The Healthcare Customer of the Future

In this episode of TCNtalks, Marcus Escobedo, Vice President of Communications at the John A. Hartford Foundation, joins Chris Comeaux to discuss the future of healthcare for aging populations. 

Marcus shares how the Foundation’s Age-Friendly Health Systems initiative transforms care for older adults through the evidence-based 4Ms framework: focusing on what matters to older adults, medication management, cognitive health, and mobility.


The conversation dives into the impact of ageism in healthcare and the importance of reshaping language and practices to serve older adults better. Marcus and Chris explore how healthcare systems can elevate the voices of older adults, address the unique challenges of the workforce, and promote age-friendly practices that honor each person’s dignity and preferences.


They also tackle communication barriers surrounding serious illness and hospice care, offering valuable insights and resources for enhancing these vital conversations. Given the growing demographic of baby boomers, who comprise most of those served in healthcare, this episode is essential listening for anyone committed to creating better systems for aging with grace and dignity.


Guest: 
Marcus Escobedo, MPA, Vice President of Communications at the John A. Hartford Foundation

Host:
Chris Comeaux, President / CEO of Teleios

https://www.teleioscn.org/tcntalkspodcast/the-healthcare-customer-of-the-future

Teleios Collaborative Network / https://www.teleioscn.org/tcntalkspodcast

Chapters

• 0:00 Introduction to TCN Talks and Guest
• 7:31 The John A Hartford Foundation's Mission
• 15:15 Reframing the "Silver Tsunami"
• 21:31 The 4Ms Framework for Age-Friendly Care
• 32:36 Implementing Age-Friendly Health Systems
• 41:15 Combating Ageism in Healthcare
• 47:39 Finding Age-Friendly Health Systems
• 51:24 Addressing Workforce Challenges

Transcript

 Melody King: 0:01

Welcome to TCNtalks. The goal of our podcast is to provide concise and relevant information for busy hospice and palliative care leaders and staff. We understand your busy schedules and believe that brevity signals respect. And now here's our host, Chris Comeaux.

Chris Comeaux: 0:23

Hello and welcome to TCNtalks. I'm excited our guest today is Marcus Escobedo, MPA. He is a Vice President of Communications and a Senior Program Officer at the John A Hartford Foundation. Welcome, Marcus, it's so good to have you.

Marcus R. Escobedo: 0:37

Thanks, Chris, it's great to be here.

Chris Comeaux: 0:38

I want to read from your bio. So, Marcus is the Vice President of Communications, Senior Program Officer at the John A Hartford Foundation, where he develops and implements the organization's communication strategies. He oversees a grants portfolio of communications and special projects. He joined the foundation back in 2006. As a program team member, he has managed grant initiatives to support academic geriatric training programs for specialist physicians and improve emergency departments surgical care for older adults. So, Marcus, what did I leave out that maybe you might want to add, or just what you might want the audience?

Marcus R. Escobedo: 1:13

Oh well, thanks, Chris.

Marcus R. Escobedo: 1:14

It is a real pleasure to be here with you and your audience.

Marcus R. Escobedo: 1:17

I think I'd add just that not only is my being here part of my professional world I'll talk a little bit about how our foundation, the John A. Hartford Foundation, focuses on serious illness and end-of-life care but it's also personal for me, like it is with many of you and your audience.

Marcus R. Escobedo: 1:33

So, I just want your audience to know how filled with gratitude my heart is for the work that people in hospice and serious illness care organizations do every day. That's both the people delivering the care, the people behind the scenes, and operations organizations like yours, Chris, that are helping support organizations doing a great job, because, I tell you, what you're doing every day is helping people like me and my family in some of the most terrible times in our lives, and for me, that was in 2018, when my younger sister passed away from breast cancer, and I tell you, the memories that stick with me are of the palliative care team in the hospital and the hospice care team that transitioned us into the home during the last stages of her life, and what I saw there in terms of the expert, compassionate care made my professional work even more meaningful.

Marcus R. Escobedo: 2:19

So, just want your audience to know heart filled with gratitude for what they do.

Chris Comeaux: 2:22

Well, thanks for saying that, Marcus. I smile and then also heart hurts at the same time for you and your family. Smile from the standpoint. Our mission at TCN is care as it should be, and we are stitching together this network of community-based nonprofit hospice and public care programs. So, the experience that you had is not the exception. As you know, there is an interesting time in the variants of health care throughout the country and much of health care which is going to be a really good segue to what I want to talk to you about.

Chris Comeaux: 2:51

I've really been looking forward to this show, and so your boss, Terry Fulmer, had actually come to an incredible meeting at TCN that we call our Visioneering Council meeting, and the focus of that show is, or the focus of that meeting is we're living at interesting times and changes afoot in so many segments of our society. We're blessed and challenged. There's about once every 100 years. You're alive at a time when many things are changing at the same time. Well, we find ourselves in one of those times and one of the things maybe people aren't totally aware of, especially those like me that have been in hospice for 30 years our customer is changing. We've cared for the greatest generation, for, again, I've been in 30 years, but as we sit here, the aging of the baby boom population is increasing, which means they're becoming more and more our customer, the patient, the family that we're serving, and people have kind of couched that or framed that as the silver tsunami, which maybe sounds scary, and I love our kind of pre-show stuff you and I were talking about.

Chris Comeaux: 3:51

You're going to do a reframe on that, which I actually love. I think it's an interesting visual for people, but it's not a visual that inspires you to rise to the moment. It almost makes you want to run from the tsunami, and so and tsunami, or that population segment is really coming to fruition now the 2030s, all the way into the 2040s, when then it starts to decline. So, we're in for a very interesting kind of sea change. So, that's where we're going to go in just a second, before we do, though, I think it's going to set the table even further. Talk about the John A Hartford Foundation. Whenever our team member, Tina Gentry, met Terry and understood what you guys did, she came to me. She said we've got to bring them to our network, and I did not know about the work you guys are doing. And then, after Terry shared, I'm like we've got to do a podcast together, so share with our listeners.

Marcus R. Escobedo: 4:43

Oh, happy to, and thank you, tina, she's great. Yes, we love this topic. It's what our foundation is all about. So, the John A Hartford Foundation is a private, nonpartisan, national philanthropy. We're based in New York City, but all of our funding is going across the country to meet our mission, which is to improve the care of older adults. So, aging and health is all that we focus on, which is why this topic is so great.

Marcus R. Escobedo: 5:07

I will go back in time a little bit. We were established in 1929 by the family owners of one of the world's first grocery store chains, the A&P. So, for those in the Northeast may know the A&P, so that's where our foundation came from. It was John and his brother, george Hartford, who started that company and had no children and so left their estate to set up the Charitable Foundation which we are today, and we're private and independent at this point.

Marcus R. Escobedo: 5:33

Since the 1980s, the foundation has had the singular mission, as I mentioned, to improve the care of older adults.

Marcus R. Escobedo: 5:40

For decades and when I started the foundation 19 years ago, I can really focused on building the field of geriatrics and gerontology, focused on healthcare professionals and helping them be better prepared to care for an aging America. We were also testing and disseminating evidence-based models of care that give better outcomes for older adults, or the gold standard in these healthcare models for older people, and so we award about $25 to $30 million each year in grants that are going mostly to national nonprofit organizations, some academic health centers that are working national. Again, that's our focus national and we are an engaged funder and, for your audience, I should let them know we don't have open calls for proposals, unfortunately, for you all. We are an engaged funder. They go out in the field with our expert staff to co-develop the projects that we want to fund, and so we're always scanning and looking for the next idea and where we're going to go with our funding. But we're all about improving care for older adults and happy to be working with groups like yours. That's awesome.

Chris Comeaux: 6:49

Marcus, well, I remember there mission-critical three areas. I think I may be framing that correctly age-friendly health systems, family caregiving, serious illness and end of life. Why were those chosen and how are those congruent? I mean, they feel very congruent to me, but I'd love for you to unpack that just a little bit happy to.

Marcus R. Escobedo: 7:08

Happy to because it's a great segue from where we started and when I was at the foundation focused on that better workforce and those models of care. About nine years ago 10, almost 10 years now Terry Fulmer, our president, who you've met, came on board as our president and she really has a background as a developer of these evidence-based models of geriatric care. She's a nurse, an educator, a researcher, she was a former dean at NYU and at Northeastern, but she really focused on improving hospital care for older adults through nursing-led initiatives, had been funded by the John A Hartford Foundation and knew many others in the field with these incredible evidence-based models that deliver better outcomes, but was so frustrated when she came on board. She was so frustrated. She was like why are these models not reaching all of the older adults who could benefit? There's this huge, what we ended up calling this no-do gap. We know what the evidence says we should be doing for older adults when it comes to their medication management, to their mobility issues, to screening for delirium and depression and dementia, and it's just not happening and we have these adverse events and harm in healthcare that continue to be at higher rates for older adults, so she's just incredibly frustrated. So how do we get evidence-based practice out into the world more readily? So, she transitioned us into this focus on spreading what we call age-friendly care, and that is care that is evidence-based, that is reliably delivered, evidence-based care that's really focused on reducing harm in healthcare and that is laser-focused on what matters what really matters to older adults and their family caregivers. And so that launched our primary portfolio, which, as you mentioned, is called Age-Friendly Health Systems helping health systems become age-friendly. That has both a signature initiative within it that I'll talk about, called Age-Friendly Health Systems, but many related initiatives that are all about health care and some are specific to settings like surgical care, emergency department care, home-based care. We do a lot that are focused on dementia care as well. So that's one portfolio helping healthcare be better for older adults and connected to community-based services and public health.

Marcus R. Escobedo: 9:17

By the way, a second area, as you mentioned family caregiving. We did a lot of work with healthcare professionals and saw this big blind spot and a gap. When we're thinking about the workforce, right, we think about those paid professionals, but what about the 53 million family caregivers that are out there delivering care every day to older adults and other people who need assistance. They are essential to making our crazy fragmented healthcare system work, and so we developed a portfolio helping healthcare providers and systems better meet the needs of family caregivers, and we work a lot on policy in that area.

Marcus R. Escobedo: 9:51

And third is for your audience in particular, serious illness and end-of-life care. When I started the foundation, we already had a really strong track record of trying to spread palliative care. We actually frame that as an evidence-based model of care, because not only is it a discipline and a specialty of medicine, but it's team-based, it really organizes care differently, brings in spiritual and social care, and so we were already doing that and saw an opportunity to develop a portfolio again that was needing this blind spot, this gap in age-friendly care at a particularly vulnerable time for many, many older adults. And so, again, we do a lot of work around clinical training and quality improvement in serious illness care, as well as policy work and some communications work as well, which I hope to talk about.

Chris Comeaux: 10:35

That is so cool. Again, I was just so impressed when Terry was presenting, but just again, listening to you now, it just feels we are so symbiotic, very good potential collaborators and again, all of our listeners, I think, would smile at everything that you just said. Well, I want to go back because of, again, I love our kind of pre-show banter back and forth between you and I. We've used that term the silver tsunami and I love what you did. Just literally with one little sentence you shifted my perspective and I'll give you just a really kind of cool table setting.

Chris Comeaux: 11:08

We have been having this fascinating thing. We call it future councils. So, we had seven years of research and we've come to the conclusion that there are eight challenges facing every hospice and power to cure organization. There are eight broad challenges. And so then we started these future councils this year, where we broke those eight challenges into these future councils. And so it's leaders within all of our hospices. They've recruited some of their board members and we recruited national experts.

Chris Comeaux: 11:33

The conversations are so robust, but I've seen this shift from this challenge, this problem, to what is possible. It's like we got our minds wrapped around the challenge. It's not such a big boogeyman or whatever, and now we're looking at what's possible, how to literally shape the future, and one of my favorite quotes is the best way to predict the future is to actually create it. And so I feel like you did that with the silver tsunami, so can you take that from there, because you admonished me in a wonderful way, actually in a good coaching way. Why do you call it the silver tsunami? So, do you want to talk about that?

Marcus R. Escobedo: 12:12

Happy to. Happy to, and I'm a communications professional, so, yes, I love it and I have to say I mean we used to use the silver tsunami at the Johnny Hartford Foundation and, as a comms guy, part of my comms brain really loves it. Right, it's alliterative, it's visual, it paints a picture that sticks with you when you think about this silver tsunami in terms of triggering or bringing forward particular mindsets, particular viewpoints, particular frames that they put around different social issues. And, as you just said, and I asked that question, why do we use the silver tsunami and what does that mean for you? What does it picture for you? And you just said it, you said a silver tsunami. What is that when you and you just said it, you said a silver tsunami.

Marcus R. Escobedo: 13:06

You know a tsunami. What is that? It is this massive wave, um, that is coming towards you and what is it going to do? It's going to leave a wake of destruction and devastation, complete annihilation. Uh, horrible, right, it just is. Oh my gosh.

Marcus R. Escobedo: 13:19

And then you layer on to that what do you do about a tsunami? Nothing. You can't stop it. So you run, you run away from it, or maybe you put your head in the sand and hope for the best, links to what you just alluded to, which is our already negative views of older adults.

Marcus R. Escobedo: 13:46

Particularly in this country, where youth is valued, older adults and aging are not valued, and therefore it reinforces this notion that older adults are a problem, that this is a massive problem because of this huge cohort of baby boomers that are coming through our demographic pipeline and that there's nothing we can do about it. So we think that there is a way to talk about this demographic shift that doesn't prompt that negative view of older adults and that fatalism, that nothing can be done about this opportunity that we have, with older adults growing, contributing to our society in really valuable, vital ways, and that we can really, like you just said, think about opportunities to harness the growing number of older adults in our world. And so, we love talking about how we can reframe that notion of the silver tsunami and there's many other ways that we can reframe how we talk about aging. It really does matter to our audiences, to our customers, our clients, our patients, and can really shift society in big ways to help us meet this demographic shift that we are experiencing.

Chris Comeaux: 14:52

I so love where you're going with this. One of the things that occurred to me one of our groups out of those future councils adopted the Chinese symbol, which is crisis, opportunity and every challenge. There is this amazing opportunity and again, just in a few interactions, you have, first off, made me check my language, because actually I'm very big on language. My mentor was Stephen Covey's mentor and he would actually say his name was Dr Lee Thayer. We create the worlds that we exist in based on the language that we use, and you would smile, mark, because he won a Lifetime Achievement Award in communication, as you can imagine and so I've seen this shift in our future councils and you just did it. For me, it's like this is a huge opportunity. This is why we've come A lot of us as hospice and healthcare people, those of us that got that 20, 30 years.

Chris Comeaux: 15:44

We inherited this beautiful model of care, the pioneers a lot of them amazing women that were pioneers and they created, they fought for what became a Medicare hospice model. Some of them then became the pioneers of palliative care. We inherited that and I love the quote. We've stood upon the shoulders of giants. For what reason? And what will they say about us 20 and 30 years from now and hopefully it's that we rose to the occasion in a beautiful way. So maybe that's a cool segue again why I think we're talking today. So you alluded to earlier when we kind of talk about those initiative focus areas, and of course Terry talked about it when she came to our meeting about age-friendly health systems, and you even alluded to evidence-based practices and she referred to the 4Ms. So, can you just unpack some of that a little bit?

Marcus R. Escobedo: 16:31

Sure, and I should have mentioned that right up front, because the 4Ms framework are essential component to what we call age-friendly care and, as healthcare providers, organizations, professionals are out there delivering care, we want them to be thinking about this, these 4Ms of age-friendly care. So, again, age-friendly care is all about delivering evidence-based practices, reliably reducing harm in healthcare and really always focusing on what matters to older adults and their family caregivers. And, as I mentioned also, terry was really frustrated, Dr Fulmer, with this no-do gap and this inability to really spread and scale these evidence-based models, and so what she did back in 2017 in our organization was gather experts in geriatric care, along with the Institute for Healthcare Improvement, an amazing global quality improvement organization that did tons of work around patient safety you might remember the quality chasm back in the day and that was their work and they're terrific. And we gathered all of these folks also with health system leaders and healthcare providers on the front lines, clinicians who came together and said, okay, how can we tackle this problem of the lack of spread and scale of these evidence-based models? And the one idea that came up was around complexity. As we age and with multiple conditions and tough circumstances both medically and socially, the complexity of care for older adults can be overwhelming and has gotten in the way of initiating and embedding these evidence-based models. And so one of the challenges was okay, can we look at all of these evidence-based models and identify the most essential common features across all of them?

Marcus R. Escobedo: 18:19

So, this group, in an August you know hot summer August vacation season, they all came together, this group, and dedicated their time to reviewing these evidence-based models that were well-tested, well-proven to get better health outcomes. And they went through a process and distilled down and first it was 93 features that all of them had and we're like okay, 93 features, that's a lot. Let me get it down further. Yes, okay, 13. 13 are really core. Okay, 13 is still, it's still a lot for a busy nurse on the bedside or you know, clinicians that are out there in hospice organizations and other places. Okay, so they challenged them to get down to what they call the four M's and this four M's framework really represent together what are the essential elements of care for older adults from which you can really build a base to get those better health outcomes.

Marcus R. Escobedo: 19:13

So, what are they? The first one is what matters to older adults. Right, I've been talking about what matters a lot. That is the first and foremost M. It is about making sure that all care is aligned with the goals, values and preferences of the older adults and their family caregiver as they deem fit. And that is absolutely essential and is amazing to me, as someone who's not a healthcare professional, how often that gets forgotten in healthcare. You know, you walk into a medical appointment and the focus I was just with my dad and mom, spent four months taking care of them taking care of my dad, who was having some health issues, you know, and the focus on the body parts or on the disease or the condition, rather than him as a person and what matters to him. Just continue to like, you know, because when you do that, you really can align care in a way that's going to get the outcomes that everybody wants. So then, what matters? First M, second M medication.

Marcus R. Escobedo: 20:07

Older adults are on many, many medications Again, my dad, oh my gosh. Daily 10 medications trying to sort them through. And then all the changes, because as we get older, medications can become dangerous for you and become inappropriate for older adults. They may interact inappropriately, get prescribed by different clinicians and have dangerous interactions. Polypharmacy is an issue among older adults, and so deprescribing is often a good practice when possible. So. medication is really important. A lot of adverse events.

Marcus R. Escobedo: 20:36

The third M is mentation, or when we talk to the public, we talk about mind, and this is everything dealing with cognitive health. You can think depression, dementia, delirium as a quick and easy way. It's memory and mood. It's making sure that we're screening for these conditions and then acting on them and making sure that older adults are getting what they need to think about their mental health, their memory, their mood cementation. And the fourth is mobility. Mobility is critical. It's really about preserving function, maintain an older adult's level of activity, no matter their health or ability or disability status. Even in the ICU you should have a mobility plan that's helping someone keep active and functional so that way they have good outcomes when they come out of the hospital.

Marcus R. Escobedo: 21:20

For years in geriatrics we focused on falls prevention. Right Falls is a huge issue among older adults and preventable, and we realized you know that focus is too narrow. It's really about mobility. If we can keep people active, moving, preserve their mobility and their function, then we will prevent falls.

Marcus R. Escobedo: 21:39

So those are the four M's what matters medication, mentation and mobility and we want everyone in healthcare and all older adults and their family caregivers to think about those 4Ms, apply all the evidence-based tools and practices that are out there to support those 4Ms, which again are a set, and I'll leave that as the point here that you think about it.

Marcus R. Escobedo: 22:02

If your medications are off, that could affect your mentation right and create cognitive problems that could lead to a fall or a lack of mobility, all preventing you from doing what matters to you.

Marcus R. Escobedo: 22:16

So. they are interrelated. It is a set and the four M's are really powerful and we're seeing it spread across the country. And so the great news is there's an initiative called Age-Friendly Health Systems. It's a movement that was sparked out of this work, and now we have over 5,000 sites of care hospitals, nursing homes, medical practices, convenient care clinics, hospice and home health organizations that have adopted the 4Ms framework are being recognized by the Institute for Healthcare Improvement and they're showing better outcomes, which is what's the best thing, right? So we see, you know, reductions in length of stay at the hospital for older adults when 4Ms are applied. We see reductions in unnecessary re-hospitalizations, we see patient satisfaction scores go up. So that's the age-friendly health systems movement and the 4Ms framework we would love everyone to learn more about that at johnahartfordorg slash agefriendly, because we've got ways for all health care organizations to join into that movement largely underwritten by our foundation, and so a great opportunity for your audience.

Chris Comeaux: 23:23

That's awesome and, Marcus, what we'll do is we want to put a link in the actual show notes directly to that, and accreditation bodies have picked up on this as well. Right, like, we have our first hospice in our network that actually got the age-friendly seal of approval I don't know the exact word, but we really celebrated that with them. They were the first one, through their CHAP accreditation, to go in this direction. I'm just curious what are some strategies that you are trying to embed that within the hospitals? First off, the framework is brilliant, and I love how you just went through that. I mean, literally, I could see in my mind's eye the process of distilling down, because we had to do something similar with the challenges that I was sharing with you earlier. That is not easy what you just described, and to get it down to four such brilliant sticky and I love the fact that it's almost like a Venn diagram. It's not like four individuals. They're very interrelated with each other. So, again, I think it's actually brilliant.

Marcus R. Escobedo: 24:21

Yeah, and we have gone. It does take a lot to get this embedded in hospitals and other settings of care and I should mention part of the way that it's being spread and embedded is through incredible partners at the national level and down at the local level as well. But the Institute for Healthcare Improvement I mentioned is a key partner. The American Hospital Association is our other founding partner and together they continue to develop and facilitate what are called action communities seven-month learning experiences for healthcare teams to join in with no fee, because we're underwriting it from the Johnny Hartford Foundation and it's an opportunity for groups of about 100 or so individuals from these different healthcare teams to come together, get coaching on the 4Ms, share best practices with each other, create a learning community where they really can get into testing and developing ways of delivering the 4Ms that look at their data and really have a focus on quality improvement to keep getting better.

Marcus R. Escobedo: 25:23

And I will also say we've been working at a structural level to help promote age-friendly care and get it embedded, and the Centers for Medicare and Medicaid Services this year actually implemented a quality measure, that is, the age-friendly hospital measure, and so this is now in the inpatient quality reporting program through Medicare, and so most hospitals participate almost all participate in that program. Most hospitals participate almost all participate in that program, and if they don't want to lose their Medicare payment updates that increase that they get every year they need to report on whether they're delivering age-friendly care now. And that measure is based on these four Ms and then adds to it a couple of key areas around screening for social vulnerability and making sure there's leadership in place to support age-friendly care.

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Marcus R. Escobedo: 26:54

So those are the ways that we're spreading. I have to say, partners, though, abound. So, I mentioned IHI, AHA. The VA has adopted age-friendly care in the 4Ms throughout the Veterans Health Administration. We had all minute clinics that are in CVS pharmacies join in and become committed to age-friendly care in the 4Ms. We've had the other federal agencies, like the Health Services and Resources Administration that has a geriatrics workforce education program these 48 sites across the country that are training up clinicians and others in geriatrics. They embedded the 4Ms as part of their framework. So this is how we are working to get age-friendly care in the 4Ms out. I will also say we're doing work on the public side as well to create demand for age-friendly care, because we think it's really important for older adults to ask for and get age-friendly care.

Chris Comeaux: 27:46

That's actually a great segue, so it is interesting. I don't know if this is totally true, but I'll just frame it this way. So, in the United States maybe, aging and older adults maybe are viewed from maybe less than maybe a negative lens. But obviously your foundation is working against ageism and reframing and I love in the beginning you said, like you know, we have tended to hold up youth and maybe want to hide the beauty of aging and what that means.

Chris Comeaux: 28:18

And again, baby boomers have not gone quietly through any demographic segment of their lives. I mean SUVs and suburbia and all these things literally that we look at today and go, oh, that's just normal, it wasn't as they were actually aging, and so they're going to push on a lot of things, and this is probably one as well, and you can see it right now in some of the commercials which I just love, kind of pushing the viewpoint of what does this stage of life look like. So, can you share how you guys are working to counter ageism? And this is where you're brilliant. So, I can't wait to see how you reframe. Well, sure.

Marcus R. Escobedo: 28:55

Well, I, you know, I will know. Number one ageism is real, it's pernicious and it has true impacts on health outcomes. And so, there's a body of research and data out there showing that ageism which is referring to how we think, how we feel and how we act towards older adults or any age Ageism is not only against older adults right, it can be against any age but it's basically discrimination based on age and it is prevalence. There was a great survey done by the National Healthy Aging Poll at the University of Michigan and they published in JAMA the results that something like 93% of the older adults 50 plus that they surveyed nationally represented sample experienced everyday ageism. They were able to show that's very common, very common in healthcare, very common internalized as well.

Marcus R. Escobedo: 29:49

Ageism can both be interpersonal, it can be institutional and it can be internalized. And there is where we see a lot of really negative impacts from ageist views. Becca Levy, a researcher at Yale, has shown that on the opposite side, positive views of aging show a correlation with extended life, show a correlation with extended life 7.5 years, she found when there's positive views of aging that are internalized rather than ageist views inside. So it is a huge issue in healthcare. We see it all the time in clinicians. Terry, dr Fulmer, talks about Grandpa Frank, who had, you know, was not getting around like he was able to, like he was used to, and he said his leg was bothering him. And he said his leg was bothering him and he said, oh yeah, and the doctor he went to just said, oh yeah, you're getting old. And Terry said, well, is that? It Checked it out? He had a fracture, and once he got care for that fracture he was actually back to getting to do what matters to him. But that's ageism in health care, right? It was dismissing a condition because he's old. So ageism is a problem. So, let's start there.

Marcus R. Escobedo: 30:52

We can reframe ageism, though, or reframe aging in a way that counters ageism, in part by using language and communication strategies that are evidence-based and tailored to help us get around and beyond those negative views that we have so deeply ingrained in us in this country, from the birthday cards that make fun of older people to some of the commercials we see. So reframing aging is actually not just a concept, it is an initiative, and so I will point people to reframingagingorg and the National Center to Reframe Aging, which we've supported now for about 10 years and it did foundational research with the group called Frameworks Institute, which are just terrific. They look at all these social change issues from the perspective of how do our brains work when we hear messages, and they found these deeply negative views of older adults. And then they, really importantly, tested ways to help us move beyond those negative views, and those include a few simple practices that all of your audience can use. One is do try to avoid terms like silver tsunami or that are overly crisis language that parks fatalism in a sense that you can't do anything. Be careful of that. So, we've talked about that one.

Marcus R. Escobedo: 32:10

Another great one is what I call the power of pronouns. It's amazing how no one in the United States is old. They did this research. They asked people and no matter their age 75-year-old they could be asked you know who's old? Are you an older adult? No, is someone 10 years older? Because we have such negative views of aging, so we otherize older adults. It's them, those older adults over there, and when we use a power pronoun to talk about we who are aging, all of us who are aging, not them over there aging that has a power to it. We can start being inclusive in our language and start referring to all of us who need good care as we get older, good age-friendly care, all of us who are going to need hospice potentially could need hospice care at the end of our life. Being inclusive and talking about we is really powerful.

Marcus R. Escobedo: 33:06

And, lastly, there's many other recommendations. One other one is just to focus on how these are societal issues, right. Oftentimes, as we're aging and dealing with some of the complexities that come with that, it's deeply personal, it's intimate, it's a family matter. Well, yes, and this is an issue for our society, for our healthcare system, our long-term care system, policymakers, and so, by our language, focusing on the structures and the changes we can make to policies and programs, and being careful about using language that overemphasizes personal choice as the key to healthy aging. It is, but we have to also, in our language, make sure that we are talking about the structures and the systems that are in place, helping us make those good choices as we age.

Marcus R. Escobedo: 34:01

So those are some reframing aging principles. Again, go to reframingaging.org. There's more tips there and a great way for us to counter ageism in our everyday language and in our healthcare organizations.

Chris Comeaux: 34:13

We're going to include a link to that as well, Marcus. So, it feels like you're alluding to this. So there are a lot of older adults that aren't satisfied with the healthcare system. In fact, I saw this with my dad. He actually had gotten a diagnosis.

Chris Comeaux: 34:27

Luckily it turned out to be incorrect, but it was a year's journey with Parkinson's, and so I actually took a week off and actually went with him, which was awesome on a lot of different levels, but I got to see firsthand what you're actually describing and it's almost a disrespect of sorts, a dismissing because of the as aging, you know, you can't hear as well and things like that, and, as opposed to people leaning in, I felt like I witnessed judging and certainly my dad did not feel listened to. So, what do you think that? What would you advise people throughout healthcare? Of course we've got a lot of hospice and palliative care leaders, but I bet you have some good pearls. What can we do so people can feel heard? Because literally I could picture it in my mind's eye and my dad did not feel heard.

Marcus R. Escobedo: 35:19

I'm so sorry that you and your dad experienced that and it happens too often and I saw that happening with my parents as well and we've seen that it's an incredibly common experience. I saw that happening with my parents as well and we've seen that it's an incredibly common experience. We did a national survey with this wonderful group Experts in Longevity called Age Wave. We partnered with them and the Harris Poll and did a big national survey of more than 2,500 older adults all over the age of 65 as nationally representative, and the findings were super clear. People were highly dissatisfied with the US healthcare system. Only 11% gave the US healthcare system an A grade. 82% said that the healthcare system was not prepared for an aging America and, in addition to the cost of care, the complexity of the system and navigating it people not feeling listened to was really driving those dissatisfaction rates.

Marcus R. Escobedo: 36:14

Again, it was about a focus on the disease or the body part and not on me as a person in these healthcare encounters. And so, for your members and for everyone out there, we go back to the four M's of age-friendly care and, most importantly, what matters, and just continually coming back to that intense focus on asking and acting on what matters to the older adult and that means at every encounter and at different levels and really embedding that into our systems and our practices, that we're asking what are your goals, values and preferences and revisiting those over time. And when we take that moment to do that, to ask what matters to you, then we can really change the dynamic and have people feel listened to. So that's one big piece. The other, I think, is going back to what we were just talking about and using some of the tools from Reframing aging.

Marcus R. Escobedo: 37:04

I think your group in particular might benefit from some research and tools around elderspeak. I don't know if you've heard of elderspeak. It's a concept that we too often see where with older adults, particularly those that are very frail, maybe with dementia, but many older adults Healthcare providers and others, healthcare clinicians and others will come in and suddenly start talking in baby talk or using sweetie, dear honey, incredibly condescending to older adults. And the research has been done with older people to say it just feels so, so diminishing and disrespectful. And it happens a lot and there have been studies actually analyzing the communications of professionals and so there are tools out there to help watch for elder speak and those kind of ageist practices which, again, if by countering that will help people in our healthcare organizations being served by us feel listened to and feel like what matters to them is being attended to.

Chris Comeaux: 38:01

Awesome. We're going to include a link to that as well. Marcus, that is so good. We do a podcast where we cover the top news stories of the month, so I literally read thousands of articles so that way the hospice leaders don't miss. And that was actually an article this past month actually about that language. I can't remember if it was KFF, but it was someone who actually put a really good article out about that and I actually parked that under the. We have, of course, categories to make sense of the articles, and the demographics of our customer changing is the one that I parked under that. So well, well stated.

Marcus R. Escobedo: 38:35

And just a note there we happen to. We support KFF Health News and set up an aging health desk and navigating aging column. That was done by Judy Graham, a reporter there that's transitioned now to Paula Spann at the New York Times, who did that article, and so keep an eye out for those articles that she'll keep putting out about the new old age and more tips to come from that great series.

Chris Comeaux: 38:56

Good deal. I have an idea I'll share with you at the end of the show, kind of along those lines. Well, of course, the good thing is because of my parents, for one, they listen to my podcast and they pass it around to their friends. So how can people find age-friendly health systems around the United States?

Marcus R. Escobedo: 39:13

How can they locate those? Sure, there are, as I mentioned, about 5,000 sites that are recognized for being a part of the age-friendly health systems movement, delivering the 4Ms. So people can go to IHI Institute for Healthcare Improvement IHI.org slash age-friendly where they can find a map and a list of recognized sites. The same map and information can be found on our site. We like to make this accessible everywhere. Johnaharford.org slash age-friendly and you can find that map in the locations. And I will mention our other partner, aha, americanhospitalassociation.org slash age-friendly. Make it very easy Get to these places.

Marcus R. Escobedo: 39:49

But another key message I want people to walk away with is yes, look for and choose, when you can, healthcare organizations that are recognized as age-friendly. And, just as important, demand it from your current healthcare providers. Go into every encounter and ask do you deliver age-friendly care? Can we talk about the four M's? We believe that that is a powerful way to drive more uptake of quality, age-friendly care. We've been working with partners like WebMD and NBCUniversal to get that message out to the public like WebMD and NBC Universal to get that message out to the public and we have tools that can help people do that. There's this great document, this publication called my Health Checklist that's available on our website and ihiorg slash age-friendly and ours. That helps people walk through the 4Ms with their providers, and so we hope everyone will use that and demand age-friendly care, because we all deserve it. That's awesome.

Chris Comeaux: 40:46

Well, as I think we have so many interesting challenges. Of course, I mentioned again the age challenges we identified, and one of the huge ones that's common. We have a lot of people out there. I go to conferences. The number one that we all agree upon is the workforce challenge, and so, as we think about that going forward, it's going to be huge. And so what are some things that we can do maybe to ensure, as our wonderful older baby boomers are aging, that we have the people to be able to do it? I love what I mean. You're bringing so many resources to do it in the right way. When things are stressed and resources are light, unfortunately people don't show up as their best version of themselves, and that would concern me listening to the wonderful solutions you're bringing forward. So I'm just curious what you think about that.

Marcus R. Escobedo: 41:35

Yeah, workforce issues are huge. I mean they just come up over and over and over again. You know one I will keep on hitting. We do think the age-friendly health systems movement and the 4M's framework is one piece of a solution there, because we're now taking the basics of geriatrics competence and helping every person in the healthcare system understand and deliver that. So that's one.

Marcus R. Escobedo: 42:00

Two is we do need more models that show that kind of reframe aging and show positive experiences that can be in healthcare settings working with older adults. I'll give one quick, because it helps bring the expertise from the schools of nursing into the nursing homes, those skilled nursing facilities, to improve quality of care and it is creating an environment for those nursing students to see what good quality care in a nursing facility can be like, driving forward quality improvement around the fully care, and that builds a pipeline of workforce. So. building more models like that, where we have that engagement and give experiences to trainees and students, is another key. And then we need payments and policy restructured and reorganized and I can go on for another hour about that and how that needs to change to help us build the workforce that we need.

Chris Comeaux: 43:04

I didn't tell you I was going to ask you this, but we had a board meeting a couple weeks ago so we had people travel from all over the United States. It was a great time. You just get a whole different level of kind of brainstorming because you're in person with each other and live. And we got to self-driving cars and someone used out loud to go there'll be a lot of displaced truck drivers. Maybe we could recruit them as healthcare workers. Just curious what your thoughts are, because then I would say, well then we, because the number one question is well then, how do you prepare them for healthcare? And it feels like you've got a lot of basic, really potent and powerful tools that could prepare them. That should be part of any curriculum.

Marcus R. Escobedo: 43:43

You know, I think it's a great point there is going to be large-scale transformation that happens in this country with AI, with our aging baby boomers and what they're doing and how they are not.

Marcus R. Escobedo: 43:55

You know they're not retiring in the way that we think of retiring and so right. So, there is opportunity there to think about, you know, retraining programs, positioning people in healthcare environments. So, I think there's great opportunity. There is more that needs to be done around funding and both from government and from philanthropy and others and healthcare organizations to invest within their own workforce. I mean, we've seen health systems now setting up high schools that are specifically tied to the health system, so that way they create a pipeline up through high school to medical school into their health system. I think there are ways we can be creative to help get where we're going and to seize those opportunities. I will go back to some fundamental policy changes that we need around, like the direct care workforce, and I think more people could be home health aides and direct care workers, which are so vital to our healthcare system but so underpaid and undervalued and with no opportunities for professional development. So, there are things we can do there on the policy side as well, totally agree.

Chris Comeaux: 44:59

Well, you know, we live this on a day-to-day basis, and I love this is we have so many overlaps. But the big part of our Venn diagram overlap is our passion of serious illness and hospice, and people have an aversion to speaking about it, and you're such a great communication expert. You guys have done research around this area, so I'd love to hear what ideas you have around messaging. And just one final thought there, Marcus I had an incredible opportunity to go to England in 2018. And so, we met with some of the top hospice and palliative care people in England. It was at Oxford. It's an amazing experience, but we're sitting with the St Christopher's folks, which are, you know, they were the founders of Modern-Day Hospice, and it was a poignant moment for me because they said well, we need to educate people more, and I thought you're the people who created it.

Chris Comeaux: 45:51

Unfortunately, and probably not intentionally, we have educated them, and hospice means death and we're just so death adverse as human beings. And that barrier goes up and you can't get beyond the barrier, and we were actually one of the first movers for seasons where I was a longtime CEO and that barrier goes up and you can't get beyond the barrier and we were actually one of the first movers for Seasons, where I was a longtime CEO. We rebranded as Four Seasons and so the hospice wasn't in the name, not because we were trying to hide it, but because we didn't want that barrier. We wanted to meet people with palliative care services. I'd say we were marginally successful because we'd never it created a lot of interesting internal turmoil about.

Chris Comeaux: 46:26

Are we trying to hide the fact that we're a hospice and how do you navigate this thing? I now have I'm older and wiser and have a lot more gray hair. I think it comes down to one of your superpowers, which is it comes down to communication and words that you use. So, I'm curious. You guys have done a lot of good research in this area, so what would you recommend?

Marcus R. Escobedo: 46:44

Sure, sure we did. We funded a coalition of 12 of the biggest leading national serious illness care organizations that I think your audience would know, including National Hospice Palliative Care Organization, which I know has merged and become a new organization, the Coalition to Transform Advanced Care, C-tac, the Center to Advance Palliative Care, and this is based out of the University of Washington and their palliative care center and led by a palliative care physician, tony Bach, who's just incredible, and he leads an organization also called Vital Talk which focuses on communication skills around serious illness care. So, I encourage everyone to check out Vital Talk. But they got together on this very point about the barriers that they were all seeing in the public's understanding and acceptance of serious illness care, including hospice and palliative care. And you're spot on. I mean, one of the big challenges and the findings that they did in their literature review and the research was around our in this country in particular, our views of death and really getting in the way of productive conversations around the kind of care we should be getting. So, what they did is they did this research, they came together and instead of coming well, they do have messages, but I think even more brilliant, much like the reframing, aging work.

Marcus R. Escobedo: 48:00

They came up with five messaging principles. So, five principles to think about in serious illness care that will help you get your messages across. I think they're powerful and helpful. The first is to and I think most important talk about the benefits. So, for example, in hospice care, they noted and they give some examples of you know, sometimes you know it becomes a technical oh, you are eligible for the hospice Medicare benefits qualify by six months. You know, and they recommend really start with talking of the benefits, about what hospice can do for you, how it can help you live well to the very end of your life, and to describe that meaningfully. So, talk up the benefits was their number one recommendation principle to follow Two present choices at every step.

Marcus R. Escobedo: 48:47

One of the findings is that people experiencing serious illness and at the end of life feel a loss of control around what's going to happen, and so making sure that in our communications and our messaging that we're framing everything as the choices that people will be able to make for themselves with help from their excellent hospice providers. Three is to really use positive stories and stories actually was kind of what they emphasized here, which is, tell the stories of the good outcomes that your organization is achieving, and we hear a lot of the negative and the horror stories and some of the problems, but making sure that you are conveying stories that are powerful and that convey the positive nature of what you're doing. Fourth, invite dialogue, and not just once and so this idea again, of choice and what matters to you may change at different points in your trajectory, and so revisiting conversations and letting people know they will be a part of a dialogue. And that leads into the fifth principle, which was to invoke a new team that most people in healthcare, through our healthcare system, don't experience themselves as part of a healthcare team. They often don't get asked what matters to them, but they are and they can be, and hospice is excellent at this right.

Marcus R. Escobedo: 49:58

So, making sure messaging and communications is conveying that you, you family member, you person who is going to need hospice, you're a part of our team and you're going to be helping make decisions and making those choices along the way. So those five principles are really important. They can be found. One more website, though I'll give you seriousillnessmessagingorg, and a really nice site that will help you take some of these messaging principles, some examples, and use them in your day-to-day work. Perfect, Marcus, that's just solid gold.

Chris Comeaux: 50:29

Final thoughts.

Marcus R. Escobedo: 50:34

So many, I think, final thoughts would be just to summarize I think everyone should learn about age-friendly care and the four Ms. So come visit us at johnnyharford.org slash age-friendly and our partners at ihi.org slash age friendly. Use that serious illness messaging toolkit I just mentioned. Use reframing aging resources at reframingaging.org. Maybe I'll close with one final thought that I hope everyone will get a chance to see.

Marcus R. Escobedo: 50:59

We just released a new documentary film on PBS called Aging in America Surviveica survive or thrive.

Marcus R. Escobedo: 51:05

So one last website if you go to aginginamericasurviveorthrive.com, you can find a ways to access this film and it was airing on pbs and in certain locations around the country, will continue airing throughout the summer and then is accessible via amazon and pbs, and we also will make the film freely available for screenings.

Marcus R. Escobedo: 51:26

It's a powerful one-hour documentary narrated by Martin Sheen, and it tells a story of longevity and how that's expanded over time and what that means for this country, and it talks to real people around the country who are experiencing serious illness and health care issues and economic insecurity and raises up these issues as well as the solutions via experts that they talk to. So, it's a powerful film. I encourage everyone to check it out. It is based in part actually it is based in full on Dr Robert Butler, who was a pioneer in geriatrics and gerontology, the founding director of the National Institute on Aging. He coined the term ageism. It's based on his work in a book he published 50 years ago this year, called why Survive. So, check it out. I'll leave you with that thought.

Chris Comeaux: 52:19

That's awesome, Marcus. Well, I just want to just thank you for you and the entire team everyone in your organization I've met just so impressive. Your passion for this work is so evident and kind of feel like we are very kindred people. Hospice and palliative care people are pretty passionate about the work that we do. So you become a great admirer of other people that are passionate, and you guys are just doing great work, and so, thank you, give Terry our love and our thanks and your entire team and again, just really appreciate you and we're going to include all of those links that you actually mentioned.

Chris Comeaux: 52:49

And so, to our listeners, we want to thank you for listening to TCNtalks. Please hit that subscribe button, pay this one forward to a lot of your friends and peers at Hospice Empowered Care. There are so many pearls that I think can help us in the work that we do and a lot of good affirmations in the work that we do as well. And as we always want to leave you with a quote, actually, Marcus picked this one. I love it. It's from Dr Robert Butler, whom he just mentioned. "Today's children will one day be older people, and today's older people were once children. There's a unity and a continuity to life which we must bear in mind." Thanks for listening to TCNtalks.