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Discovering the 4Ms: A Framework for Creating Age-Friendly Health Systems

Terry Fulmer August 27, 2018

Momentous! That’s how I describe progress toward our goal of creating Age-Friendly Health Systems—vital work that incorporates what is talked about at the kitchen table into what needs to happen throughout health care.

In partnership with the Institute for Healthcare Improvement (IHI), the American Hospital Association, the Catholic Health Association and other experts, we’re promoting the kind of systems we want for ourselves and those we care about. For more than a year we’ve worked with five health systems as they rethink their care—Anne Arundel Medical Center, Ascension, Kaiser Permanente, Providence St. Joseph Health and Trinity Health.

The lessons learned are incredibly valuable. Our system champions tell us the work can be slow and difficult—the fatigue associated with transformation is real—but the signs of progress are nothing short of revolutionary.

We need this kind of revolution. America’s aging population is skyrocketing, along with demand for health care services. Two out of three older adults have multiple chronic conditions. Many are on more than five medications. In this environment, even health systems that have a clear understanding of what’s needed for excellent geriatric care become overwhelmed by what’s expected of them.

This work is all about doing better for older adults and their caregivers. Participating clinicians learn where care can be improved and how to operationalize it—and they’re taking a health systems approach, because geriatric care involves hospitals, primary care, home health and other settings.

In addition to clinicians, we’re involving patients and caregivers in this initiative. That means we’re learning together what patients want, where care is inconsistent, where interventions are needed and which are evidence-based. We’re also wrestling with where duplicative or unnecessary work of health care teams can be redirected.

We’ve learned that four high-level interventions—what we call the “4Ms”—are the essential, initial elements that systems need to provide older adults with the best care possible:

What Matters: Understanding what each patient’s health goals and care preference are across settings to know and align care, including (but not limited to) end-of-life.
Medications: If medications are necessary, using age-friendly medications that do not interfere with What Matters, Mentation or Mobility.
Mentation: Preventing, identifying, treating, and managing dementia, depression and delirium across care settings
Mobility: Ensuring that older adults move safely every day to maintain function and do What Matters to them.

The 4Ms provide a much-needed framework for helping system leaders and frontline teams consistently deliver high-quality, age-friendly care. The 4Ms offer a new way of organizing care for older adults, ensuring that essentials are covered consistently in every setting.

I’m thrilled by the passion that focusing on the 4Ms unleashes. At our recent meetings, you could feel the excitement for this new paradigm. There is pent-up energy and enthusiasm for a better way. The 4Ms have become a mechanism for rethinking the care process.

To be clear, hard work lies ahead. Harnessing that enthusiasm into a package of tested tools that hospitals and health care practices can use for quantifiable change is daunting. In fact, there may be a desire among some participants to take on some, but not all, of the 4Ms. But we’re learning how mutually reinforcing they are.

The first “M”—identifying “What Matters”—is proving to be a powerful starting point. Asking patients what matters most to them, in terms of their health goals and care preferences, has galvanized initiative participants. Hundreds of hours have been dedicated to studying how to ask, document and act on this question. It has become the springboard to action.

We’ll soon invite up to 100 more health system teams to join the Age-Friendly Health Systems initiative, and we’ll look at what different interventions yield. Ultimately, our challenge is to scale age-friendly innovation nationwide.

We face hurdles, including an insidious ageism that suggests older people feel how they feel and can’t improve much. The Age-Friendly Health Systems approach rejects that notion. It respects older adults and acknowledges that they can feel better, think more clearly and move more readily—if the health system is designed to help them meet their needs.

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Terry Fulmer

Terry Fulmer, PhD, RN, FAAN, is President of The John A. Hartford Foundation in New York City, a national philanthropy dedicated to improving the care of older adults. She serves as the Foundation’s chief strategist and is nationally and internationally recognized as a leading expert in geriatrics. She previously served as Distinguished Professor and Dean of Health Sciences at Northeastern University and is an elected member of the National Academy of Medicine.

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