Discovering the 4Ms: A Framework for Creating Age-Friendly Health Systems

Terry Fulmer, President of The John A. Hartford Foundation, Summit speaker and advisory board member shares lessons learned from their work creating Age-Friendly Health Systems. In partnership with IHI and five major health systems, Fulmer extracts four high-level interventions, or the “4Ms” that are essential, initial elements that systems need to provide older adults with the best care possible.

By Terry Fulmer | August 7, 2018 | This post originally appeared in The John A. Hartford Foundation blog


Discovering the 4Ms: A Framework for Creating Age-Friendly Health Systems

Dear Colleagues —

Momentous! That’s how I describe progress toward our goal of creating Age-Friendly Health Systems (AFHS) — vital work that incorporates what is talked about at the kitchen table into what needs to happen throughout health care.  We have a vibrant partnership with the Institute for Healthcare Improvement (IHI), the American Hospital Association, the Catholic Health Association, and other experts to promote the kind of systems we want for ourselves and those we care about.

For more than a year we’ve worked with five health systems as they rethink their care—Anne Arundel Medical Center, Ascension, Kaiser Permanente, Providence St. Joseph Health, and Trinity Health. The lessons being learned are incredibly valuable, and this summer has been filled with wonderful opportunities to accelerate and share our work from coast to coast.  Our system champions tell us the work can be slow and difficult – the fatigue associated with transformation is real – but the signs of progress are nothing short of revolutionary.

We need this kind of revolution. America’s aging population is skyrocketing, along with demand for health care services. Two out of three older adults have multiple chronic conditions. Many are on more than five medications. In this environment, even health systems that have a clear understanding of what’s needed for excellent geriatric care become overwhelmed by what’s expected of them.

Doing better for older adults and their caregivers is what this work is all about. Participating clinicians learn where care can be improved and how to operationalize it. They’re taking a health systems approach, because geriatric care involves hospitals, primary care, home health, and other settings. Having clinicians, patients, and caregivers all involved in this initiative means we’re learning together what patients want, where care is inconsistent, where interventions are needed, and which are evidence-based. We’re also wrestling with where work of the health care teams seems duplicative or unnecessary and can be redirected. We need to be reliable in our care processes.

We’ve learned that four high-level interventions that form a bundle—what we call the “4Ms” — are the essential, initial elements that systems need to provide older adults with the best care possible.

A key insight is that the 4Ms provide a much-needed framework for helping system leaders and frontline teams consistently deliver high-quality, age-friendly care.

Many of the participants discovered that the 4Ms are not an overlay or addition to what they’re already doing. Instead, they offer a new way of organizing care for older adults to be sure that all essentials are covered, consistently, in every setting where care is delivered.

I’m thrilled by the passion that focusing on the 4Ms unleashes. At our recent meetings, you could feel the excitement for this new paradigm. There is pent-up energy and enthusiasm for a better way. The 4Ms have become a mechanism for rethinking the care process.

To be clear, hard work lies ahead. Harnessing enthusiasm into a package of tested tools that hospitals and health care practices can use for quantifiable change is daunting. There may be a desire among some participants to take on part, not all, of the 4Ms. We’re learning, though, how mutually reinforcing they are. Suppose a patient says what matters most to her is feeling more alert and steady throughout the day. If we don’t get her medications right, we can’t address her mobility and mentation, because both are affected by medication. It’s hard to imagine an approach other than the 4Ms to do it all.

Identifying ‘what matters’ is proving to be a powerful starting point. Asking patients what matters most to them, in terms of their health goals and care preferences, has galvanized AFHS participants—whether clinicians, older adults, or caregivers. Hundreds of hours have been dedicated to studying how to ask, document, and act on this question. It has become the springboard to action.

We’ll soon invite up to 100 more health system teams to the Age-Friendly Health Systems initiative, and we’ll look at what different interventions yield. Ultimately, our challenge is to scale age-friendly innovation nationwide. We face hurdles, including an insidious ageism that suggests older people feel how they feel and can’t improve much. The AFHS approach rejects that notion. It respects older adults and acknowledges that they can feel better, think more clearly, and move more readily if the health system is designed to help them meet their needs.

To receive updates on the Age-Friendly Health Systems initiative, please contact If you have questions or observations to share with me, don’t hesitate to reach out.


Terry Fulmer, PhD, RN, FAAN
President, The John A. Hartford Foundation

@dhealth2018 2019


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