Outcomes Evidence Must Keep Up with the Implementation of the 4Ms Framework to Ensure Age-Friendly Health System Transformation

Abstract

The Age-Friendly Health System (AFHS) movement was conceptualized as a transformative solution to reliably deliver evidence-based care to older adults. Guided by the 4Ms framework: What Matters, Mobility, Mentation, and Medication, AFHS healthcare systems have been given the flexibility to tailor 4Ms interventions and care processes to their context, preferences and populations. This flexibility has facilitated the widespread adoption of 4Ms care. However, as our understanding of 4Ms implementation grows, evidence of the impact of 4Ms care on outcomes must keep up with implementation to ensure AFHS transformation. It is only through assessing the 4Ms as a whole and understanding the interplay between the Ms in relationship to outcomes that we can understand: (1) value-generation to-date, (2) how variation in 4Ms implementation can maximize equitable value realization, and (3) if, and how, to expand the framework most effectively. We propose seven strategies to catalyze the generation and dissemination of robust evidence to support AFHS transformation. These strategies are organized around activities that individual healthcare delivery organizations, researchers and evaluators, and other key informants can pursue. Expanding evidence generation and disseminating findings using these proposed strategies will support the 4Ms framework as an effective vehicle for improving health outcomes for older adults.

Introduction

The number of Americans aged ≥65 years old is projected to increase from 47% from 58 million in 2022 to 82 million in 2050.^1,2 Older Americans feel deeply dissatisfied with the US healthcare system, reporting that it is unresponsive to their needs and preferences.^3,4 In response, the Age-Friendly Health System (AFHS) movement was conceptualized and offers a potentially transformative solution. ³ This movement, guided by the 4Ms framework – What Matters, Mobility, Mentation, and Medication – aims to reliably deliver evidence-based care to older adults. Since 2017, nearly 5,000 healthcare delivery organizations nationwide have received AFHS recognition from the Institute for Healthcare Improvement (IHI). ⁵ AFHS recognition means an organization is reliably delivering evidence-based 4Ms care to older adults. ⁵ The rapid spread of AFHS and adoption of the 4Ms framework has been supported by IHI recognition and implementation Action Communities, alongside setting-specific efforts such as the American College of Emergency Physicians’ (ACEP) Geriatric Emergency Department Accreditation (GEDA).^6,7

Within these recognition and accreditation programs, healthcare systems have been given the flexibility to tailor 4Ms interventions and care processes to their context, preferences and populations. Notably, the IHI 4Ms implementation guide offers examples of potential care interventions (e.g. screening for cognitive impairment/delirium). ⁸ It specifies a minimum frequency of 4Ms care delivery by care setting, but organizational preferences dictate which screening tool(s) to use, which clinical setting to implement (e.g. primary care, nursing homes), and which patient populations to target (e.g. based on patient sociodemographic or clinical characteristics). This flexibility, combined with other factors such as health system and clinician buy-in, infrastructure readiness and availability of resources, has facilitated the widespread adoption of 4Ms care, but has resulted in implementation variation within and across organizations.^9,10 Early studies have revealed that the diffusion of AFHS implementation typically spreads over many years and can occur setting-by-setting or M-by-M. ⁹ To specifically understand how to achieve organization-wide adoption of the 4Ms, IHI recently launched a collaborative focused on identifying strategies to support care delivery organizations transitioning from initial implementation to enterprise adoption. ¹¹

As our understanding of 4Ms implementation grows, evaluating the impact on patient and health system outcomes is a crucial next step in the evolution of AFHS.^{9,10,12 -16} To date, only a handful of studies have specifically examined the impact of the 4Ms framework as a set on healthcare outcomes and none have done so across diverse health system settings.^{17 -20} Examples of outcomes reported in these studies include life sustaining treatment documentation, falls rates, deprescribing of potentially inappropriate medications, hospital readmissions, disruptive behaviors, emergency room utilization, length of hospital stay, total direct costs, and number of facility free days.^{17 -20} While these early studies are highly valuable, there is an urgent need for more robust evidence. The objective of this commentary is to examine the necessity for evidence on the outcomes of AFHS implementation and to propose strategies that catalyze such evidence generation.

Why the Need for Additional Evidence on 4Ms Outcomes Impact?

Despite evidence behind each individual M in the 4Ms framework, the collective impact of implementing all 4Ms simultaneously on older adult outcomes has yet to be fully examined and evidence remains limited. ²¹ In particular, important questions persist regarding the potential synergies among each of the Ms. Conceptually, practicing the 4Ms together should result in greater benefits given the “sum of the parts.” For example, Mentation-centered delirium screenings, together with Medication-focused efforts to deprescribe medications known to cause delirium, represents a tight connection between Ms and improved patient outcomes. ²² A less understood, yet potentially impactful connection exists between “What Matters” and the three other Ms; how a patient’s priorities and goals can inform their care plan and then impact on outcomes is unclear. For example, does a patient who prioritizes independent living, sets more aggressive mobility goals and receives goal-aligned care have improved functional mobility and independence? It is only through assessing the 4Ms as a whole, as well as understanding the interplay between the Ms in relationship to outcomes that we can understand: (1) value-generation to-date, (2) how variation in 4Ms implementation can maximize equitable value realization, and (3) if, and how, to expand the framework most effectively. This holistic approach will provide critical insights into the efficacy of the 4Ms framework in improving care for older adults.

Value-generation to Date

Key informants are advocating for stronger evidence linking 4Ms implementation to tangible outcomes.^23,24 Healthcare organizations facing competing pressures require compelling data on cost-savings and clinical improvements to justify and motivate ongoing investments in the 4Ms framework and to drive clinician buy-in and change management efforts. ¹⁰ Much of the work of 4Ms implementation is focused on standardizing existing geriatric care practices, aiming to ensure consistent, evidence-based care delivery. That is, many of the care practices and processes included in the 4Ms framework are not new to health systems but are foundational to geriatric care. Thus, implementing the 4Ms as a cohesive framework seeks to achieve standardized, reliable delivery of evidence-based geriatric care. For example, while delirium screening is commonly included in geriatric care, the 4Ms framework prompts health systems to select and consistently use a specific screening tool, integrating it into the defined workflows of certain clinicians or visits. ⁸ While the value of care standardization on outcomes has been shown in other settings, it is important to similarly demonstrate similar impact in the context of 4Ms care delivery given the complex, costly, interdisciplinary effort involved in defining care standards and then adhering to them on an ongoing basis. ²⁵ The Centers for Medicare & Medicaid Services (CMS) FY25 Inpatient Prospective Payment Systems final rule includes an Age-Friendly Health measure that requires attestation for hospital settings including inpatient, emergency department and surgical settings. ²⁶ This policy presents a catalyst to further operationalize standardized 4Ms workflows and care processes and a significant opportunity to evaluate the value added to patient and health system outcomes. It specifically offers a catalyst to extend gaps in 4Ms implementation to non-geriatric care settings and populations such as emergency departments, surgical settings or the outpatient setting such as primary care, where there may be an even greater impact on outcomes because of 4Ms driven care.

How Variation in 4Ms Implementation Can Maximize Equitable Value Realization

A second key domain in which evidence is needed is an assessment of the equitable realization of benefits from 4Ms care across different subsets of older adults. While equity is now widely-recognized as important health system priority, such evidence is particularly critical in this context given recent assessment of the association between Age-Friendly care and several health equity factors within an academic internal medicine clinic. ²⁷ This cross-sectional study involving over 3,300 patients found that a patient’s preferred language, gender and ability to access their electronic health record (EHR) were associated with differential receipt of Age Friendly 4Ms care. A second study of 29,000 inpatient encounters at a different institution also identified inequitable 4Ms adherence, with lower adherence for patients who met the definition of obesity and were on Medicaid. ²⁸ While it may be possible that these findings are a reflection of existing disparities regardless of the type of care provision, given that the AFHS movement aims to address healthcare inequities, this early evidence showing a potential association between socio-demographic characteristics and receipt of 4Ms care points to an urgent need to investigate this topic further. Rigorous research must identify the drivers of these disparities and develop targeted strategies to eliminate them, ensuring that the 4Ms framework fulfills its promise of equitable, high-quality care for all older adults.

If, and How, to Expand the Framework

Even with nascent evidence assessing 4Ms impact, institutions have moved to expand the framework to include additional Ms. For example, some are now including multi-complexity, which refers to the management of a variety of health conditions, ²⁹ and a large health system has added malnutrition as a 5th M. ³⁰ This experimentation naturally lends itself to generating evidence that guides the evolution of the AFHS framework and whether additional Ms can add value to the existing framework. Further, the 4Ms framework has the potential to extend Age-Friendly Care beyond older adults by integrating it into routine practice across other specialties. This could be highly relevant given the heterogeneity of aging and presentation of geriatric syndromes in younger cohorts.^31,32 However, until we have stronger evidence linking 4Ms implementation and outcomes in older adults, it remains uncertain whether this subset of geriatrics care practices can be effectively scaled and embedded in different specialties, settings and age groups.

Strategies for Building the 4Ms Evidence Base

Turning from the why to the how, we suggest seven strategies that we believe will catalyze the generation and dissemination of robust evidence to support AFHS transformation. We organize these strategies around activities that individual healthcare delivery organizations, researchers and evaluators, and other key informants can pursue (see Figure 1).

Figure 1.

Strategies for building the AFHS 4Ms evidence-base: Activities for healthcare delivery organizations, researchers and evaluators, and other key informants.

Strategies for Individual Healthcare Delivery Organizations

• 1. Embrace the learning health system (LHS) model to bridge research and clinical practice. Approaching evidence generation under a learning health system (LHS) model is a strong fit for AFHS research given the natural alignment between these health system models.^33,34 An aspirational age-friendly LHS is one where evidence-generation processes are embedded in daily practice, bringing together science, informatics and care culture to generate new research that seamlessly delivers patient-centered best practices for continuous improvement in health and healthcare. An age-friendly LHS would also align research efforts with healthcare delivery system goals, facilitate the inclusion of patient voices into research processes and combine research, quality improvement and implementation science methods to promote rapid cycle innovation to determine evidence-based 4Ms care. Moving from an aspirational age-friendly LHS model to actual realization has the potential to be transformative to rapidly adapt to 4Ms evidence generation and health outcomes.

• 2. Build interdisciplinary teams with diverse skill sets for AFHS implementation and evaluation. AFHS champions will likely need to partner with experts in research, quality improvement, implementation science and informatics to collectively have the expertise to evaluate 4Ms care. Effective examples of this approach are emerging, and prior work describes the need to convene three types of experts: (1) an AFHS champion who understands how the 4Ms have been implemented in real-world clinical settings, (2) a health services researcher trained in observational study design and analyses, and (3) a data analyst who can build research datasets from the EHR to measure 4Ms care and outcomes. ³⁵ The data analyst role was identified as key to bridging the gap between the AFHS lead’s understanding of 4Ms care documentation in the EHR and developing robust measures of that care along with specifying outcomes, covariates, and defining the sample population of older adults. The development of AFHS dashboards with high-level metrics of 4Ms adherence presents an additional opportunity for collaborations between clinical, data and research experts to evaluate the impact on outcomes.^36,37 Regardless of the composition, AFHS implementation teams should be formed as early as possible to best align implementation efforts with evaluation needs. These teams should also focus their implementation and evaluation on the broad range of settings where the 4Ms have been adopted (academic, non-academic, inpatient, outpatient, post-acute care, long-term care) to generate a more generalizable understanding of impact.

Strategies for Researchers and Evaluators

• 3. Identify a shared set of priority outcome measures. A growing set of studies examining heterogeneous outcomes will not be as impactful as studies that examine a shared set of outcomes that have broad support from key AFHS informants. Current and widely used 4Ms outcome measures in the inpatient and ambulatory include length of stay, hospital readmissions, emergency department visits and patient satisfaction.^8,38 These have often been pragmatically chosen given they can be easily accessible from EHRs. However, these outcomes limit the research scope to specific care settings, are health system-focused, and may not reflect the outcome priorities of other key informants, including older adults themselves. Examples of potential patient-centered outcomes that are setting-agnostic include quality of life or number of healthy days at home.^24,39 Systematic engagement of the broad range of constituents involved in AFHS should commence to identify priority outcomes that, in turn, are integrated into 4Ms evaluations. New measurement models have been proposed that specifically link AFHS care processes with outcomes within individual Ms and across them as a whole. ²⁴ These models detail feasible, reliable, and valid measurement opportunities and offer a starting point for discussions about standardization with key informants.

• 4. Standardize measurement of 4Ms implementation processes. The association between care processes and outcomes is essential for 4Ms evaluation. Therefore, each implementing organization must capture adherence to the specific 4Ms care processes, which can then be tied to outcomes. This will require thoughtful and deliberate strategies to standardize methods and data sources that capture adherence to the care practices that constitute each M that includes ensuring the correct attribution to the patient encounter, site of care or period of time. ³⁵ These strategies will also have to address emerging evidence of differential 4Ms documentation based on patient and hospital characteristics. ⁴⁰ EHR data offers the only scalable approach to such measurement, but this will be a major undertaking given the variation across sites in how 4Ms care practices have been implemented and how they have been documented in EHRs. For example, screening efforts to capture “What Matters” to patients are diverse and range from validated tools (e.g. Serious Illness Conversation Guide), to whiteboards that prompt patient-clinician conversations about goals and values, to completion of advanced directives.^27,41 The recent creation of a 4Ms Evaluation Metrics Resource Library that provides a centralized repository of 4Ms implementation measurement approaches ⁴² should be used as a starting point to determine how standardized measurement could be operationalized.

• Develop composite measures that capture 4Ms care. Beyond standardized measures of individual 4Ms care processes, composite measures of 4Ms care will also likely need to be developed. Composite measure development has been effective in other settings including for inpatient quality, health and socioeconomic indicators.^43,44 Since individual 4Ms care process measures are captured at different frequencies (e.g. per shift, per day, per encounter), there are various approaches to create a composite measure that represents 4Ms care receipt. For example, continuous (what percent of 4Ms care was received), ordinal, or binary (was a minimally acceptable threshold of 4Ms care received). These topics should be addressed alongside efforts to capture individual 4Ms care processes. A recent study at the University of California San Francisco (UCSF) offers one template for developing and using an overall 4Ms-level and M-level composite measure using structured EHR data. ³⁵

Strategies for Other Key Informants

• 5. Investments in AFHS research and evaluation. Securing both organizational and extramural resources to build the AFHS evidence base is needed to incentivize, engage and support the research community. It is therefore encouraging to see federal funders such as the Agency for Healthcare Research and Quality (AHRQ) publish a notice of their commitment to support grants that advance high-quality care delivery to older adults. ⁴⁵ In addition, continued Health Resources and Services Administration (HRSA) funding for Geriatric Workforce Enhancement Programs (GWEPs) to support the education and spread of AFHS, especially among non-academic healthcare systems and community-based organizations, should be leveraged for AFHS evaluation training in these care settings.^46,47 The newly formed AFHS Research Network, supported by the John A. Hartford Foundation also provides a forum to advance the evidence of 4Ms impact on outcomes and research advocacy. ⁴⁸

• 6. Dissemination of AFHS research and findings. Beyond building interdisciplinary teams and securing funding for research activities, dissemination of AFHS evidence is essential. Research rigor remains central to 4Ms evidence generation. However, peer review processes should not disincentivize the dissemination of well-conducted single-site evaluations given the variation in how AFHS and the 4Ms have been operationalized to date. Over time, findings from single-site studies can then inform larger multi-center evaluations. It is also encouraging that journals such as this one are creating special collections on AFHS to enable the sharing of evidence and ideas to support debate and dissemination efforts. Finally, ensuring that all research on AFHS, whether on one M or all four, is clearly situated in the literature will facilitate the process of developing a cohesive evidence base. In practical terms, we encourage researchers to consistently use established vocabulary, specifically Medical Subject Headings (MeSH) terms, that exist in the National Library of Medicine related to AFHS (e.g. Age Friendly Health System(s), Age Friendly Health Care).

Conclusion

Evidence of the impact of 4Ms care on outcomes must keep up with the implementation of the 4Ms framework to ensure effective AFHS transformation. It is imperative that we expand our research and disseminate findings widely to establish the extent to which the 4Ms framework is an effective vehicle for improving health outcomes of older adults. In this perspective article, we have identified several strategies designed to catalyze evaluation efforts across the AFHS ecosystem. These strategies are essential actions that we hope will inform and galvanize researchers, AFHS clinicians, implementers and leaders to drive evidence-based progress in age-friendly care. By adopting these strategies, we can bridge the current evidence gap and propel the AFHS movement toward its full potential, ultimately transforming healthcare delivery for older adults.