The Origins and Importance of Age-Friendly Care
The 4M framework was developed in 2017 by geriatric experts and health system executives in collaboration with the Institute for Healthcare Improvement (IHI) and the John A. Hartford Foundation. It emerged from the recognition that the traditional healthcare system often fails to meet the unique and complex needs of an aging population. Instead of being a separate program, the 4Ms are a guiding philosophy intended to be integrated into all existing care services for older adults, from emergency rooms to long-term care facilities. This philosophy organizes care and focuses on the older adult's wellness and strengths, rather than solely on disease.
By focusing on these four key areas, healthcare professionals can reduce harm, improve health outcomes, and increase the satisfaction of older adults with the care they receive. The framework provides a structured yet flexible approach that allows for patient and family involvement, which is a critical component of its success.
What are the Four Key Areas of the 4M Framework?
The four areas of the 4M framework are intentionally interconnected, with "What Matters" serving as the central, guiding pillar. Each of the other three areas—Medication, Mentation, and Mobility—should be considered and addressed in a manner that is consistent with the patient’s goals and preferences established under "What Matters." This holistic perspective ensures that all care decisions are person-centered.
1. What Matters
At the core of age-friendly care is understanding and aligning treatment with what matters most to each older adult. This goes beyond their medical diagnoses to include their personal health goals, care preferences, and priorities in life. For a patient, this might mean being able to live independently, attend a grandchild's wedding, or simply enjoy a favorite hobby. This pillar emphasizes shared decision-making and communication between the patient, their family, and the healthcare team.
- Key actions for What Matters:
- Openly discuss and document the patient's specific health outcome goals and preferences.
- Engage with family and other caregivers to understand the patient's values.
- Use the documented goals to guide all other care decisions.
2. Medication
Older adults often manage multiple health conditions, which can lead to complex and potentially risky medication regimens. The Medication pillar focuses on using age-friendly medications and regularly reviewing all medications to ensure they align with the patient's overall goals and don't interfere with their mentation or mobility. This includes a strong emphasis on "deprescribing," which involves reducing or discontinuing unnecessary or high-risk medications.
- Key actions for Medication:
- Conduct comprehensive medication reviews to identify and address high-risk medications.
- Educate patients and caregivers about all medications, including potential side effects.
- Ensure a simplified medication regimen to improve adherence and reduce risks.
3. Mentation
This area focuses on preventing, identifying, treating, and managing brain-related issues, including dementia, depression, and delirium. Cognitive and mood disorders can significantly impact an older adult's quality of life and safety, and addressing them is essential for maintaining a clear mind and positive mood. Regular screening and management are crucial for early intervention.
- Key actions for Mentation:
- Screen for dementia, delirium, and depression regularly using evidence-based tools.
- Educate caregivers on recognizing the signs of these conditions.
- Develop management strategies that minimize the use of medications that could worsen mentation.
4. Mobility
Maintaining safe and independent movement is vital for older adults to remain active and do the things that matter to them. The Mobility pillar ensures that older adults can move safely every day to preserve their function and independence. Healthcare teams assess mobility limitations and implement interventions to manage them, often in collaboration with physical therapists.
- Key actions for Mobility:
- Screen for mobility limitations and fall risk.
- Establish and encourage daily mobility goals for the patient.
- Provide physical therapy referrals and advice on ensuring a safe home environment.
The Collaborative Power of the 4M Framework
The true strength of the 4M framework lies in its integrated, interprofessional approach. The framework is not meant for one discipline but for all members of a healthcare team—physicians, nurses, pharmacists, social workers, and physical therapists—to collaborate towards a common goal. This team-based care is more comprehensive and effective than siloed efforts, as each professional brings unique expertise to the patient's care plan. The process often involves regular team huddles or rounds to discuss a patient's status across all 4Ms.
4M Framework vs. Traditional Care: A Comparison
To highlight the shift in philosophy, consider this comparison:
| Aspect | 4M Framework | Traditional Care |
|---|---|---|
| Focus | Person-centered, proactive, and holistic | Disease-focused, reactive, and episodic |
| Decision Making | Shared and guided by patient's goals (What Matters) | Directed primarily by clinician and medical condition |
| Medications | Optimized for appropriateness and safety, with deprescribing goals | Often polypharmacy, with less focus on cumulative effect or age-related risks |
| Mentation | Proactively screens for and manages dementia, depression, and delirium | Often addresses cognitive issues only when they become severe or acute |
| Mobility | Assesses and supports daily movement to maintain function | Manages mobility problems typically after a fall or injury has occurred |
| Teamwork | Interprofessional collaboration with shared goals | Often siloed, with limited communication between specialists |
Challenges and Future Directions
Implementing the 4M framework reliably across an entire health system can present challenges. Barriers have included physician disengagement, siloed implementation efforts, and difficulty meaningfully capturing the "What Matters" component in clinical workflows. However, health systems that have successfully adopted the framework show significant improvements in patient outcomes, communication, and overall satisfaction. Moving forward, the continued integration of the 4Ms into electronic health records and educational programs will be key to sustaining this age-friendly culture change. As the aging population grows, expanding the 4M philosophy to different care settings—from hospitals to home health—remains a critical goal for providing high-quality, dignified care to older adults.
For more in-depth information and resources on implementing the 4M framework in clinical practice, consult the Institute for Healthcare Improvement's Age-Friendly Health Systems materials, such as their "Guide to Using the 4Ms in the Care of Older Adults". This initiative continues to expand its reach, improving the lives of countless seniors by focusing on what truly matters.
