Action Communities: Health System Teams Learn to Implement the 4Ms

Editor’s note: The John A. Hartford Foundation, the Administration for Community Living and The SCAN Foundation fund the Aging and Disability Business Institute (www.aginganddisabil ity­, led by the National Association of Area Agencies on Aging (n4a). The mis­sion of the Aging and Disability Business Institute is to build and strengthen partnerships between aging and disability community-based organizations (CBO) and the healthcare system. As partners in the Aging and Disability Business Institute, ASA and n4a are collaborating on a series of six articles and case studies in Aging Today that highlight the Age-Friendly Health Systems initiative. 

In the movement to ensure that all health systems are age-friendly, spearheaded by The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI) in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA), health systems are learning to integrate the 4Ms (What Matters, Medication, Mentation, Mobility) into their workflows to improve care for all older adults. This can occur in a medical prac­tice, outpatient facilities and aging and disability CBOs (for more details on the Age-Friendly Health Systems [AFHS] initiative, see the article on page 13).

Action Communities: On-Ramps to Learning

One way to instill the understanding necessary to pull off this shift in how older adults are treated in the healthcare system is through education and peer support. This is where IHI Senior Director Leslie Pelton comes in. Tasked with the responsibility for implementing the AFHS initiative at IHI, she and her team, including Dr. Kedar Mate, IHI’s Chief, Innovation and Education, oversee AFHS Action Communities.

“An Action Community is an on-ramp,” says Pelton, “an active community of learners across health systems who want to come together to accelerate adoption of the 4Ms.”

Asking an older adult “What Matters” can be surprisingly difficult, Pelton says. How to ask the deeply personal question about an older adult’s goals for achieving the highest quality of life, in the near and far term, is tricky, and the words used can make a huge difference in how easy—or diffi­cult—it is to ask and answer the question. “Some teams are very comfortable doing this, and less comfortable teams can learn from them how to ask What Matters,” says Pelton.

This is the beauty of the Action Communities, which are free, and open to any team member in a health system who would like to learn more about adopting the 4Ms. Communities meet virtually once a month for seven months, viewing webinars and interacting online nationwide. IHI highlights bright spots in the AFHS work, featuring teams particularly adept at implementing the 4Ms. Once a month there is supplemental peer-to-peer coaching, also online, and once in the seven months teams gather in person for a day and a half of peer coaching.

The Action Community faculty, also called the AFHS Advisory Group, is 34 members strong, and is a Who’s Who list of advocates who have been pushing healthcare reform for years, from President Emeritus at IHI and former Administrator of the Centers for Medicare & Medicaid Don Berwick to The John A. Hartford Foundation President Terry Fulmer. They have “a great depth of expertise in each of the 4Ms,” says Pelton. Faculty teach webinars and are available to advise and support Action Community participants.

“The 4Ms are evidence-based and may be intuitive and appealing,” says Pelton, “but they are not how everyone practices healthcare. If [everyone applied the 4Ms], we wouldn’t see the harms we have today occurring with older adults.”

Through the Action Communities, the health system team (or a hospital, PACE site, or outpa­tient clinic) has the opportunity to reach two sequential levels of recognition from IHI. An Age-Friendly Health System Participant is recognized for being on the journey to becoming an Age-Friendly Health System and has submitted a description of how it is putting the 4Ms into practice. The teams submit this description through an online survey. The next level of recognition is an Age-Friendly Health System Committed to Care Excellence. These are exemplars in the move­ment. Their description of the 4Ms is aligned with the definition of an Age-Friendly Health System and they have shared at least three monthly counts of older adults benefitting from evidence-based 4Ms care.
IHI publicly announces such designations and provides health systems with communications kits to help market the achievement.

How to Join the AFHS Movement

Joining an Action Community might be the most intensive and guided way of taking part in the AFHS movement, but interested parties also can go directly to the IHI AFHS site, click on Join the Movement, and proceed through the outlined process.

IHI has a slate of tools for any practice to use that is interested in becoming an AFHS, as it is the initiative partners’ hope to get the information out to as many systems as is possible, as quickly as possible. The links above also walk applicants through how to gain the two official designations. For health systems already practicing a version of the 4Ms, they can fill out the site’s section de­scribing how they are implementing the 4Ms and become officially recognized.

In the partners’ commitment to bring all health systems on board quickly, all tools and informa­tion is open source and free of charge to download, including a Return on Investment calculator (scroll to the bottom of this page to access the calculators) that details the overall financial impact of putting the 4Ms into practice.

The Movement Catches On

The AFHS movement is catching on so rapidly that the number of health systems holding one of the two designations changes daily.

As of mid-September, there were 177 hospitals and practices that had been recognized as AFHS Participants, with 100 of those designated as AFHS Committed to Care Excellence. “Our aim is to reach 1,000 hospitals and affiliated practices by Dec. 31, 2020,” says Pelton.

“We’re not going to stop, this is a social movement and we already have a 2030 goal in place,” she adds. The partners behind AFHS plan to help so many health systems adopt the 4Ms that any late adopters will eventually be pulled along in the stream of others, says Pelton.

“But forget the numbers for a moment. When you see physicians who have been practicing for 20 to 30 years, when you see their faces light up as they start talking about the 4Ms—it is remark­able,” says Pelton. “This is what has re-energized their careers.

“Nurses talk about the pain of having had to act in ways they knew were not working to re­flect what mattered to older adults, and how practicing the 4Ms makes them happy to go to work each day. They know they are reducing older adults’ exposure to harm. It’s incredibly reward­ing,” says Pelton.

For information about becoming an Age-Friendly Health System or participating in an Action Community, visit Also, watch for upcoming articles in Aging Today high­lighting the work of CBOs partnering with health systems and AAAs on implementing the 4Ms.