐centered values whenproviding care to older adults in the community. Students reflected on barriers tohealth for older adults in low socioeconomic states and the importance of improvingcare across the continuum.Conclusion: The 4Ms framework provided a valuable construct to guide thecommunity experience and teach geriatric evidence‐based practice to nursingstudents.KEYWORDS4Ms framework, geriatrics, nursing student‐baccalaureate, older adults, social determinants ofhealth1 INTRODUCTIONand related dementias, hypertension, heart disease, diabetes, osteoarthritis, and chronic obstructive pulmonary disease.4,5 Chronic diseasesThe emerging healthcare workforce must be educated to care for ancan limit one's mobility and independence, causing significant financialincreasingly older and diverse population.1,2 By 2030, it is projected thatand care burdens and result in frequent hospitalizations.6378 million seniors will be over the age of 65. Older adults experienceThe older population is not only growing, but is becoming in-higher percentages of chronic conditions including Alzheimer's diseasecreasingly more racially and ethnically diverse. Racial and ethnicNursing Forum. 2020;1– 2020 Wiley Periodicals LLC 1

2 AVALLONEminorities comprise 22% of the older adult population, and the3 ET AL.DE SC RIPTION OF P ROJ E C Tpercentage is projected to increase to 28% by 2030.7 Rates ofpoverty are more than doubled in Hispanic and Black/AfricanThe reconfigured community clinical experience was part of the NewAmerican populations over the age of 65 compared with the WhiteJersey (NJ) Geriatric Workforce Enhancement Program (NJGWEP), apopulation of the same age group.7 Socioeconomic disparities in the5‐year grant supported by the Department of Health and Humanolder diverse adult population increase the risk for poor healthServices‐Health Resources and Services Administration, the goal ofoutcomes and increase healthcare needs with age.8which is to “develop a healthcare workforce that integrates geriatricsNursing graduates must be educationally prepared to close gapsinto primary care and maximizes patient/family engagement.”13 Thein quality healthcare that exist for older adults in low income andIHI 4Ms framework provided the model to reconfigure the existingdiverse communities. Clinical experiences linking educational objec-community clinical experience.tives with services intended to benefit the community heightenThe NJ Institute for Successful Aging at Rowan School ofawareness of social justice and appreciation for the impact that so-Osteopathic Medicine, Fairshare Support Services, Inc. at Northgatecial determinants play on the health of a population.9,10 Clinical ex-II Housing development, and the Rutgers School of Nursing‐Camdenperiences that provide opportunities to work in interprofessionalwere established academic‐practice partners for several years beforeteams and learn evidence‐based care for older adults may helpthe fall of 2019. However, the decision was made to strengthen theprepare the future workforce for the populations they will serve.learning experience for students and improve outcomes for olderThe purpose of the project was to integrate the Institute foradults by integrating the 4Ms framework into the clinical experience.Healthcare Improvement (IHI) Age‐friendly 4Ms framework into anAn interprofessional planning team, with representatives from theexisting baccalaureate nursing community clinical experience toNJ Institute for Successful Aging, the Rutgers School of Nursing‐build geriatric and interprofessional competencies and promote po-Camden and Fairshare Support Services met during the summer ofsitive health outcomes within a high‐risk older community.11 The2019 to redesign the clinical experience. This redesign included re-early experience using this learning strategy and initial studentvisions to the clinical learning objectives, the weekly interprofes-outcomes are described. Preliminary plans to continue learningsional case presentation format, orientation plans for student andwithin a coronavirus disease 2019 (COVID‐19) environment are alsostaff, as well as processes for student evaluation. Finally, a retro-discussed. Specific resident health outcomes will be the subject ofspective pretest–posttest evaluation of change in knowledge surveyadditional publications.was developed with team input, based on desired end‐of‐rotationlearning outcomes. A retrospective pretest–posttest survey designhas benefits in program evaluation because it allows participants to2 AGE ‐FRIENDLY 4MS F RAMEWORKreflect on changes in knowledge or skills that occurred over theevaluation period. In a retrospective pretest–posttest survey, parti-The IHI Age‐Friendly 4Ms framework is based on principles of age‐cipants rate their status using the same frame of reference andfriendly health systems and communities.11 The model was derivedtherefore reduce the tendency to over‐rate their competence orfrom research, evidence‐based geriatric models, and recommenda-knowledge at the beginning of a program.14 IRB approval was ob-tions from geriatric specialists. It gives healthcare providers, systems,tained for this quality improvement project.and communities a roadmap when addressing gaps in care for olderadults across the continuum of care. The 4Ms framework may be oneconstruct to guide curricular initiatives and clinical experiences when3.1 Settingteaching optimal care for older adults. The four components of themodel include: what matters, mobility, medications, and mentation.11Northgate II, a 23‐story highrise building with 308 apartments,served as the setting of the redesigned interprofessional clinical(1) What matters: involves knowing and acting on each older per-learning experience. Northgate II is part of the Fairshare Housing, ason's specific health outcome goals and care preferences to501(C)(3) nonprofit organization, providing affordable housing forprovide true person‐centered care.residents in the city of Camden, NJ. Fairshare Support Inc. provides(2) Mobility: healthcare providers “help older adults move safelysocial and wellness services for 340 residents of Northgate IIevery day to maintain function and do what matters, and preventHousing, The residents are predominantly Hispanic in origin (65%) orcomplications of falls and immobility”.12Black (29%), disabled, and older. Thirty‐three percent (33%) of the(3) Medications: when possible, healthcare providers should opti-residents are aged 55–64 and another 32% are over the age of 65.13mize the use of medications to reduce harm and burden, focusingOverall, the city of Camden, NJ is one of the poorest cities in theon medications that will not adversely affect mobility, mentationUnited States. The percentage of persons living at or below 100% ofor what matters.the federal poverty level in the city of Camden is 40.9%, as compared(4) Mentation: efforts are made to prevent, identify, treat, andmanage delirium, depression, and a 13.5% poverty rate throughout other cities in the UnitedStates.15

AVALLONE ET AL.The Rutgers School of Nursing‐Camden is located less than33.2.2 Clinical structureone mile from the Northgate II Housing Development. Theschool's curriculum reflects a commitment to educating studentsAfter successful completion of all orientation requirements, nursingon the specific issues and challenges facing underserved com-students were paired with bilingual social service staff for weeklymunities of disadvantaged backgrounds.home visits for the remainder of the seven‐week clinical experience.The social service staff, comprised of social workers and communityhealth workers, have established rapport with the building residents. Clinical experience3.2They are also knowledgeable about the availability of socialresources within the community to assist in meeting the needs ofDuring fall 2019 and the first half of Spring 2020, 15 senior nursingresidents with socioeconomic complexity and cultural diversity. Thestudentsparticipated in the redesigned experiential learning opportu-addition of the nursing students, with support from doctor of nursingnity, joining an interprofessional team of social workers, communitypractice faculty and a doctor of pharmacy faculty member, providedhealth workers, nursing faculty, and a doctor of pharmacy (PharmD) atnursingthe Northgate housing development. This redesigned interprofessionalplanning, health promotion, disease management, and medicationexperience was one clinical option for students enrolled in the entandcaremunity Health Nursing and Global Health course. Students are si-Teams made scheduled visits to resident apartments and usedmultaneously enrolled in an Aging in Healthcare course. Each studentthe RHRA to develop individualized, resident‐centered plans of care.participated in a 7‐week rotation at Northgate Housing, 1 day per weekResident visits were prioritized for those recently discharged fromfor seven weeks. The rotation was canceled for the second half of theinpatient facilities, older residents with two or more chronic diseases,Spring 2020 cohort due to the COVID‐19 pandemic.and individuals with potential safety or fall risk concerns. Follow‐upvisits were structured around the 4Ms framework and helped residents develop strategies to successfully age in place, based on in-3.2.1 Orientationdividual healthcare goals.On the first day of clinical, students received a comprehensive orientation provided by School of Nursing Faculty, Fairshare Support3.2.3 What mattersServices staff, and faculty from the NJ Institute for Successful Aging.Orientation topics included the 4Ms framework, healthy aging con-At the beginning of each health assessment interview, the nursingcepts, cultural considerations when making home visits, and inter-students sought to establish rapport with residents. The teams de-viewing techniques using an interpreter. Medication issues in theveloped individual goals and person‐centered care plans with theolder adults, functional assessment and fall risk assessment in theresidents, by first, identifying “what matters” to the individual. “Whathome were also presented to students. A refresher on dementia andmatters” formed the basis of the subsequent interviews and caredepression in older adults was provided as well as part of orientation.planning. For example, one resident identified that “what mattered”Students were assigned a module from the Centers for Diseaseto her was the ability to attend her place of worship. Due to mobilityControl (CDC) entitled Stopping Elderly Accidents, Deaths, and In-issues and lack of transportation, she was unable to leave herjuries (STEADI) Older Adult Fall Prevention Online Training forapartment. The team worked to remove barriers to her mobility andProviders before the beginning of the clinical experience.16worship attendance by obtaining prescriptions for a walker and forLearners were familiarized with all components of a resident healthrisk assessment (RHRA) form. This assessment tool, developed by the NJhome physical therapy, and arranging transportation to worshipservices with church members.Institute for Successful Aging in collaboration with its NJGWEP partners,Many older adults identify that aging in their home “matters”was structured using the 4Ms framework. The assessment was used tomost to them. When the team demonstrated their shared goal toobtain information on building residents regarding basic health and socialpromote aging in place, they built trust with residents and workedhistory, medication use and knowledge, functional assessments, menta-jointly to problem solve. Aging in place also means optimizing health,tion screening and what mattered to the individual, contributing to de-providing needed services and preventing hospitalizations. The stu-velopment of a person‐centered plan of care. Students were alsodents supported this goal when teaching about disease management,educated and evaluated on their ability to accurately administer andmedications, and home safety.score the Minicog screening for cognitive impairment in older adults. Thisinstrument takes about three minutes to administer and is part of aholistic memory screen and evaluation.17,18 To evaluate student com-3.2.4 Mentationpetency performing this assessment, students administered the Minicogto a family member or a friend, scored the assessment, and then up-The Minicog screening was incorporated into the RHRA during homeloaded the video and scoring sheet to the course learning managementvisits. Residents who screened positive for dementia were referredsystem. Faculty then provided constructive feedback to an Interprofessional Memory Assessment Program for further

4 AVALLONEET AL.evaluation and treatment, if necessary. Residents were also screenedstructured using the 4Ms framework. Using the 4Ms framework forfor depression using the patient health questionnaire (PHQ‐2) asinterprofessional communication helped all team members plan carepart of a mentation and mood assessment.19 If residents screenedin a more organized fashion and also provided necessary structurepositive in the PHQ‐2, additional follow‐up was provided by thefor student learning. The team conferencing provided a forum forsocial work staff as warranted.problem‐solving, interprofessional education, and learning amongdisciplines.To enhance learning and promote critical thinking during the3.2.5 Medicationsexperience, students completed weekly semi‐structured reflectionsbased on recommendations for service‐learning settings.25 StudentsMultiple chronic conditions, medication overload, inappropriatewere encouraged to reflect on experiences and insights relating tomedication use, financial burdens, and low health literacy fre-themselves, their values and attitudes.quently result in adverse drug events (ADEs) causing serious harmin the geriatric population.20,21 Students were educated specificallyon issues surrounding medication administration in the older adults.4 RES ULTSDuring apartment visits, students performed medication reviews toidentify medication discrepancies, issues surrounding access, poly-A total of 15 students participated in the 4Ms interprofessionalpharmacy, improper medication use, lack of knowledge regardingclinical experience from September 2019 to March 2020. In themedications, and use of high‐risk medications. The updated Amer-spring of 2020, the clinical experience was terminated early due toican Geriatric Society Beers Criteria was used to identify possiblethe COVID‐19 pandemic. Student competencies were evaluatedhigh‐risk medications in the older age group.22 Residents werethrough direct observation by faculty, participation in the inter-provided individualized medication education to promote ad-professional conferences, and end‐of semester self‐reported changesherence and reduce the risk of ADEs. Medications were organizedin knowledge and achievement of learning objectives. Students de-to promote accurate administration and reduce likelihood of du-monstrated competence conducting cognition and depressionplication. The PharmD faculty member provided pharmacologicscreening, medication review, and functional and fall risk assess-consultation during weekly interprofessional rounds and made re-ments using standardized screening instruments.commendations to improve management and reduce ADEs. TheFollowing a 7‐week experience, 1 day per week, students com-social work staff assisted with follow up phone calls to providerpleted a confidential survey. Students evaluated how well the clinicaloffices to facilitate medication optimization.experience met each learning objective (on a five‐point scale from“Did not meet at all” to “Completely met”) (Table 1). Mean scores forachievement of learning objectives ranged from 4.3 to MobilityMobility issues in the older age group may result in functional impairment and increase the potential for falls, with or without injury.Falls are the leading cause of fatal and nonfatal injury in olderadults.23 Each resident was screened for fall risk by ascertaining ifthey had fallen in the past year or were afraid of falling. If yes, theresident was screened using the Timed Up and Go (TUG), part of theCDC STEADI toolkit.16 Other factors relating to fall risk were assessed, including orthostatic hypotension, diabetic management,medications affecting balance, or gait, musculoskeletal issues, andenvironmental safety concerns.24 Interventions to reduce risk of fallswere developed collaboratively with the residents, using materialsfrom the STEADI toolkit. When appropriate, prescriptions were obtained for physical therapy.3.2.7 Interprofessional teamworkStudents presented their resident cases during weekly interprofessional conferences to promote team collaboration, communicationand planning. Students, social service staff, and faculty attended theconference. Students used a case presentation template that wasTABLE 1Learning objectives (n 15)How well did the clinical experience meet the followingobjectives?Did notmeet at anAssessment: Assess healthcare needs of vulnerable residentsusing a screening tool.4.4Mentation: Screen for dementia and depression usingevidence‐based tools (MiniCog, PHQ‐2)4.8Mobility: Assess mobility and implement evidence‐basedstrategies to prevent fall‐related injuries.4.7Medications: Screen residents for presence of age‐relatedhigh‐risk meds, med discrepancies, and recommendchanges to reduce med‐related events.4.4IP teamwork: Communicate with health professional teammembers to share patient‐centered and population‐focused problem solving.4.3Health promotion: Identify and implement evidence‐basedstrategies for health promotion and behavior change forvulnerable residents4.4

AVALLONETABLE 2 ET AL.5Pre–post change in knowledge (n 15)MeanPre1‐Novice 2‐advanced beginner 3 competent 4 proficient 5 expertPostDiff2What matters: Identify the importance of integrating patient values and priorities/preferences into health care decisions. the relationship between social determinants of health, health risk factors, and patient outcomes. opportunities for advocacy and collaboration with community and clinical partners that can be used to address unmetpatient needs.4.11.82Explain the link between culture and its influence on individuals, communities, and provision of culturally appropriate health care. the importance of the interprofessional team‐based approach when making healthcare decisions4.21.4Students also assessed their knowledge level in five contentEconomic Security Act, P.L. 116‐136 (CARES Act) Supplementalareas before and after the experience in a retrospectiveFunding for Health Workforce Modernization.26 The funding willpretest–posttest survey (on a five‐point scale from novice to expert)help establish a tele‐education network to connect the School of(Table 2). Positive increases in the level of knowledge were reportedNursing with the Institute for Successful Aging, Northgate II, Fair-by students for all five content areas (culture and health care, socialshare Support Services, and other community partners directly withdeterminants of health, advocacy and collaboration, integrating pa-the older adults with multiple comorbidities to address their healthtient values in health care decisions, and importance of inter-care needs in relation to COVID‐19. Students will also gain experi-professional team‐based approach).ence with the use of telehealth and related technologies in provisionAll students were asked to reflect on the experience in open‐endedof assessment and care in the new environment created by thewritten comments at the end of the evaluation. Student observationscoronavirus pandemic. Resident‐specific outcome data and otherincluded reflections about person‐centered care in the home. For ex-quality and outcome measures collected as related to the NJGWEPample, one student wrote, “I realized that recommending to remove a ruggrant will follow in additional prevent falls isn't that simple when it is someone's home and aThe academic‐practice partnership between the School of Nur-cherished possession.” Students expressed a better understanding of thesing, Fairshare Support Services, and the NJ Institute for Successfulbarriers older adults face when managing chronic health problems in theAging was an established and valuable interprofessional partnershipcommunity, and the importance of providing comprehensive care acrossbefore the fall 2019.9 However, the incorporation of the 4Ms fra-the continuum. One student stated, “I realize now that you can't justmework provided the context to develop an evidence‐based clinicalhand out a bunch of discharge instructions or a medication list and ex-experience to improve health outcomes for vulnerable older re-pect patients to manage their health at home.” Another student men-sidents in an affordable housing, inner city apartment complex.tioned, “I will be more patient and a better nurse in the hospital because IStudents demonstrated competence conducting geriatric‐basedunderstand the bigger picture now.” Students appreciated the complexityscreenings and interventions. Students rated the learning experi-of healthcare issues, the effects of social determinants of health and theirence positively. Open‐ended comments denoted important learningeffect on vulnerable members of the community. One student com-about care across the continuum and barriers to health for oldermented, “Actually seeing the impact of poverty on health made it moreadults in low socioeconomic states.real for me.” When asked what students liked best, they especially en-Using the 4Ms framework as a strategy to teach geriatric‐basedjoyed carrying a caseload of clients, working in a team with socialcompetencies in the undergraduate nursing population within anworkers, and establishing rapport with a group of individuals. “We neverinterprofessional community clinical experience has been positive toget to see the same clients in the hospital. This experience made me feeldate. This project was designed as a curricular quality improvementlike a real nurse. I feel like I made a difference,” expressed one one School of Nursing. Evaluation findings may not be general-Students valued the opportunity to partner and learn from the socializable to other programs. Further study is recommended in addi-workers. “I learned what social workers do and how they advocate fortional settings to evaluate the utility of the framework as an effectiveresidents in the community.” stated one student. Another student com-learning strategy.mented about the interprofessional teamwork when she stated, “Welearned from each other.”ACKNOWLEDGM E NTThe authors would like to acknowledge Marilyn Mock MSW, MelonieHandberry MSW, Fairshare Support Services, and the NJGWEP team5 C O N CL U S I O N O R N E X T S T E P Sat the NJ Institute for Successful Aging, Rowan School of Osteopathic Medicine for their contributions to student learning and in-In the fall 2020, the Rutgers School of Nursing‐Camden will continueterprofessional collaboration. This project is supported by the Healthto participate in the NJGWEP and expand the work to includeResources and Services Administration (HRSA) of the U.S. Depart-components related to the 2020 Coronavirus Aid, Relief, andment of Health and Human Services (HHS) under the Geriatrics

6AVALLONEWorkforce Enhancement Program (GWEP) grant U1QHP28714 to-12.taling 3,750,000 over 5 years, and a one year CARES Act GWEPCOVID supplement T1MHP39061 of 90,625 to support telehealth.The contents are those of the author(s) and do not necessarily re-13.present the official views of, nor an endorsement by HRSA, HHS orthe U.S. Government.C O NF L IC T O F IN T E R ES T S14.The authors declare there are no conflict of interests.ORCIDMargaret .R EF E RE N C E S1. Public health: recommended baccalaureate competenciesand curricular guidelines for public health nursing: a supplement tothe essentials of baccalaureate professional nursing practice. ion%20Health/BSN-Curriculum-Guide.pdf. Accessed July 4, 2020.Committee on Educating Health Professionals to Address the SocialDeterminants of HealthBoard on Global Health; Institute of Medicine;National Academies of Sciences, Engineering, and Medicine. A Framework forEducating Health Professionals to Address the Social Determinants of Health.Washington (DC): National Academies Press (US); 2020.Roberts Andrew W, Ogunwole Stella U, Blakeslee Laura,Rabe Megan A. The Population 65 years and older in the United States.2018. U.S: Census Bureau; 2020.Ward BW NCHS Data Brief. Barriers to health care for adults withmultiple chronic conditions: United States, 2012–2015. NCHS DataBrief. 2017;(275):1‐8.National Council on Aging (NCOA). Data trends, publications, andimplications from National CDSME and falls prevention database.2019. . Accessed July 4, 2020.McGrath RP, Snih SA, Markides KS, et al. The burden of healthconditions across race and ethnicity for aging Americans: disability‐adjusted life years. Medicine. 2019;98(46):e17964. of Older Americans. U.S. Department of Health and HumanServices Administration for community living. 2016. ct-profile-older-americans2016. Accessed July 4, 2020.Di Biasi A, Wolfe M, Carmody J, Fulmer T, Auerbach J. Creating anage‐friendly public health system. Innovations in Aging. 2020;4(1):1‐11. MA, Cantwell R, Pacetti S. Clinical introduction into population health management using a peer mentoring strategy. J NursEduc Pract. 2018;9(4):79‐85. H, Robinson M. Academic partnerships: social determinantsof health addressed through service learning. Int J Nurs EducScholarsh. 2019;16:1‐11. for Healthcare Improvement (IHI). Age‐friendly health systems: guide to using the 4Ms in the care of older adults. hSystems GuidetoUsing4MsCare.pdf.Accessed April, 2019. AL.Fulmer T, Berman A, Mate K, Pelton L. Age‐friendly health systems:the 4Ms. Try this: best practices in nursing care to older adults.Hartford Inst Geriatr Nurs. 2019:35. iendly-health-systems-4msChopra A. Geriatrics Workforce Enhancement Program (NJGWEP)U1QHP28714. Project Abstract. Supported by the Health Resources and Services Administration (HRSA) of the U.S. Departmentof Health and Human Services (HHS). 2019.Geldhof GJ, Warner DA, Finders JK, Thogmartin AA, Clark A,Longway KA. Revisiting the utility of retrospective pre‐post designs:the need for mixed method pilot data. Eval Program Plann. 2018;70:83‐89. Census US. Accessed July 4, 2020.Centers for Disease Control and Prevention. STEADI: StoppingElderly Accidents, Deaths, and Injuries. Older Adult Fall Prevention. 2020. AccessedJuly 4, 2020.Borson S, Scanlan JM, Chen P, Ganguli M. The Mini‐Cog as a screenfor dementia: validation in a population‐based sample. J Am GeriatrSoc. 2003;51:1451‐1454.Tsoi KK, Chan JY, Hirai HW, Wong SY, Kwok TC. Cognitive tests todetect dementia: a systematic review and meta‐analysis. JAMAInternal Med. 2015;175(9):1450‐1458. roenke K, Spitzer RL, Williams JB. Patient health questionn

1Rutgers University School of Nursing‐ Camden, Camden, New Jersey, USA 2Department of Geriatrics and Gerontology, Rowan School of Osteopathic Medicine, Stratford, New Jersey, USA Correspondence Margaret Avallone, DNP, RN, CCRN‐K, CNE, Rutgers University‐Camden, 530 Federal St., Camden, NJ 08102.

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