The 4 Ms with Dr. Khai Nguyen

In this episode of TCNtalks, host Chris Comeaux welcomes Dr. Khai Nguyen, a geriatrician and age-friendly care champion. They discuss the 4Ms framework for age-friendly care, which includes what matters, mentation, medications, and mobility. 

Dr. Nguyen shares his personal journey into geriatrics, inspired by his father's health challenges, and emphasizes the importance of integrating the 4Ms into healthcare practices, particularly in hospice and home health settings. 

The conversation highlights the need for a paradigm shift in care, focusing on quality and patient-centered approaches.  

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Guest: 
Dr. Khai Nguyen, Geriatrician and Age-Friendly Care Champion for Care-At-Home with CHAP - Medical Affairs & Innovation at Community Health Accreditation Partners. 

Host:
Chris Comeaux, President / CEO of TELEIOS

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

Chapters

• 0:00 The Aging Shift And Care At Home
• 1:19 Meet Dr. Kai Wynn And His Why
• 7:38 Gratitude, CHAP, And Care At Home
• 10:15 Defining The 4Ms Framework
• 18:02 Applying 4Ms To Hospice And Home Health
• 24:04 Stories That Show What Matters
• 29:10 From Good To Great: Paradigm Not Program
• 34:58 Cake Analogy: Integrating The 4Ms
• 41:12 Baby Boomers’ Expectations And Mobility
• 48:06 Reframing Hospice With The 4Ms

Transcript

 Dr. Khai Nguyen: 0:00

You know, most older adults get their care daily, not in the hospital or the acute care setting. They actually get it in the care at home space. And interestingly enough, here in the United States, by the time we all hit 2030, the last baby boomer will have turned 65. And around that time, older adults will outnumber children less than 18 for the first time in our country. And I think that that demographic shift, that demographic milestone, is something that we are starting to feel today. Your care doesn't just start and stop in the hospital. And I think I oftentimes, uh, share with patients what happens to be in the hospital is like the tip of the iceberg. And 80% of your care is what's after uh the hospitalization.

Chris Comeaux: 0:51

You know, there's a quote that I grew up with in the hospice that I've just recently revisited. You know, sometimes when phrases become cliché, we lose the richness and the wisdom. But it's when basically a hospice is about adding life to days when days can't be added to life. But now we know people getting care from a good hospice also can add days to life.

Jeff Haffner: 1:15

And now our host, Chris Comeaux.

Chris Comeaux: 1:18

Hello and welcome to TCN Talks. I'm so excited today. We have a guest. Our guest today is Dr. Khai Nguyen. He's a geriatrician and age-friendly care champion for Care at Home with CHAPTER, Medical Fairs and Innovation at the Community Health Accreditation Partners. Welcome, Dr. Nguyen. It's so good to have you.

Dr. Khai Nguyen: 1:37

Well, it is wonderful to be here, Chris. Thank you very much. Thanks for inviting me.

Chris Comeaux: 1:42

I want to read from your bio. Dr. Nguyen holds a profound interest and a passion for the convergence of health policy and medicine, which is pretty cool. Dr. Nguyen is a board-certified physician in internal medicine and geriatrics, and he is a former hospice medical director. He provides comprehensive care to senior patients, prioritizing disease prevention, managing chronic illnesses, and geriatric syndromes, and preserving their functional abilities. Dr. Nguyen completed a fellowship in geriatric medicine at the University of California, San Diego School of Medicine, and residency in internal medicine at Scripps, General Hospital in La Hala, California. He earned his medical degree from the University of Vermont College of Medicine in Burlington, Vermont. And he holds a master's degree in health policy and certification and health finance and management from the John Hopkins Bloomberg School of Public Health. His health and policy experience includes previous work at the Centers for Medicare and Medicaid Services, CMS, Division of Health Promotion and Disease Prevention, where he contributed to the Healthy Aging Project. So, Dr. Nguyen, I am so excited. What maybe I left out, or what would you want our audience to know about you?

Dr. Khai Nguyen: 2:51

Well, first of all, Chris, thank you very much. And I appreciate the audience joining us today. But I think that the the roles that I took on was really a journey towards uh you know geriatrics and age-friendly care. And for me, Chris, it started when I was 12 years old, uh, believe it or not. Uh and at 12, um, my dad, who was significantly older than my mom, uh, he had suffered a stroke. And at that time, that really changed a lot of things uh for me, not only as a 12-year-old, but ended up changing the trajectory of which I wanted to go down. And over time, I just realized that, you know, seeing the doctors, the nurses, uh, all the healthcare professionals, you know, uh uh mainly I uh a physical therapist comes to mind for me helping my dad after his stroke. You know, these were the individuals that I wanted to emulate. I wanted to hopefully be one day to kind of help people like my dad. So that that was what shaped me to be a future healthcare professional and eventually go down a path of public health medicine and uh led me uh to take care of older adults like him. And seeing him and his healthcare journey uh and his set of illnesses, where he became more frail and more frail as time went on, uh, then developing dementia uh was something that that uh touched my heart as a son uh and eventually as a student and uh then into a professional and a physician and a public health practitioner.

Chris Comeaux: 4:41

I love that. And first time you and I, it's Cordt Kassner who connected you and I. He goes, you’ve got to meet Dr. Nguyen. And when we did connect, and you shared that story, and it I could tell it just comes from a deep place of passion and authenticity. Um, you are, and you want to make a difference in healthcare, and you're doing it with a really unique skill set. If you don't mind, I'll give you a compliment. You're a unicorn when you put all of those things together. And I mean that in in every sense of a positive way as it possibly could be. Well, I've really been looking forward to this show. I have fallen in love with the concept of the forums. And so, Marcus Escobedo from the John A. Harford Foundation, he was on the podcast earlier this year. And there's something in the way, like I had heard of it before, but there's something in the way that Marcus, you know, kind of a history buff, the way like how it came to be, it's almost like I saw the light. Like this is amazing. And so, and we'll we'll put maybe the show notes for folks to go back and check that one out too. And so how we got to the 4 M’s is just, again, it's amazing to me. And thinking about your background. So, we're gonna go there next about the 4 M's, sure. But first of all, maybe you want to talk a little bit because maybe it could further from your personal story. But the fact that you bring your unique unicorn skill set, but having such a strong background in geriatrics, how has that perspective maybe shaped the way you think about quality, safety, person-centered care, and healthcare? And how you're bringing that to CHAP is just so cool, which by the way, we're huge CHAP fans. We looked at we vetted all the other accrediting bodies and we said, you know what, we need an accrediting body we could recommend to our members. And we basically CHAP is who we actually partner with as TCM members, and now we do have a couple of members who are age-friendly certified. So that the 4 M’s is bubbling up kind of from the ground up within TCM, which is super cool.

Dr. Khai Nguyen: 6:32

That's wonderful. And really appreciate the work that you do. But I before I answer that question, is I just wanted to really uh share my gratitude for not everyone join everyone joining here, but also for uh Cordt Kassner who made this connection. Cordt has been uh just a really uh influential figure and a thinker and an innovator um you know on our board and leading our board. So that's always been appreciated. Um additionally, you know, you mentioned uh Marcus, uh, you know, Marcus and the Johnny Hartford Foundation, you know, gee, what this work could not have been done, and the very foundation of the work could not have been done without the Johnny Hartford Foundation, Terry Fulmer and the team there. So, a big shout out to uh to John A. Hartford, thank you very much. And uh, you know, the in the work that they're doing with the Institute for Healthcare Improvement as well. Um, but also uh, you know, the work being done, um Chap does center and root from the work that we're that you're talking about with geriatrics and that geriatrics perspective. And when I was asked to join CHAP several years ago and uh think about medical affairs and innovation is what can we bring to the care at home space? And at that time, I had just uh completed uh bringing age-friendly care to the health system where I'm at, which is University of California, San Diego, and I'm a professor of medicine there and uh helped to teach geriatric medicine. Uh, you know, the key thing there is that, you know, bringing age-friendly care to a large health system and hospital back in 2015, 2016, that that was something that uh was what was being uh kind of touted at that time, and that's where all the funding streams were. But what really affected me in thinking about genes, you know, most older adults get their care daily, not in the hospital or the acute care setting, they actually get it in the care at home space. This is where most older adults uh get their care. And you know, when I had an opportunity to work with CHAPTER and really the wonderful team there, uh not just the leadership, but all the way up to uh the site visitors and our teams and specialists, I realized this is the team to help bring age-friendly care to the home space. So, we worked very hard to work with the Institute for Healthcare Improvement, and uh we were awarded not one but two grants to help bring age-friendly care at home. And CHAPTER uh is the first accrediting organization um to help bring age-friendly care standards to the home space. And by virtue of that, we were the first to help uh bring age-friendly care certification into the home space for home health and hospices at first, and then a subsequent grant that brought it to private duty caregiving and you know we continue to the goal to expand because if we can bring age-friendly care to the care at home uh in a community setting, then I think we can influence more people. But I think I I didn't answer your question on the geriatrics there, because it was so there was there were so many pieces there and I think I think we can't move on uh from the beginning part of the answer uh from gratitude. And I think a lot of age-friendly care is gratitude, gratitude of older adults’ um who are oftentimes uh not only our grandparents, but our parents, uh like me, yeah, and who contributed so much to not only our lives, but our society.

Chris Comeaux: 10:30

That's so good. And you you're reminding me so much, and maybe I'll just give a couple of talking points of what I feel like I learned from John A. Hartford, and you clean it up if you need to, Dr. Wynne. But thinking about like we have a generation shift occurring. I've got 30 years now in hospice, so we care for the greatest generation. So, the baby boomers are now coming into health care, healthcare throughout the whole country, different aspects of all of our different um verticals that we have throughout healthcare, hospitals, skilled nursing facilities, ALFs, um, home health agencies, hospices, et cetera. And so, the baby boomers have not gone quiet in any part of our economy ever. And so, this is a major shift. And the four M's is a framework that deeply, I think would absolutely have resonated with the greatest generation, but very much resonates. And so, the four M's is a great framework to be an age-friendly organization. Um, would you say that differently or would you clean that up?

Dr. Khai Nguyen­: 11:27

You know, I wouldn't clean it up. I would add to it if I can. I mean, I think I think the very structure of what you're saying is an appreciation and respect of a generation that has really helped to build this country to where it is. And I think that, you know, even though we have challenges, but every generation has challenges, I think we just have to meet it. And I think as part of meeting this challenge for the baby boom generation, it's it really affects us down the line because it is one of the largest aging populations. And you know, the thing that that still uh is most interesting to me is that most, I would say, even doctors and nurses I work with may not know that we are currently in the decade of healthy aging. Uh and that's according to the World Health Organization from 2031, um sorry, 2021 to 2030. And the purpose of that is to really celebrate this this global aging phenomenon that we see. And interestingly enough, here it in in in the United States, by the time we all hit 2030, the last baby boomer will have turned 65. And around that time, older adults will outnumber children less than 18 for the first time in our in our country. And and I think that that demographic shift, that demographic milestone is something that we are starting to feel today. We are starting to feel it in our our daily lives when we're taking care of uh our moms and dads and our grandmothers and our aunts and uncles. But also for those watching, is you're feeling it in your daily work and that that frustration of how are we going to meet that challenge? And so, when the rough get going, the the tough get going as well. I think I think I miss misstated that the Billy Ocean song, but uh but I think he'll forgive me.

Chris Comeaux: 13:38

Well, we've I think we've got our listeners like hanging on the edge of the s their seat. What is the 4Ms? Uh-huh. Yep. So, can you briefly explain it?

Dr. Khai Nguyen: 13:48

Sure. I I I think that is key to really understand what uh the age-friendly care and the 4Ms are. Um and uh but you know, as I describe the 4 M’s of care, I'll describe how they came about in a few moments, but let's not have people uh hang at the edge of their seats. Uh the age-friendly care is is essentially described by a 4 M’s framework that was developed uh based on evidence. Um and so number one, the first M is actually what matters, it's the matters part. And what matters is about knowing, aligning the care of each individual older adult and how their specific health outcomes connect with that, and what are their goals and preferences? We're not just talking about uh limiting it to end-of-life care, but we're talking about current goals of care and across all care settings. So that's what matters. Then we now move into mentation, and mentation is really the brain health and mind and thinking about how the in the work that we all do is preventing, identifying, treating, and managing d dementia, uh, or major neurocognitive uh deficits, but also coexisting depression. Uh, and in cases where we're talking about acute care, post-acute care is how delirium can oftentimes affect that care and be prevented. The next M is medications. Uh, and the idea here is that, you know, there are medications that affect older adults more significantly. I know we oftentimes hear the beers list, but you know, medications generally that do not interfere with the other M's. Uh and we think about it in all care settings. And it doesn't mean that older adults shouldn't be on some of these medications, but that if they are on it, that we do have a way of considering deprescribing the lowest effective dose and really limiting those to the best uh possible way. And the last M, but not least, is mobility. And you know, oftentimes, you know, we think about mobility as about allowing older adults to move safely uh around their home and their and their environment, maintaining and preserving their function. And the key thing here that I just want to share with the audience is that when we think about these four M's, um I've been told before, you know, it's something that we already do, Dr. Lynn. Um it is something that you already do, but you may be doing in separate pieces and portions. But the key thing here is to really work with it as a set. That's the innovation in age-friendly care. Is that is that when you think about medications, you think about it how it may affect uh an older adult's mobility and how their mobility affects what matters to them, if they want to be taking their dog out for a walk or gardening um or being with their family, and also how mentation is affected by medications. And then so it's really something that all connects with one another.

Chris Comeaux: 17:13

That's so incredibly well said. And I think probably the first time I heard it, we had a we have an incredible team member, Raquel Braithwaite, who actually grew up in hospice but spent time in senior living, and she was the first person to share it with me. And I think I kind of had that, and it's that horrible human condition that AI is making worse. Been there got the t-shirt. Oh, yeah, the 4Ms. But there's something about the way Terry first with um Jenny Hartford and then Marcus communicated it that was like, oh, wait a minute, this is profound, and this could actually be, I think, very powerful for our future. So, I'm gonna repeat them for our listeners because I have them now memorized. And so, what matters medication, mentation, and mobility. And so, how do you see that, Dr. Wynn, translating specifically into the hospice and powered care environments since that's where most of our listeners are?

Dr. Khai Nguyen: 18:04

Yeah. So, you know, I think it fits perfectly in that because, you know, with home health and hospice and in the care at home, your care doesn't just start and stop in the hospital. And I think, you know, I oftentimes uh share with patients what happens to you in the hospital is like the tip of the iceberg. And 80% of your care is what's after uh the hospitalization. And really when we think about the 80%, uh we are thinking about oftentimes home health hospice. Sure, there's outpatient care where I I do clinic as well. But when we think about that is that you're if someone's on home health, they are getting skilled care to get back to where they were. Um to and it m there is a what matters to why you want to get back and to you know uh regain your skills and preserve your skills for your mobility. But also, that's affected by what medications you're on. Perhaps new medications that you're on. Uh and not all those new medications are gonna be medications a person's gonna be continuing uh throughout. So uh and then uh of course we can't forget the mentation aspect as well. That's still very important. But for a home health uh organization and home health team to come in and understand how to use the four M’s effectively will lead to better outcomes. Uh, you know, this is a an evidence uh evidence-based care practice, is that, you know, when they when they thought about bringing the four M’s to light, meaning the Institute for Healthcare Improvement, was they brought in all experts uh nationally and they said, hey, let's look, let's look at all these models of care for older adults and geriatrics and what works. Uh and they brought in an interdisciplinary team. And they distilled it down to the four M's and they said, if you practice the 4Ms, each older adult patient, each time, every interaction, then you will have achieved evidence-based care and medicine. And the same uh very similarly goes for hospice. And I and I certainly respect that home health and hospice are not the same thing. But the similarity in the care, in the dignity of care, I think is even ever more so uh when it comes to home health and specifically for hospice. Um we do our are thinking about end-of-life care, and you know, oftentimes uh and I think I'm really speaking to the crowd here when you know you may hear, well, hospice is about giving up. And I always share with families it's not about giving up, it's certainly a different philosophy of care, but there's still so much medicine, nursing, and care to be practiced and to be to be provided to you as a patient. And that care oftentimes can be age-friendly care. Um, and I think that again, this is a rather simplified framework, but oftentimes, you know, we're going really back to the basics um and the foundational, foundational pieces uh when I say basic.

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Chris Comeaux: 22:11

Yeah, I you know, there's a quote that I grew up with in hospice, but I've just recently revisited, you know, sometimes when phrases become cliche, we lose the richness and the wisdom. But it's when basically a hospice is about adding life to days, when days can't be added to life. But now we know people getting care from a good hospice, we also can add days to life. And so, it's life to the full. And in many cases, sometimes people do live more deeply in their time in hospice because they're faced with their own mortality. And there's beautiful things that could occur. And what I've recently, the light bulb is going off is, and using that framework, like, do we know what matters most? Um, one of the stories, Dr. Wynne, my I fell in love with hospice at 25. That's how young I was when I came in. And our hospice would ask that question, what matters most? And it was a dad and son that had been estranged for 35 years, um, had not seen each other in 35 years. The long story short, our volunteers arranged a fishing trip because that's what mattered to them. They were both under hospice care at the same time, had no clue. And it yeah, I would say heartbreaking story. Obviously, the son was much younger. And then the dad died like two weeks later after that reunion. But just beautiful, just like, oh my gosh, what is this thing? Um, but because they asked what mattered most, this amazing reconciliation occurred before the dad passed away. And then actually the son was on our care for quite a while, actually. And so, when I think about like bringing that in on a day-to-day basis, and of course, you know, the medication, there's a lot of good deprescribing. Um, there's so many contraindications and things because the left hand and the right hand don't communicate in the rest of health care. Um, I'm seeing new frontiers. Uh, now there's some pharma genomics, I think that's the right word, that are coming in to, you know, even like how they metabolize different medications, it goes down to the gene level. Um, mobility. We don't do therapy as often as we probably should in hospice, but you have to be thoughtful about that as CHF patient versus other patients. Um and, you know, so and then the mentation side, it's so funny. I came in and taped this podcast. Uh, we have these future councils that we've actually conducted this year, that there are eight challenges facing all hospice empowered care programs. Well, one of those future councils is mental health, because we're seeing the lack of a true mental health care system in our country washing up on the shores of our hospices. And now we're seeing more challenges. Like we literally in this meeting, just a really horrible situation that's now in the hands of this hospice, that there's so many other points of failure in the rest of the healthcare system. And now you got hospice people that really don't exactly have the right tools that are caring for someone that is terminally ill, but it's really a mental illness that's actually leading that situation. So I can see where these four M's are almost like, be careful, people are like, oh yeah, been there, got the t-shirt. No, no, no. I think there's a whole new frontier here where we could go deeper and become even better experts at doing that well. Would you say that differently?

Dr. Khai Nguyen: 25:20

Or yeah, you know, I would say that while I do recognize for our colleagues that the hard work and the just, you know, really the hard work and the effort that we all put in every day to care for our patients, it's not that that's not the right work, you know. Um, but it's it's really thinking about how we can do it better, more efficiently. And then we then we think about quality and what makes sense, right? So, all you know, all those things that you said earlier are really moving us from good to great. And I think that, you know, yes, it does take effort. It does take effort. Uh and uh you know, I but I I think it's well worth effort, especially when getting from good to great and being more efficient is actually easier. Um, you know, oftentimes when I do talk about uh and what I want to add on to what you were saying is that oh, not another program, Dr. Nguyen. Not we don't wanna do one more thing on top of what we're already doing. Please don't add something else. But age-friendly care in the 4M's framework is not about adding a new program, it is about a paradigm shift in care on things that honestly most of our audience is already doing. But doing it now with intention and keeping in mind that connection between what matters, mentation, mobility, and medications is very key in how they interact with one another. And I'll just share with you a quick story here. Um, I was with a uh a medical student, and I I really enjoy working with medical students because uh they all come from various backgrounds, you know, just like you and I, right? And uh this particular medical student, it was right before lunch, and I was sharing my forums like I just did to you all, and my medical student says, um, I don't want to be mean to you, Dr. Wen, but we already do all those things. You know, we get a pulse, a physician order for life-sustaining treatment, or in some states it's a MOLS, right, for medical order. Um, we already reconcile their meds, we ask them about their medications, we have them uh they're getting up out of bed in in physical therapy, and uh we also uh making sure that you know uh their mentation is is well as well, and we check up on them and ask them the PhQ9 and so forth. And I said, well, okay, that's good, but uh, you know, they still don't understand that sort of the interaction. So, I I said, well, let me let let's identify here. It's about lunchtime and we're all both getting hungry. I go, what do you what do you enjoy doing? And the medical student says, I enjoy baking. So I go, okay, let's choose baking as an analogy here. And I said, well, if I gave you, if I gave you flour, eggs, sugar, and chocolate, you know, if you ate that alone in each of the ingredients alone, would it taste good? Would it be chocolate cake if I asked you? And they go, oh no, that would be gross. You know, that would make no sense. You it'd no sense at all. You're just eating the ingredients alone. And I go, aha. So in order to really bake something in and make a good chocolate cake, you have to put a lot of you know, TLC in there and mix things up, and that is truly baking a cake. Um, and then you have your chocolate cake, right? So, they and they said, yes, that makes sense. And I said, that's the thing with age-friendly care, is that you really have to it it has to be baked into care. And when you think about the cake once it's fully done, you can't be like my nine-year-old son who just eats the icing only, you know. And I said, if you want to enjoy a cake, you gotta enjoy all layers of the cake. And this cake is four layers. It's what matters, medications, mentation, and mobility. And so, and you gotta eat all four layers to really get the sweetness of the cake. And you know, we just have to let them eat cake.

Chris Comeaux: 29:47

That's really good. That's I I love that analogy. I'm gonna definitely quote that one several times. And would you also agree, Dr. Wynne, that I cause, and I love your graciousness, because yes, most really great hospice and powdered cure teams. They're attending to the four M's. But I also wonder, just like great medicine, right? There are always new frontiers being discovered. There are probably frontiers of our thinking about these four M's and then how they also synchronize together that are probably yet to be discovered. Like how can we relook at it fresh eyes? Like the one I poked on. I don't know if you would agree. But I do think that there's probably some level of therapy that could become part of standard of care and hospice that is very rare currently. And I think as we go into the baby boomers, and I hope our listeners don't miss this, the customer is changing. If we were running a typical business, we would not lose the fact of, well, wait a minute, what does the customer want? The customer wants the 4Ms, and the customer wants it incredible. They have wanted the best of the best in every other part. You know, why is Starbucks a thing? All these interesting, great experiences now, you know, vacation homes and experience vacations. I mean, baby boomers were the leading edge of all that. And we would be we would be incorrect to just go been there, got the t-shirt, and we're gonna do the hospice thing into the future with the baby boomers like we've done for the past 30 years.

Dr. Khai Nguyen: 31:11

Yeah, you know, I and I so I do agree with you. I I think that, you know, this is care is it's not just a target, right? A target assumes that we are going to hit it at some point. Um certainly we do target good care. I think that's wonderful. I think we should be precise and as accurate as possible. But I think it's a moving trajectory because there are expectations to what is quality, right? What is value in care. And I think with the baby boomer generation, I don't pretend to know everything about this amazing cohort, but it is something that we do have to meet, um, and that challenge of that. You also mentioned that, you know, hey, physical, you know, therapy, right? Physical therapy, mobility. Um I think that there are there are certainly aspects of maintaining, preserving functioning that we ought to really consider is that as people are, you know, especially in home health, we know that. But even with hospice, I think yes, we do see that as end-of-life care, but we still have to really focus on all these aspects that really help to have to help people have that quality of life. And a part of it is mobility. It's not just being bedbound and but again, I think we're preaching to the choir here, but I do think at some point that that has to move and change, absolutely.

Chris Comeaux: 32:38

You've also alluded; I love that you've used good to great several times. And so, this is beyond the scope of today's show, but I have this theory that revisiting good to great, like there's something about the season where we are, and I've noticed you've used it several times.

Dr. Khai Nguyen: 32:51

Yeah. You know, I mean, it's uh, you know, it's a very good book. Um, and the piece here is I, you know, I hear it oftentimes an awful lot, that you know, it is hard in the in the mix of daily care um to be, you know, we're doing good already. You know, this is this is good work. And it is good. But I think it's one of those things that if we aim, if we aim for the stars, um, you know, and we hit the skies, it's it that's great. You know, I mean, right, you know, and perhaps that's not the best analogy. I'm sorry if I'm actually analogies.

Chris Comeaux: 33:32

I think it's actually really good.

Dr. Khai Nguyen: 33:33

Yeah, but I do feel that the work that we all do, sometimes we do feel it it's just good, but it's actually great to most of the world. I think that, you know, whenever I get a chance to um, you know, I'm not out in the field as much anymore. I'm mostly relegated to the clinic, as you can see with these scrubs. But whenever I do get out to do a home visit, uh, I do get out to to uh observe care at home, you know, I just I gotta say, I get tingles talking about it because I think that's where great work actually happens. You know, when you're when you're in the hospital, and I'm not picking on any nurses or doctors working in the hospital here, but the hospital is this very specialized space that is, you know, state of the art and it has all these tools and everything, um, and you can get a lot done in there. And sure, great things happen in there, but nobody wants to be in a hospital, right? And when people are home um and they're getting care, even the simplest, basic but foundational pieces of care can be great. And I think that the work that that really, I'm just speaking to the audience here, that you all do every single day, home to home, door knock to door knock, uh, is that it is great work. And I think that great work deserves to have a foundation with great evidence-based care. Uh, because a majority of people you take care of are going to be older adults, uh, and older adults of this generation that I agree with you, Chris. I think people do expect uh great care.

Chris Comeaux: 35:14

Another question I'd like to run by you. Um, I have a theory since I've again fallen in love with the 4 M's. You know, we've struggled most of our, at least I know, well, beyond my 30 years, even before, um, about how to talk about hospice. And so, Dr. Byock recently, I'm sure you're I'm a great admirer of Dr. Byock. We've had him on the podcast. And he wrote a strategic framework about the path forward for hospice. And one of his, he had four components of it. One of them was he called it the authentic brand of hospice. And I believe what he's saying there is how do you talk about what we do in such a way that the patient and family will receive it? Because today, when you use the word hospice, oh no, we're not ready for you yet because we're not dying tomorrow. Hospice has become synonymous with death. And it creates this great wall of communication that we can't get beyond. And so, here's my theory. I think the forums gives us a framework to talk about what we do in such a way that the patient and family will hear it and go, I need that. And we don't have to use the word hospice. And it's not like we're trying to fool anybody. I mean, there'll be paperwork that says hospice, but we could talk about what we do in a way that actually they understand, as opposed to, oh no, no, no, I'm dying tomorrow, and then they can't receive it. And one last thing, and I'd love to hear respond, um, and this will be for those that are watching. We have this amazing team member, Tina Gentry, she used to do this great presentation in the community, and she'd points her head and say, you understand hospice. In other words, you understand in your brain. But once you experience it, she would then put her arms around her heart and she would say, and now you really understand what hospice is. And it's like you've almost got to do those motions to connotate to people that after you experience this, you have a much deeper understanding. Unfortunately, because the words that we use, people then don't choose it. 50% of people in America still have 14 days or less of care, which is horrible. It's a six-month benefit. It's a beautiful benefit. It's as much for the caregiver as the patient. So, all that to say, my theory is the 4Ms is a way to talk about what we do without having to use that word. What do you think?

Dr. Khai Nguyen: 37:21

No, I honestly have not thought about that until you during this interview, uh, as you were just sharing that. I think the 4 M’s can be used for that. I mean, I think it that's the wonderful innovation in that. And, you know, you know, as strange as it may sound to to you in the audience, but you know, for some of my patients and their families who really do need hospice, I mean, they it's something that I feel at the core. Uh it's not just the philosophy, but really the benefits, the, the, the number of benefits people have um and the ease of care uh made easier and more efficient. Um, I do say, look, at the end of the day, the key components of why the doctors feel that you would benefit from hospice and your care would benefit from hospice um are there. And it, you know, you paid into the Medicare system. It's something that, you know, should not cost extra to you at all. Um but you can call it whatever you want. You don't have to say, you know, the hospice program. There's no there's no requirement that I'm aware of, Chris, that says you have to call it hospice. And I'm not suggesting anyone here to lie to family members, but really, you know, for instance, I think about hospice as a journey as well, right? Speaking of journey, my journey into uh age-friendly care and geriatrics is hospice is like a journey, you know. I I remember um, you know, I so we're huge Disney fans uh in our family. So we love going to Disneyland, Disney World, and Disney cruises. Um, but oftentimes when we refer, you know, as something as wonderful as Disneyland and enjoying it, um, we don't always say it's our Disney vacation. We just say it's our family vacation. And it's not that we're lying to one another, but it is, it is our family vacation. And in a way, when people are getting care in hospice, you're getting care, you're getting the best care, you're getting age-friendly care. You are getting care towards the end of life, yes. Um, but I really appreciate what your colleague said. You understand it in your head, but you feel it in your heart. And we all do, we all do know that. A majority of people, you're right, do get care just in the last two weeks. And um I it is something that I think um we're gonna hopefully help people shift away from that. Um, but I I think what's also affecting that too is that there is this, not only is it in the mind and the heart, but it's also in wallet and regulations that, you know, there's a lot of regulations on hospice, and there's also a lot of press on hospice uh with perhaps some negative press on it, which is which is not helping it as well.

Chris Comeaux: 40:07

Yeah, what we said in a prior podcast, or Court Kastner, actually and I, that, you know, hospices that we take what we're talking about in the forums and go, this is a framework. You know what? We're gonna make sure our team is highly skilled in these areas. Yes, we're good today, but we're gonna become great in those areas. We're gonna go all in on that. We're even gonna think about our language and how we talk about it. We're gonna think about our marketing around that. Um, I think that's uh road less traveled. And what's getting the negative facts, they're not even in the same game as that. That's they're playing a different game that's fraught and very icky at a very vulnerable time of people's lives. And you know, if you're the trendsetter in some business, you're not talking about some podoc crappy business that supposedly is in the same industry as you, you're setting the standard. And that's where I'd like to put our energy going forward, which again is why to me these forums is just brilliant, which maybe leads a good segue. So, how is CHAP then helping organizations move forward towards becoming more age-friendly? And do you see the 4Ms influencing how those accreditation standards and quality metrics then evolve? Because then they could be assisting kind of this vision that we're painting with each other.

Dr. Khai Nguyen: 41:16

So that's a two-part question. And so, the first part is yes, you know, uh CHAP, uh community health accreditation partners having uh received two amazing grants from the John A. Harper Foundation. So, we are the ones that are working with the standard bearers of this movement. And I think there's something to be said about that because you know, the Institute of Healthcare Improvement, we still work with them very closely to make sure that all the work that we're doing continues to align and grow with the movement. Uh and with that said, though, developing the first certification, that certification um is the first set of standards. And the way, the way I certainly look at it, and the way we look at it at CHAP, is that your certification is the foundation of quality for which you can launch off from. And I think having that badge that says age-friendly care certified at home is is important. It is good to celebrate it, it is good to share it with you with your community that we are an organization that really thinks about the care that we provide for our older adults, but beyond thinking about it, we actually accomplish it. Um, and uh so that that's something that is available to uh any organization that is newly interested in uh their accreditation and also organizations that are you know recertifying. And the interesting thing is that there is no additional cost if you are initially certifying for getting and uh essentially applying for the age-friendly care at home certification and also for recertifying. There is no additional cost, in addition to obviously your site visit fees. So, uh that's something that I I think is just another bonus. You know, it's a total bonus. It's not a new program and it's not a new fee either. Uh and it's because we do believe that this is something good and great for our organizations to be able to consider uh and not at the end, but the final result is its good patient care. There's a second part to that though, Chris.

Chris Comeaux: 43:26

The second part was do you see maybe the forums influencing the standards and quality metrics and how we evolve into the future?

Dr. Khai Nguyen: 43:34

Yes. Um I I it's not only if I see it, but also already happening. Now some of you may have already heard in 2024, I think towards the latter half of 2024, the Centers for Medicaid and Medicare Services that that administers Medicare now has approved uh and it is running a CMS age-friendly measure on the inpatient service. So, for hospitals, um they required now to in 2025 to report out if they are doing the four M's of care. So and uh, you know, I I think that that is a huge step because any hospital that participates in the uh Medicare, I think it's the IQR uh reporting program and essentially receives Medicare, uh is at risk of you know, losing money and dollars and funds uh down the line if they don't uh address the four M's of care. Um and the first, I think that the 2025 is gonna be a report out a structural measure. And then I think as the years go on, as we can imagine, it's going to be then attached with a certain uh level and percentage uh of accomplishment. And so, you know, and we do know sometimes that what happens in the inpatient and hospital acute care setting oftentimes finds their way washing up on our shores in home health and hospice. And so even if it it isn't happening now, I think it's gonna happen in the near future. But even for organizations that are hoping and wanting to work with a certain hospital that is that is needing to fulfill their structural measure, but you also say, oh, we are also age-friendly care certified. We also practice age-friendly care. It's the same language to be able to market uh and directly have conversations with and really distinguish your organization and your practice from the myriads of others in your community.

Chris Comeaux: 45:43

I totally agree with that. I think that's brilliant. So, as we start to land the plane here, if you could share one or two calls to action for hospice leaders in particular listening today about embracing age-friendly, forum-based care, what would it be?

Dr. Khai Nguyen: 45:58

I think the one or two calls to action is uh firstly, you're already doing it. Uh joining this podcast, uh learning about it. And if you said, oh, I already know about it, great. This is a good uh a good uh other uh impetus to say, you know what, maybe we should take a step uh towards age-friendly care and have our organization move into that space. Um there are resources uh on CHAP uh at chapink.org uh or the Institute for Healthcare Improvement as well. Uh and I think that these are the first steps, and there's usually no cost for the first steps. I mean, time, time is always a cost, right? But I think time well spent is an investment that has uh dividends uh of return on that one. So, the first step you've already taken, and the second step is to move forward into that space, uh, contact us and uh start your journey. Start your journey from good to great. And if you're already great, you could even be greater. Absolutely.

Chris Comeaux: 47:02

So, there's no there there.

Dr. Khai Nguyen: 47:03

Yeah, there's no, yeah, exactly. So I think that with this moving trajectory of care, um, it's just staying on top of it and having the four M's at your side is just it makes it run so much more efficiently.

Chris Comeaux: 47:18

That's so good. Yeah, no, thank you, Dr. Wayne. Thank you for the work that you're doing. Because I I really do believe that the 4M's and the age-friendly um initiative is I think the time is now. And again, you know, kudos to John A. Hartford because they deserve a lot of credit. We actually are connecting with IHI. We're gonna probably have them on a podcast as well. So, we're gonna keep singing this from the mountaintops, because as I said, we believe that number one, it's the right thing to do. It's where the customer is wanting us to go. Um, interestingly, I have a family member who is diagnosed with Parkinson's. And um it was back in the fall. And then in the spring is more when I first really connected deeply with what the forums was really saying. And then going back to that whole care experience and thinking, oh my gosh, this is what was missing. And, you know, thank God I'm in healthcare, helping a family member traverse this kind of just labyrinth that we've created in healthcare. But it's really what I was grasping for because I knew what was most important for that family member, but didn't have a framework to even have the communication with them. I was trying to be that Rosetta stone between them. So, there's just so many applications, I believe, to what you're working on here. So again, major kudos to you and your team. Uh I'm obviously pretty passionate about it. We're gonna have links to the um forums within the chat website. And anything else you want to share with us, we're gonna include those.

Dr. Khai Nguyen: 48:40

And and so I do have the quote here. Um and uh so the quote is you and I actually have this in my college essay, but I I think it has really followed me through and throughout as I went on through my journey to become a geriatrician and in a space. And it's a quote from pilgrims that were requesting permission to sail to the new world. And it reads, It is not with us as with other men or people whom small things can discourage um or small discontentments shall cause to wish themselves home again. And you know, that holds true to me because you know, it is that perseverance, it is that desire to not settle with what is good or what is great, and even go for something that is greater. And and I think that we are all going through a time in in our new world in healthcare, in this new healthcare that is is coming up. And to me, 2030 is a is a number in a year, but in order for us to get there, we do have to have these building blocks to continue to build upon a foundation. And I think that the 4M's age-friendly care and age-friendly care certification can be that foundation for you as a health professional, um, but also for your organization and to continue to build on top of that. And don't let these discouragements and discontentments wish for you to go back or home again, that we can go forward. So, um I I thank everyone very much, and again, gratitude for uh Chris to inviting me here and for everyone's time. Uh, really appreciate it.

Chris Comeaux: 50:28

Thank you, Dr. Nguyen, and thank you for the work that you and CHAP and just all the wonderful people that you're influencing. And to our listeners, we thank you. Be sure to hit that subscribe button. Pay this one forward, especially to your friends, your co-workers, your colleagues, not only within your own hospice, but other hospices you know as well. We want the forums just to catch on like wildfire so we can make a great difference as we go forward into this future. So, Dr. Nguyen, thank you, and thank you to our listeners. Appreciate you listening to TCnTalk.