Hospital mobility programs can improve outcomes in older patients

A paper published today in the Journal of the American Geriatrics Society reported results of an initiative designed to enhance implementation of hospital mobility programs aimed at improving quality of care and outcomes for older patients.

Sharon K. Inouye, M.D., M.P.H., Director of the Aging Brain Center in the Hinda and Arthur Marcus Institute for Aging Research at Hebrew SeniorLife, headed the effort and is the paper's senior author, and her mentee, Songprod Jonathan Lorgunpai, M.D., Division of Geriatric Medicine, Mount Auburn Hospital, is the paper's lead author.

Research shows that keeping older hospitalized patients confined to their beds often does more harm than good.

Immobility contributes to poor patient outcomes, including increased risk of injurious falls, delirium, aspiration pneumonia, pressure ulcers, functional decline, prolonged length of stay, institutionalization, readmissions, increased healthcare costs, and mortality.

Despite this reality, older adults are largely immobilized throughout their hospital stay. According to estimates in 2009 and 2013, patients spent more than 95 percent of their time in a bed or chair.

Protocols in place to prevent falls are a driving force behind this statistic. In 2008, the Centers for Medicare & Medicaid Services enacted new payment provisions that would no longer reimburse hospitals for diagnosis-related groups resulting from hospital-acquired conditions, including falls with injury.

As an unintended consequence, many hospitals routinely use bed and chair alarms that discourage mobility as part of their fall prevention programs, despite large randomized clinical trials that have clearly demonstrated bed and chair alarms are ineffective at reducing falls.

As part of a 2016-2017 Health and Aging Policy Fellowship, Dr. Inouye worked with the Center for Medicare & Medicaid Innovation (CMMI) to develop a new care delivery model designed to promote quality improvement related to mobility in hospitals participating in CMMI's bundled payment programs.

The overarching goal of the initiative was to improve mobility and decrease use of bed and chair alarms with hospitalized older adults. To achieve this goal, Dr. Inouye and her team developed a Mobility Action Group (MACT) Change Package that provides a conceptual framework, roadmap, and step-by-step guide to help hospital mobility teams set and meet their mobilization goals.

The MACT Change Package provided more than 40 participating hospitals of varying sizes across the United States with an innovative framework of peer support, expert faculty, and resources to create a successful culture of mobility in the care of hospitalized older adults.

The Change Package was an essential tool and starting point for each hospital, while the peer support and assistance they received through the group meetings proved to be another key factor in their success."

Sharon K. Inouye, M.D, M.P.H, Director of the Aging Brain Center, Hebrew SeniorLife Hinda and Arthur Institute for Aging Research

Results indicate that successful implementation of mobility programs was achieved at most (76 percent) participating sites in medical, surgical, and intensive care units, with 43 percent of mobility programs fully implemented and an additional 33 percent partially implemented by the end of the active initiative.

Most (54 percent) reported a high likelihood that their mobility program would continue long-term. There was a more than twofold increase in the proportion of patients who received at least three walks per day and a 1.8-fold reduction in the use of bed or chair alarms across sites.

"I'm greatly encouraged by the results of this effort," said Dr. Lorgunpai, who is also an Instructor in Medicine at Harvard Medical School.

"While additional study is needed to determine if this approach can improve patient outcomes such as decreased falls, functional decline, and readmissions, this initiative demonstrates that emphasizing system-wide change through a flexible approach can catalyze a culture of mobility in hospitals and improve care of older adults."