Origins of the Age-Friendly Health Systems Initiative
The 4Ms framework is the cornerstone of the Age-Friendly Health Systems (AFHS) initiative, a movement launched in 2017 by the John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI) in partnership with other leading health organizations. The initiative was born out of a pressing need to address the fragmented and often-failing healthcare system for older adults, whose population is rapidly growing. The goal is to ensure that every older adult receives high-quality, evidence-based, and person-centered care that improves health outcomes and reduces harm. By focusing on these four essential elements, healthcare providers can streamline processes and resources to deliver more effective and reliable care.
The First M: What Matters
The 'What Matters' component is the foundation of the 4Ms framework, emphasizing that care must be guided by the older adult's unique health outcome goals and preferences. This goes beyond standard medical assessments to understand a person's life priorities, including their passions, fears, and personal values. By taking the time to ask and document what matters most to the individual, healthcare providers can ensure that the care plan is truly aligned with the patient's wishes.
Putting 'What Matters' into practice
- Goal Setting: Collaboratively establishing specific, measurable, achievable, relevant, and time-based (SMART) goals with the patient.
- Advance Care Planning: Documenting preferences for future care through advance directives or life-sustaining treatment plans.
- Visible Documentation: Recording these priorities in a visible location, such as a patient's electronic health record or a bedside whiteboard, so the entire care team is aware.
The Second M: Medication
The medication component focuses on using age-friendly medications and deprescribing high-risk medications whenever possible. Older adults are more susceptible to adverse drug events due to age-related physiological changes and often manage multiple chronic conditions with numerous prescriptions (polypharmacy). The 4Ms framework promotes a careful, ongoing review of all medications, including over-the-counter drugs, to ensure they don't interfere with what matters to the patient, their mentation, or their mobility.
Key medication management practices
- Regular Review: Systematically reviewing all medications to assess their continued necessity and appropriateness.
- Risk-Benefit Analysis: Carefully weighing the risks versus the benefits of medications, particularly those on the Beers' criteria list, which identifies potentially inappropriate medications for older adults.
- Patient Education: Ensuring the patient and their caregivers understand the purpose, dosage, and potential side effects of all medications.
The Third M: Mentation
Mentation, which refers to 'Mind and Mood,' is the third pillar of the framework and focuses on preventing, identifying, treating, and managing conditions like dementia, depression, and delirium. These cognitive and mental health issues can significantly impact an older adult's quality of life and safety. The framework emphasizes early screening and appropriate management strategies to address these concerns effectively.
Actionable steps for addressing mentation
- Universal Screening: Implementing universal depression and cognitive screening protocols during patient visits.
- Preventative Measures: For inpatients, providing activities like puzzles, reading glasses, and hearing amplifiers to prevent delirium.
- Comprehensive Management: Addressing contributing factors to mental health decline, such as sensory limitations, social isolation, and bereavement.
The Fourth M: Mobility
Mobility is crucial for maintaining functional independence and allowing older adults to do what matters to them. This component ensures that care teams encourage safe, daily movement to maintain functional ability and reduce fall risk. For older adults, immobility can lead to a cascade of negative health outcomes, from muscle atrophy to social isolation.
Promoting safe mobility
- Daily Movement Goals: Encouraging and assisting older adults with safe movement every day, both in inpatient and outpatient settings.
- Fall Risk Assessment: Regularly assessing fall risk and modifying the environment or providing assistive devices as needed.
- Physical Therapy: Engaging in physical therapy and other targeted exercises to maintain strength and balance.
Comparative Look at 4Ms and Other Care Models
While other care models exist, the 4Ms framework is distinct in its integrated, person-centered focus. Unlike some models that target a single condition or setting, the 4Ms are designed to be universally applied across all clinical settings and to all older adults, making it a system-wide approach rather than a single program. This table provides a quick comparison:
| Feature | 4Ms Framework | Traditional Geriatric Care Model | Condition-Specific Programs | Home Health Care |
|---|---|---|---|---|
| Focus | Holistic, patient-centered care for older adults. | Often disease or symptom-focused. | Narrowly focused on one condition (e.g., heart disease). | Provides care primarily in the home environment. |
| Scope | System-wide, for all older adults in every setting. | Varies by setting; may be limited to specific units or clinics. | Limited to patients with a specific diagnosis. | Primarily for homebound individuals. |
| Driver | Patient's personal goals and preferences drive all care. | Care often follows standardized clinical guidelines. | Follows a strict protocol for the specific condition. | Based on needs identified for in-home support. |
| Resource Use | Efficiently redeploys existing resources. | Often requires dedicated resources or programs. | Additional resources for the specific program are needed. | Requires a dedicated team of in-home providers. |
| Coordination | Improves communication between care settings. | May face challenges in communication between different settings. | Can lead to siloed care if not integrated properly. | Communication often focused on in-home needs. |
The 4Ms: A Collaborative, Sustainable Approach
At its core, the 4Ms framework is about integrating evidence-based practices into routine clinical care for older adults. It is not about adding new layers of bureaucracy but about creating a more reliable, consistent, and effective system by organizing existing resources and efforts. The framework's success hinges on a cultural shift within healthcare, where all providers—from front-line staff to leadership—are trained to assess and act on each of the 4Ms. This leads to better communication, improved outcomes, and increased patient and staff satisfaction.
For more detailed information on the 4Ms and Age-Friendly Health Systems, visit the official page of the Institute for Healthcare Improvement (IHI). Age-Friendly Health Systems | IHI
Conclusion: The Future of Senior Care
The 4Ms framework represents a powerful paradigm shift in how we approach senior care. By focusing on what truly matters to older adults and addressing the core pillars of Medication, Mentation, and Mobility, healthcare systems can deliver higher-quality, safer, and more compassionate care. As the older adult population continues to grow, the adoption of this evidence-based, person-centered approach is not just a best practice—it's a necessity for ensuring a healthier, more dignified future for all seniors.
