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.aginganddisabilitybusinessinstitute.org), 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.
Aging-sector professionals have spent decades developing care models to ensure that older adults can live better lives, producing copious evidence to show what strategies work best. Despite these efforts, U.S. healthcare delivery remains uneven. In every healthcare care organization there are providers who dispense stellar care, while others don’t use evidence-based best practices, providing care that can be harmful to older adults.
In 2016, 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), launched the Age-Friendly Health Systems (AFHS) initiative to address this problem. That initiative, according to Amy Berman, a senior program officer at The John A. Hartford Foundation, has now become more of a movement, due to its overarching vision and scope.
From Myriad Models to the 4Ms
The partnership members examined all of those evidence-based care models produced over the years, distilling from them 90 model features and ending up with 13 that are crucial to delivering good care. Gathering feedback from researchers who built the models, health system leaders and older adults and their caregivers, the list of features was narrowed down, identifying a framework to organize care that would best improve care for older adults, would best reflect what is most important to older adults and would best provide strong outcomes for health systems.
The framework, boiled down to four critical elements to great care, is now referred to as the 4Ms: What Matters to older adults (knowing and aligning care with each older adult’s specific health outcome goals and care preferences including, but not limited to, end-of-life care, and across settings of care); Medication (if medication is necessary, using age-friendly medication that does not interfere with What Matters to the older adult, Mobility or Mentation across settings of care); Mentation (preventing, identifying, treating and managing delirium, dementia and depression across care settings); and Mobility (ensuring that each older adult moves safely every day to maintain function and do What Matters).
The 4Ms are the founding principles upon which the larger Age-Friendly Health Systems movement is based. The movement’s work occurs in a range of settings, from the hospital, to outpatient care, within PACE facilities and via community-based supports and services (area agencies on aging also support this work).
Implementing the 4M process begins with talking with older adults to discover what matters most to them, and then screening for medication, mentation and mobility. “It’s really about how we weave together all existing resources, across the continuum of care, to support people to live better lives, to get better healthcare and make all [settings] age-friendly,” says Berman.
Health Systems Embrace the Initiative
Five pioneering health systems—Anne Arundel Medical System; Ascension; Kaiser Permanente; Providence St. Joseph Health; and Trinity Health—signed on to prototype the process for implementation of the 4Ms. IHI leads the national work in partnership with AHA and the CHA. Together they are convening seven-month Action Communities for health systems to implement and become age-friendly (see the article about Action Communities on page 14, or visit tinyurl.com/yx8mm593).
The 4Ms may be implemented differently depending upon a health system’s structure and resources; for example, Ascension has built the 4Ms approach into their annual wellness visits, implementing it with 10,000 of their older patients. Ascension saw that the process helps both clinicians and patients to focus on what’s most important, best tailoring care to address patients’ goals.
“Essentially, health systems are taking what they are already doing well and building it out so age-friendly care is reliably delivered at every interaction,” says Berman.
For now, the 4Ms are being incorporated into care in more than 300 sites across the country, with 162 hospitals and healthcare practices receiving formal recognition by IHI (tinyurl.com/y4j5pmz8). The Centers for Medicare & Medicaid Services also has included AFHS education and training in the AHA’s Hospital Innovation Improvement Network, which contains 1,638 hospitals. And the Health Resources and Services Administration approved a $175 million Geriatric Workforce Enhancement Program over the next five years to train the primary care workforce in age-friendly care. Also CVS MinuteClinic (the nation’s largest retail primary care provider with 1,100 MinuteClinics) will roll out this age-friendly care work across their system beginning in 2020.
Outcomes Data Drive Quality Care
The AFHS Guide To Using the 4Ms in the Care of Older Adults (tinyurl.com/y2oxwxsf) includes instructions on outcomes measurement, which can document if the 4M work has resulted in improved care and, if so, can see if the initiative succeeded in reducing 30-day readmission rates and emergency department use, and if it elevated patients’ satisfaction with their care.
The John A. Hartford Foundation and IHI, in partnership with the AHA and the CHA, created a bold vision in 2017, aiming to ensure that “all care with older adults is age-friendly care.” Considering the number of health systems and community-based organizations already working with the 4Ms framework, it seems that the partners are beginning to realize a vision for Age-Friendly Health Systems.
For information about becoming an Age-Friendly Health System or participating in an Action Community, visit www.ihi.org/agefriendly.
Also, watch this space for upcoming articles highlighting the work of CBOs partnering with health systems and AAAs on implementing the 4Ms.