The Centers for Medicare & Medicaid Services (CMS) recently selected the Cedars-Sinai CARES (Care Management/Alzheimer’s Expertise/Resources/Education/Social Support) Program for dementia patients and their caregivers as a Guiding an Improved Dementia Experience (GUIDE) Model site. The Cedars-Sinai CARES Program is among 14 established programs in California, and it is one of only two in Los Angeles selected by CMS for the established program track. 

Additionally, the medical center’s comprehensive outpatient Geriatrics Program for people 65 and older, along with its Bone Health Coaching Program, recently received Age-Friendly Health System Committed to Care Excellence recognition from The John A. Hartford Foundation and the Institute for Healthcare Improvement, in partnership with the American Hospital Association and the Catholic Health Association of the United States. Cedars-Sinai also is among just 30 hospitals nationwide recently selected to join the new Age-Friendly System-Wide Spread Collaborative, which aims to accelerate adoption of evidence-based, high-quality care for older adults across all the medical center’s sites and care settings.

“Cedars-Sinai cares for more patients over 80 than any other academic medical center in the country, so operating under an age-friendly healthcare model is critical to our continued ability to serve our growing community of older adults,” said Bryan Croft, the hospital’s executive vice president and chief operating officer. “In just over a decade, the U.S. will have more people over age 65 than children, for the first time in history. An aging population has unique care needs, and these recognitions further demonstrate that Cedars-Sinai is the premier institution to provide this level of outstanding care.”

Cedars-Sinai Medical Center first received the Age-Friendly Health System Committed to Care Excellence designation in 2020.

Age-Friendly Health Systems integrate the “4Ms” of care: what matters most to each patient, medication safety, mobility and mentation, or mental functioning.

“Integrating the ‘4Ms’ framework into models of care for older people is about providing optimal care and measures of safety while addressing what’s most important to each individual patient,” said Sonja Rosen, MD, chief of Geriatric Medicine. “You can’t assume that everyone’s goals and preferences are the same. At Cedars-Sinai, we strive to help people live as healthy and high-functioning as possible for as long as possible and at the same time, achieve their goals.”

Cedars-Sinai’s outpatient Geriatrics Program has geriatricians who treat patients throughout the community for geriatric syndromes and primary care needs. This includes conducting consultations for falls, osteoporosis, polypharmacy—which is taking five or more medications—dementia, social isolation, loneliness, and other topics of importance for many older adults.

The hospital’s outpatient Bone Health Coaching Program, part of the Geriatric Fracture Program in the Department of Orthopaedics, provides bone health assessments and counsels patients on how to reduce the risk of fragility fractures, often caused by poor bone quality associated with older age, reduced mobility and some medications. Poor bone quality is often a surprise to older adults – unless they are screened, they may not be aware. According to the U.S. Centers for Disease Control and Prevention, falls that cause fragility fractures are a primary cause of injury in people 65 and older and often lead to hospitalization, loss of independence and even death. 

“We aim to help preserve good quality of life and independence for our patients," said nurse practitioner Kathleen Breda, MSN, associate director of orthopaedic Clinical Programs. “We’re proud that our Bone Health Coaching Program has connected more than four times the national average of patients with bone health care and is an important element of our age-friendly model of care." 

The CARES Program at Cedars-Sinai provides comprehensive dementia care management for patients with Alzheimer’s disease and other dementias as well as support and training for their family caregivers.

With the CMS selection of the CARES Program as a GUIDE Model site, eligible Medicare patients in the program can access $2,500 annually for adult day care, in-home care and facility care expenses when they need additional help—for example, after a hospital stay or during times of decreased caregiver availability.

Patients in the moderate to late stages of dementia also will receive a CARES Program home visit to help evaluate their needs, ensure safety and promote sustainability of in-home care. Educational offerings for caregivers are also provided.

“The selection of our CARES Program as one of the CMS GUIDE established care sites is a testament to the high quality of care that we provide to patients with memory impairments and the support we provide to family caregivers of dementia patients,” said Zaldy Tan, MD, MPH, director of the CARES Program and the Jona Goldrich Center for Alzheimer’s and Memory Disorders. “We continue to see improved health outcomes in vulnerable patients who are enrolled in the program, and as a GUIDE Model site, we expect this to be further enhanced.”

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The findings are published in JAMA Network Open.

The development and use of medications to treat acute and chronic health conditions has improved longevity and quality of life. But for some older adults, taking multiple medications can do more harm than good. Polypharmacy—the use of five or more medications—is associated with a higher risk for falls, fractures, hospitalizations, along with functional and cognitive decline for some aging patients.

“Polypharmacy, especially harmful or inappropriate polypharmacy, is bad. But the research community hasn’t figured out how to consistently move the needle on hospitalizations, quality of life, mortality and other adverse outcomes associated with being on several medications at once,” said corresponding author Michelle Keller, PhD, a health services scientist in the Department of Medicine at Cedars-Sinai.

Investigators analyzed 14 studies that systematically evaluated various tactics used to address the risks of taking five or more medications. They could not find a clear set of practices that consistently helped polypharmacy patients, but some approaches showed promise.

“Intensive, face-to-face interventions were effective in some studies. In those cases, having a healthcare provider review the patient’s medical record, go over the drugs with them to discuss medication adherence or whether a drug was still appropriate, and providing patient education all appeared to reduce hospitalizations,” said senior author Joshua Pevnick, MD, co-director, Division of Informatics at Cedars-Sinai.

Adults 65 and older tend to take more medications. According to a report by the Centers for Disease Control and Prevention, about a third of adults in the U.S. who are in their 60s and 70s take five or more prescription drugs. Medications to control cholesterol, high blood pressure and diabetes are the most common.

“We must weigh the benefit of prescribing a new medication against the possible risk it may present. Can it interact with other medications the patient is taking or impact the disease course in the older adult? For example, a new medication may effectively treat a specific condition but make the person drowsy, putting them at higher risk for a fall or impair their cognitive abilities. The more tools we develop to help us assess the risk-benefit of medications for our patients, the better care we can give them,” said  Sonja Rosen, MD, chief, Section of Geriatric Medicine at Cedars-Sinai.

While time spent discussing medication use with a healthcare provider, in person, did reduce some negative polypharmacy consequences in a few studies, a simple consult with a pharmacist also proved protective in some cases.

“Older adults often develop a good rapport with their pharmacists, and in some of the studies we reviewed, relatively short consults with them were very helpful to polypharmacy patients—especially those who may be at risk for falls or cognitive decline. I think a lot of health systems are recognizing the important role a pharmacist can play in the overall healthcare of their patients,” Keller said.

Identifying who is at higher risk for adverse polypharmacy outcomes is critical in order to develop effective interventions and is the focus of a pilot program in development at Cedars-Sinai.

“We want to create a risk-prediction model using data from the electronic health records of patients seeing primary care physicians. For the polypharmacy patients we identify as being at high risk for health problems associated with their medication regimen. As a first step, we can flag the record and send a message to their physician recommending a consult with a pharmacist, as a first step,” Keller said.

The Cedars-Sinai pilot program is expected to begin this spring.

Funding: This work was supported by National Institutes of Health grant numbers K01AG076865 and K24AG047899.

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