ACS GSV Program Streamlines Age Friendly Hospital Measure Implementation

On August 1, the Centers for Medicare & Medicaid Services (CMS) released the fiscal year (FY) 2025 Inpatient Prospective Payment Systems (IPPS) final rule, which finalized the inclusion of the new Age Friendly Hospital measure as a mandatory measure within the Hospital Inpatient Quality Reporting (IQR) Program beginning with the 2025 IQR reporting period. The period of measurement is January 1–December 31, 2025.

Developed in collaboration with the ACS, Institute for Healthcare Improvement (IHI), and American College of Emergency Physicians (ACEP), this measure is designed to help build a better, safer environment for older adults and will help patients and caregivers find quality care.

Measure Details

The Age Friendly Hospital measure is a “programmatic composite” measure, which is a new type of metric developed by CMS in conjunction with the ACS. It considers the full spectrum of care needed for older adult patients (individuals over the age of 65) in the hospital and is substantially based on ACS Geriatric Surgery Verification (GSV) Program standards. Instead of a single metric, it is broader, akin to a “program,” and aligns with the ACS’s decades of developing quality programs that improve patient care provided by the clinical team with evidenced protocols and processes that enhance hospital efficiencies and result in better care and outcomes.

The Age Friendly Hospital measure incorporates five domains that target high-yield points of intervention for older adults comprising a total of 10 items to which hospitals must comply. The individual domains and items for compliance are described in the Table below.

The measure is mandatory within the Hospital IQR Program and is pay-for-reporting, requiring participating hospitals to submit data on quality measures to CMS each year in order to receive full Medicare reimbursement payments. If hospitals do not comply with reporting requirements, they will be at risk for reimbursement deductions and may face significant financial penalties. Hospital performance on IQR measures is publicly reported by CMS.

What It Means for Patients

Improving care for older adults is critical as this population in the US is growing more quickly than any other age group. Between 2010 and 2020, the number of people 65 years and older grew by 3.8%, reaching 55.8 million people (or 16.8% of the total population).¹

Older adults are often living with a number of chronic conditions, have higher healthcare use, worse healthcare outcomes, higher readmission rates, and higher rates of in-hospital delirium—all of which contribute to increasing healthcare costs.^2,3 Delirium alone has been shown to prolong hospital length of stay, result in functional cognitive decline, and increase risk of death in geriatric patients.⁴ Delirium is not limited to surgical patients and is just one example of an area for improvement that can be addressed by this measure, which focuses on improving care for these patients in an effort to reduce postoperative outcomes.

As the population ages, this measure is the first step in shifting focus to geriatric care on a national scale. With a national effort being put forth to care for this vulnerable and growing population, the next White House Conference on Aging will be in 2025 and help shape the landscape for older Americans in the next decade. It is critical that hospitals begin their involvement in this work now to build a foundation for more geriatric-focused work in the future.

Table. Measure Domains and Items

What It Means for Surgeons

To assist surgeons in streamlining this process and help ensure compliance, the GSV Program makes available resources to which surgeons and surgical teams will have access if they enroll in the program. These tools will give efficient and effective ways not only to comply with the measure, but also achieve improved care for this patient population.

Some aspects of the items in the Age Friendly Hospital measure are likely already being performed by most surgeons, their surgical teams, and hospitals. For example, item 3C entails collecting data on falls, decubitus ulcers, and readmission for geriatric patients, which is already being done by hospitals in accordance with other measures in the Hospital IQR Program.

Other items, such as item 1A (patient goals), are likely being done in part through the surgical consent process. To ensure full compliance and be able to attest to this domain, surgeons and surgical teams will need to continue discussing and documenting the aspects addressed in the measure (i.e., health goals, treatment goals, living wills, advanced care planning) and should continue doing this before major procedures and upon significant changes in clinical status.

What This Means for the Hospital

Delirium alone is associated with additional costs of approximately $20,000 per patient for the initial episode, in addition to contributing to significantly worse outcomes for patients, including increased mortality and readmission rate.^3,4

In surgical patients, for example, approximately 25% of both geriatric emergency general surgery (EGS) patients and elective geriatric surgical patients experience postoperative delirium.^3,5 It has been estimated that annual national healthcare costs attributable to delirium range from $143 billion to $152 billion.⁶ Targeting delirium has the possibility of not only saving the hospital money, but also generating additional revenue. The example in the sidebar on this page demonstrates the financial benefit of targeted interventions to improve delirium.

In addition to improved care, potential cost savings, and increased revenue, which we know occurs in hospitals participating in the GSV Program, hospitals can build a reputation for having the processes, structures, and resources to provide care for older adults through public reporting of their compliance with the measure.

Case Study: Financial Benefits of Improving Delirium

A 3.3 day–8 day increase in length of stay is attributable to postoperative delirium.⁷^,⁸ Additionally, approximately 30%–50% of EGS operations are performed on older adults.⁹^,¹⁰

If, for example, a hospital has 1,000 EGS cases in 1 year, approximately 500 of these will be in older adults. If, as demonstrated by Saljuqi et al., 25% of these patients (125 patients) are diagnosed with postoperative delirium at approximately $20,000 per patient, this will cost the hospital an additional $2.5 million and result in an additional 412.5 hospital days per year.

Preventing delirium will free up bed space for those 412.5 days for hospitals to admit new patients and schedule additional operations to generate revenue for the hospital. This does not account for costs saved by decreasing readmission rates which can be up to 53% of patients with postoperative delirium.⁴

The costs saved by the hospital will be much greater than the cost of the GSV Program itself, and the program entails only a small amount of additional time commitment for physicians and staff. Overall, decreasing delirium will not only improve the care of older adult patients, but also provide the opportunity for significant financial gain.

How Your Hospital Can Achieve Compliance

The ACS has been at the forefront of improving hospital care for older adults with the inception of the GSV Program, which launched in 2019 to improve surgical care for older adult patients. The new CMS measure is, as stated earlier, substantially based on the ACS GSV Program.

To help hospitals comply with the Age Friendly Hospital measure and improve care of older adult patients, the ACS has restructured the GSV Program to make it more accessible to hospitals, particularly addressing the widely varying resources existing across facilities. The new GSV Program is simple to do and is specifically tailored to address the 10 items included in the measure.

Also, hospitals that participate in the GSV Program will receive GSV status, the ACS Surgical Quality Partner diamond, and, upon request, a communications toolkit for hospital messaging about being a recognized ACS Geriatric Surgery Verified Hospital.

The collective aim is to ensure older adult patients get appropriate care, which was the nidus for developing the measure. As many of the measure’s elements may be new to various parts of hospitals, the ACS sought to help hospitals in their journeys. The ACS GSV Program will assist hospitals in starting this program by providing resources for scaling up to hospital-wide implementation. Surgical care is episodic and often standardized, so the implementation of a program in surgery is a valid and feasible way for hospitals to begin working on compliance with this measure.

It also is expected that taking a scaled approach will allow for easier management and oversight and help hospitals better allocate resources—ensuring that they are used efficiently and effectively without overwhelming the system. This approach has the potential to lead to successful and sustainable outcomes.

Depending on your hospital, surgical patients may make up a substantial number of geriatric patients, which can more efficiently meet the requirements of the measure. Of the programs that currently exist for care of geriatric patients, the new GSV Program is the only program that provides guidance for all 10 items specified in the measure.

How ACS Members Can Lead in Their Hospitals

In addition to participation in the GSV Program, surgeons can teach their teams about hospital care for older adults and champion quality improvement initiatives for these patients (see item 5B in the Table). Surgeons can serve as a point person or committee member for age friendly care to ensure that geriatric patients are prioritized in their hospitals (see item 5A in the Table). It will be critical to have champions from surgery as high-quality geriatric care is scaled up to the entire hospital. When surgeons are at the forefront of this initiative, with the resources from the GSV Program, they can help lead the rest of the hospital in complying with the measure.

For more information regarding the GSV Program, visit the GSV web page at facs.org/gsv and complete the interest form. Additional questions can be directed to geriatricsurgery@facs.org.

Dr. Sarah Remer is a general surgery resident at Loyola University Medical Center in Maywood, Illinois, and is an ACS Clinical Scholar in the College’s Division of Research and Optimal Patient Care.

References

US Census Bureau. 2020 Census: 1 in 6 People in the United States were 65 and over. Available at: https://www.census.gov/library/stories/2023/05/2020-census-united-states-older-population-grew.html. Accessed September 4, 2024.
Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and post-operative outcomes in older surgical patients: A systematic review. BMC Geriatr. 2016;16(1):157.
Leslie DL, Inouye SK. The importance of delirium: Economic and societal costs. J Am Geriatr Soc. 2011;59 Suppl 2(Suppl 2):S241-S243.
Gou RY, Hshieh TT, Marcantonio ER, et al; SAGES Study Group. One-year Medicare costs associated with delirium in older patients undergoing major elective surgery. JAMA Surg. 2021;156(5):430-442.
Saljuqi AT, Hanna K, Asmar S, Tang A, et al. Prospective evaluation of delirium in geriatric patients undergoing emergency general surgery. J Am Coll Surg. 2020; 230(5):758-765.
Leslie DL, Marcantonio ER, Zhang Y, Leo-Summers L, et al. One-year health care costs associated with delirium in the elderly population. Arch Intern Med. 2008;168(1):27-32.
Austin CA, O’Gorman T, Stern E, et al. Association between postoperative delirium and long-term cognitive function after major nonemergent surgery. JAMA Surg. 2019;154(4):328-334.
Kirfel A, Guttenthaler V, Mayr A, Coburn M, et al. Postoperative delirium is an independent factor influencing the length of stay of elderly patients in the intensive care unit and in hospital. J Anesth. 2022 Jun;36(3):341-348.
NELA Project Team. Third patient report of the national emergency laparotomy audit. RCoA, London, 2017. Available at: https://www.nela.org.uk/Third-Patient-Audit-Report. Accessed September 4, 2024.
Vilches-Moraga A, Fox J. Geriatricians and the older emergency general surgical patient: Proactive assessment and patient centered interventions. Aging Clin Exp Res. 2018;30(3):277-282.