TOWNSHEND—Grace Cottage Family Health & Hospital has received “age-friendly” certification and congratulations from the Institute for Healthcare Improvement (IHI), which called the beloved and smallest hospital in the state “a leader in this rapidly growing movement committed to care of older adults.”
In fact, Grace Cottage is among the first health care systems in the U.S. to implement IHI guidelines for age-friendly care. So far, just over 600 health-care institutions in the entire country have been named Age-Friendly Health Systems.
“Older adults are living and working longer, and our approach recognizes the unique needs of these important members of our community,” says Grace Cottage geriatrician Dr. Ron Vallario, who calls implementation of the program “a team effort.”
“We are honored to be recognized,” he said.
The Age-Friendly designation is part of an initiative organized by The John A. Hartford Foundation and IHI, in partnership with the American Hospital Association and the Catholic Health Association of the United States.
It is based on a review of Grace Cottage’s clinical care in four main areas, what IHI calls the “4Ms”: what matters, medication, mentation, and mobility.
In receiving certification, Grace Cottage has proven that it provides patient-centered care, guided by what is most important to the individual patient (what matters).
It also aims to prevent, identify, treat, and manage dementia, depression, and delirium (mentation), and to encourage older adults to move safely every day (mobility).
When medication (the fourth M) is necessary, Grace Cottage providers choose medicines and dosages with the least impact on the other three areas.
Outpatient first step
Vallario says last fall he received an email about the Four “M” framework, “and it caught my eye, being a geriatrician.”
“It looked like something I wanted to participate in, and I decided to pursue it on the outpatient side with Dr. Moss Linder; it wasn’t a solo effort,” Vallario says.
He recalls how visiting nurse Claire Bemis went out to make home safety evaluations when someone failed the mobility screening, how the information technology department helped collect data, and how Dr. Anne Brewer partnered with the team on the inpatient side.
In the first three months of the program — the time for which IHI required data be compiled — Grace Cottage served 70 patients with the 4M protocol.
“What we’ve been doing since we started last fall is when patients come for 65 and older annual wellness visit, as Medicare calls them, we apply the 4Ms during those visits. It’s considered evidence-based care for all older adults,” Vallario says.
He says the Institute for Healthcare Improvement “got a bunch of experts together and went through a bunch of items and settled on these four as being the most important to do on an annual basis, at least.”
“They required us to submit our plan, and they accepted it and recognized us as a participant,” Vallario adds. “And then you submit three months of data to them as to how many patients you’ve helped and, if they’re satisfied, they recognize you as committed to excellence.”
Vallario says there was a lot of preparation, including national webinars every other week as part of the training process.
“It was good,” he says. “And then we had to do it.”
Vallario has found patients “very open” to the protocol.
“I think most have really liked it,” he says. “Only a couple of people have said they didn’t want the dementia check, I think because they were confident in their mobility.”
“Overall, I think patients worry about these things and are glad we’re attending to them,” Vallario observes. “They’re worried about taking too many medications, so they like talking about cutting down. They’re very happy when they’re told their memory is good.”
And, he notes, the “mobility thing is really important. If we can prevent one hip fracture, that’s a really good thing.”
Importantly, says Vallario, the 4M process is not complex.
“I think the Institute for Healthcare Improvement is on to something here in terms of really helping us focus,” he says. “What’s really great about it is none of this is high-tech. The mini-cognitive is a one-minute memory test; the mobility test really takes about 30 seconds.”
“Talking to people about what matters takes the longest, as that’s different for everyone,” Vallario adds. “And medication takes time, too, but none involves equipment, really. Everything is done in an exam room with a nurse.”
Speaking with Vallario, one can tell he is pleased to have found another tool to help elder patients at a hospital he clearly loves. He’s been at Grace Cottage for three years but practicing in Vermont since 2005. He says he’d known about Grace Cottage forever and his wife “used to say, ‘You should go work there.’”
He recognizes that “asking the right questions matters,” as does taking time with each patient.
“We’re not rushing them through,” Vallario says. “It’s all been very well received. I’m going to do a presentation to staff next week, and I hope other providers will join us.”
Applying the 4Ms to inpatients
Dr. Anne Brewer, who characterizes herself as a family doctor with a special interest and qualification in geriatrics, credits Vallario with doing “the harder work of implementing in the clinic” while she “looked at our workflows in the hospital.”
As a health center that mostly does rehabilitation work, says Brewer, “we have already been doing most” of the 4Ms regarding inpatients. That’s because most of the questions asked in the protocol are more relevant to the very elderly, who often need rehab work.
“I think people are beginning to recognize those kinds of mobility issues and falling issues should be addressed by everybody before they get frail,” she says, adding that she had handrails added to her home.
“My husband and I are quite healthy and active, but I thought while doing it, ‘Let’s put these safety things in,’” Brewer says.
“There’s a whole movement now called ‘universal design’ that does this so it doesn’t have to be modified if people start having issues,” she points out.
Brewer says one of the things she has most come to appreciate, as has Vallario, is “the catastrophic effect of falls in older people.”
“Even if it doesn’t kill you, it can injure you in a way that takes a long while to recover from and, at 80 or 90, we don’t have the resilience to bounce back,” she says.
As a critical-access, rural hospital providing health care for a community that wouldn’t otherwise have access to it, Grace Cottage has three parts: the outpatient side, also known as the clinic; the inpatient side; and the emergency room.
“We don’t look anything like what most people think of as a hospital,” Brewer says. “We have only 17 beds. So it’s tiny by anybody’s standards and most of what we do is rehabilitation work for people who’ve had illnesses or injuries that have rendered them unable to go home.”
“We also do acute admissions for people in the community who get sick, but we’re limited in the kinds of things we can do,” she continues.
“We’re not supposed to keep people more than three days; and we’re staffed by family physicians, we have no specialists here,” Brewer says, noting the hospital’s “very good relationship” with Dartmouth Hitchcock Medical Center in Lebanon, N.H., which can provide that guidance.
Alternatively, patients that require more specialized care will need to go to DHMC.
“So this preventative, proactive approach is really important,” Brewer says.
A bit of history
Grace Cottage can trace its history back to 1844, when Rev. Horace Fletcher built a spacious house here. The house remained in the Fletcher family and, in 1905, Harriet Fletcher invited Mary Plumb, a teacher at Leland & Gray Seminary, to share her home.
Plumb inherited the house after Harriet Fletcher’s death. When she retired, she rented the downstairs to the new doctor in town, Dr. Carlos Otis, and his wife Ruth.
From that day in 1938, for several years, it served as both home and doctor’s office.
In 1949, Plumb offered the house to Otis to fulfill his dream of opening a hospital. With the promise of a bequest from Otis’s friend and neighbor, Dr. Abel Grout, the hospital was named after his wife Grace.
Other friends made substantial donations and sparked fund drives, and the community jumped in to form the Grace Cottage Hospital Auxiliary.
Grace Cottage Hospital opened its doors on Aug. 7, 1949, when 830 people attended the Sunday afternoon opening and toured the hospital with nurses Bessie Leonard, Eunice Bills, Valerie Streeter, and Lillian Lyons, while cook Emma Castle showed off the new kitchen. Refreshments were served on the front lawn of the hospital. The first baby was delivered the next morning at 1:08 a.m.
Within a year, Hattie Stratton’s house next door was added as specified in her will and, in 1978, Ruth Heins donated her house next door to the growing hospital campus.
Otis served as hospital administrator until 1990 and as board chair until he died in 1994.
Many additions and renovations have come over the years, as have many accolades, including that in 2017 and 2018 Grace Cottage Hospital was named a Top 20 Critical Access Hospital in the U.S. by the National Rural Health Association for “Best Practices — Patient Satisfaction,” out of 1,346 Critical Access Hospitals in the U.S.
The Messenger Valley Pharmacy, a full retail pharmacy owned by Grace Cottage, is located across the street from the hospital.
The “Age-Friendly” designation is part of an initiative organized by The John A. Hartford Foundation and IHI, in partnership with the American Hospital Association and the Catholic Health Association of the United States.