How to keep aging boomers from busting healthcare

By Leslie Pelton | May 13, 2019


Every day 10,000 people in the United States turn 65 years old. And every day too many of our society's elders are let down by the U.S. health system. In too many instances the care of older adults is not reliably grounded in evidence of how to provide excellent geriatric care.

Older adults experience more harm in the healthcare system—because they are generally frailer, because they are more likely to have interactions with healthcare providers, and because healthcare providers are not attuned to their unique needs as patients.

It's time to change that. To prevent harm to older adults, improve health outcomes, and lower overall costs, health systems must adopt evidence-based models and practices that deliver better care to our rapidly aging population across all settings, including the home and community.

In 2016, my organization, the Institute for Healthcare Improvement (IHI), and The John A. Hartford Foundation partnered with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA) to launch the Age-Friendly Health Systems initiative, which adopted the bold aim that 20 percent of US hospitals and medical practices would become Age-Friendly Health Systems by the end of 2020.

To define what it means to be an Age-Friendly Health System, The John A. Hartford Foundation and IHI convened a group of national geriatric experts along with leaders of several health systems, the American Hospital Association, and The Joint Commission, which accredits U.S. healthcare organizations and programs. Prior to the meeting, we reviewed 17 evidence-based geriatric care models to identify the primary discrete features of each care model. We found over 90 features, but after eliminating redundant and similar concepts, there were only 13 distinct features.

We then asked the participants in the expert meeting to pick the most fundamental building blocks to optimal geriatric care and arrived at what we now call the “4Ms Framework of an Age-Friendly Health System." The 4Ms framework is both evidence-based and reliably implementable across healthcare settings. Providers that follow it commit to the framework's four elements:

What Matters: Know and align 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, use age-friendly medication that does not interfere with What Matters to the older adult, Mobility, or Mentation across settings of care.

Mentation (Mind): Prevent, identify, treat, and manage dementia, depression, and delirium across care settings.

Mobility: Ensure that older adults move safely every day to maintain function and do What Matters.

4Ms Framework of an Age-Friendly Health System

4Ms framework

Each of the 4Ms represents an essential aspect in caring for older adults. Given the interconnection between the 4Ms, it is most efficient and effective to pursue the 4Ms together to amplify their outcomes and effect. For instance, changing a medication may improve mentation and mobility, which could be what matters to an older adult to maintain independence.

Health systems have the opportunity to reduce delirium and falls when they focus on all 4Ms as a set — orienting the older adult by gently keeping them connected to What Matters, avoiding high risk medications, enabling the older adult to stay hydrated by offering oral hydration with dignified water bottles, and expecting and encouraging movement every day by staying focused on What Matters to the older adult.

While most health systems integrate some of the 4Ms into the care of some older adults, some of the time, an Age-Friendly Health System reliably uses the 4Ms as a set to organize the care of every older adult, every day. An Age-Friendly Health System identifies where the 4Ms are in practice, realigns its resources to ensure they are implemented consistently, and eliminates care activities that may become unnecessary.

An Age-Friendly Health System is one in which every older adult's care accomplishes all of the following:

  • Guided by an essential set of evidence-based practices (4Ms)
  • Causes no harms
  • Is consistent with What Matters to the older adult and their family

The integration of evidence-based clinical changes (the 4Ms) into front-line practice is supported by:

  • Integrating the 4Ms into the workflow
  • Training care teams in the delivery of the 4Ms
  • Building the 4Ms as a set into the EHR including the ability to report on whether adults received all 4Ms
  • Integrating the 4Ms into role descriptions

Achieving reliable practice of the 4Ms can be accelerated when senior leaders make both the financial and mission-based case for becoming an Age-Friendly Health System, integrate recognition as an Age-Friendly Health System into the strategic plan, and set and actively monitor outcome and system quality measures stratified by age.


More than 300 teams from more than 150 organizations have joined the Age-Friendly Health System movement.

They are on their journey to decide how they will reliably practice the 4Ms and measure the number of older adults reached with the 4Ms. Our hope is that it will transform elder care in the U.S. so that our families and communities receive the care they deserve.

Leslie Pelton, MPA is senior director at the Institute for Healthcare Improvement.

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