Inpatient Implementation of Age-Friendly Health Systems: Qualitative Insights From Three Veterans Affairs Medical...

Implementation of Age-Friendly Health Systems (AFHS)-an initiative promoting healthcare safety and quality for older adults-is particularly important in inpatient settings, where older adults are at increased risk of hospital-associated complications and disability. The Veterans Health Administration (VHA) is the largest integrated AFHS in the country, but AFHS inpatient implementation within VHA is heterogeneous. To support broader implementation, we selected high-performing VHA Medical Centers (VAMCs) to examine factors contributing to their AFHS implementation success and the remaining challenges.

We selected three VAMCs with a high proportion of patients who had undergone complete AFHS 4Ms assessments (What Matters, Medications, Mentation, and Mobility) in at least one inpatient unit, as documented in the electronic health record (i.e., "high performers"). We conducted 11 semi-structured interviews with leaders and frontline staff involved in AFHS implementation, guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to elicit information on implementation strategies, facilitators, and barriers. Interviews were analyzed using template analysis, blending deductive codes aligned with i-PARHIS and inductive codes.

Across I-PARIHS domains, we identified facilitators and barriers to implementation. Facilitators included: flexibility to customize implementation to local needs; teams exhibiting interdisciplinary respect, role clarity, and passion for geriatric care; alignment of AFHS with existing patient-centered care values; leadership support alongside adequate resources; and champions who led education efforts and rallied support by demonstrating impact. Barriers included: challenges meaningfully eliciting and integrating "What Matters" into inpatient care; difficulty identifying short-term patient impact; discipline-specific staffing issues; and lack of AFHS inpatient teams to consult about implementation.

Successful AFHS inpatient implementation is affected by several interrelated domains. Learning from facilitators and barriers at high-performing VHA sites may help VHA and non-VHA health systems strengthen and tailor AFHS efforts to ensure hospitalized older adults receive age-friendly care.