Age-friendly care may improve experience, outcomes for older adults

By Jay Bhatt, D.O., managing director of the Deloitte Center for Health Solutions, Deloitte Services LP

The US health care system wasn’t designed to meet the unique needs of older adults. While the average life span in the US is 77.9 years, Deloitte calculated that Americans are living just 65.9 years (or 85% of their years) in good health. However, many Americans have the potential to live up to 95% of their years in good health and live to be nearly 90 years old (see Employers can spark healthy aging.) The Age-Friendly Health Systems initiative is intended to evaluate hospitals’ progress toward improving the care they provide to patients who are age 65 or older.¹ Among other things, the measure calls for hospitals to have protocols in place based on the 4Ms framework (what Matters, Medications, Mobility and Mentation). The measure aligns with Deloitte’s vision for The Future of Health.

This two-part series explores the evolution of age-friendly care and looks at the challenges and benefits for health care organizations as they change the way they care for older adults. I first spoke with Terry Fulmer, Ph.D., RN, FAAN, president of The John A. Hartford Foundation, which is dedicated to improving the care of older adults. Next, I spoke with Nimit Agarwal, M.D., MBA, FACP, AGSF, director of Geriatric Medicine at Banner – University Medical Center Phoenix (Arizona).

Part 1: The evolution of the Age-Friendly Health System movement

In 2016, I worked extensively on an initiative that focused on improving the type of care that older adults receive at health care organizations. This initiative was led by The Institute for Healthcare Improvement and The John A. Hartford Foundation in collaboration with several large hospital associations. The idea was to identify factors that had the most significant impact on costs and health outcomes but distill it into a message that health care executives, caregivers, patients, and their families could easily understand. What emerged was the 4Ms framework. The components are all interconnected, and when combined with evidence-based practices, older patients tend to have better experiences and outcomes. The initiative was piloted by acute hospitals, ambulatory clinics, and long-term care providers. The initial 26 pioneer sites helped to fine-tune the approach and expand it to care sites across the country, including retail settings. The program has since been implemented in more than 5,000 hospitals, ambulatory care facilities, retail clinics, post-acute facilities, and nursing homes in the US, with additional sites in nine other countries.

Prior to joining The John A. Hartford Foundation, Terry Fulmer spent nearly 40 years at a variety of universities where she focused on health sciences and improving care for older adults. Here is an excerpt from our conversation:

Jay: How has the focus of the Foundation changed since you joined?

Terry: When I joined, the Foundation was focused on developing centers of excellence in academic geriatric medicine and nursing to improve care for older adults. I was invited to think more upstream and expand clinical strategies. Since 1900, the average life span in the US has nearly doubled—from less than 50 years to close to 80.² But there were few strategies for providing excellent care to people after the age of 65. I saw that as concerning. I wanted to focus on how to take care of older adults. Over the years, I think there has been great progress in public health. New technologies such as pacemakers and renal dialysis, along with better antibiotics and other innovations, have helped to keep people with us longer. But with longevity comes a responsibility to provide high-quality geriatric care and to develop clinical programs that address that care.

Jay: How did the 4Ms models come about, and how does it work?

Terry: In 2016, [the Foundation] convened a group of health system CEOs and aging experts to think about what an Age-Friendly Health System might look like. The Institute for Healthcare Improvement helped us think about ways to scale this idea. There were some programs already out there. For example, Acute Care for the Elderly (ACE) units in hospitals focus on care for older adult patients. There are also geriatric emergency departments that specialize in caring for older adults. NICHE, or Nurses Improving Care for Health System Elders, is a program I started many years ago that focuses on the nursing care of hospitalized older adults. We studied those care models and identified their unique features. We removed redundant care constructs, such as falls-management, that were in most of the models. We came up with four evidence-based features that are non-negotiable when caring for older adults. We call them the 4Ms: What Matters, Mentation, Medication, and Mobility. When clinicians introduce themselves to an older patient, they should start by finding out what matters to that person. What matters most to a patient might be avoiding time in the intensive care unit. Or maybe they want to get back on a bicycle after hip surgery. Each of the four features are interrelated. If a person receives the wrong medication, for example, it could affect their mind and mobility, leading to a fall. Similarly, mobility is essential to independence, which has an impact on mentation. We ask people to think of the 4Ms as a set.

Jay: You have said that there is typically a cutoff once people reach the age of 65. What do you mean by that?

Terry: It’s a historical cutoff. During the late 1800s, Germany established a pension system.³ People were living longer so the government said anyone who is 70 or older would receive a government pension. [That threshold was later lowered to 65.] The idea evolved and became a benchmark. Today, many countries provide benefits to people once they reach age 65.⁴

Jay: Why do you think the health care system should consider changing the way it cares for older adults?

Terry: First, the number of older adults continues to grow—about 11,000 people turn 65 every day [in the US].⁵ And the number of people over 85 and over 95 is growing as well! I'm interested in how we deliver quality care for people in those later years of life. Our Age-Friendly Health Systems initiative considers how quality care is provided, no matter whether that care takes place in a hospital, a nursing home, a prison, or a homeless shelter. There should be a reliable approach and a strategy for quality care and safety for all patients, and especially older adults who are more susceptible to harm.⁶

Jay: You train clinicians on the 4Ms. Do you also help older people understand those elements?

Terry: Yes, and it is empowering. Whenever they go to a doctor, nurse practitioner, or physician assistant, we encourage them to say they would like to talk about the 4Ms. We are starting to see exciting momentum in our hospitals, retail clinics, and nursing homes. We are also working with home- and community-based certification programs and are having conversations with other certifying organizations. We also work with medical websites and news outlets to get the message out.

Jay: Do you feel that health care organizations are getting better at helping older patients maintain their independence?

Terry: I do. The systems of care are changing, and I have great faith we are going to see new models of age-friendly care. For example, dementia villages are being developed in Europe that accommodate cognitive changes, enabling older people with dementia to stay in their communities.⁷ In the United States, new payment models—like Medicare’s Guiding an Improved Dementia Experience (GUIDE) program—support family caregivers to help people with dementia avoid going to a nursing home.

Jay: Are you surprised that the Age-Friendly Health Systems model has resonated in other countries? 

Terry: Yes, and I am so glad it has. I think age-friendly care is good care for everybody. It’s an elegant model that is all about human function. It is simplistic, with just four elements. We have found that focusing on those four things consistently reduces hospital admissions and length of stay and improves patient satisfaction. By prioritizing the 4Ms and fostering partnerships across health care settings, we can help ensure that older adults receive the high-quality, personalized care they deserve, enhancing both their health and overall well-being.

When in good health, people can live their lives the way they envision, whether that’s spending quality time with loved ones or pursuing their passions. A highly reliable integration and deployment of the 4Ms could lead to higher quality care, lower care costs, a longer life, and potentially a longer health span. There are thousands of age-friendly deployments that give us hope and courage.

Three things to know:

1. The Age-Friendly Hospital initiative considers how quality care is provided, regardless of where that care takes place.
2. The 4Ms—What Matters, Mentation, Medication, and Mobility—are important, interrelated features for caring for older adults.
3. The model's simplicity and focus on human function have led to reduced hospital admissions, shorter stays, and improved patient satisfaction.

Three things to consider:

1. Integrate the 4Ms into care protocols. This involves training clinicians to understand what matters most to older patients.
2. Study existing care models, identify unique features, and remove redundant care constructs to help streamline and improve care for older adults.
3. Empower older adults to discuss the 4Ms with their health care providers.

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Endnotes

^{1_{FY 2025 hospital inpatient prospective payment system, CMS, August 1, 2024}}

^{2_{Life Expectancy in the US, 1900-2018, Centers for Disease Control and Prevention, November 20, 2020}}

^{3_{Social Security History, Otto von Bismarck, Social Security Administration}}

^{4_{Social Security around the world, The ISSA}}

^{5_{America is hitting "peak 65" in 2024, CBS News, January 29, 2024}}

^{6_{Providing care to a diverse older adult population, National Institute on Aging}}

^{7_{Do dementia villages actually work?, STAT, October 24, 2023}}

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