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How Even the Best Geriatric Care Can Get Better

Why It Matters

When you simplify the universe of beneficial interventions down to the “must-haves” of the Age-Friendly 4Ms, it increases the reliability of those practices being performed for every patient, every time.


How Even the Best Geriatric Care Can Get Better

When the Institute for Healthcare Improvement (IHI) launched the Age-Friendly Health Systems initiative in 2017 — with the John A. Hartford Foundation, the American Hospital Association, the Catholic Health Association of the United States, and others — we made a few assumptions.

We understood that there were many organizations already providing high-quality care for older adults in the US. Some health systems had a Nurses Improving Care for Healthsystem Elders (NICHE) program in place. Others ran Acute Care for Elders (ACE) specialty units in their hospitals. We knew that many teams were familiar with the elements of care we incorporated into the Age-Friendly Health Systems 4Ms Framework — What Matters (knowing and aligning care to match an older adult’s goals and preferences), reducing exposure to potentially harmful Medication, focusing on Mentation (dementia and depression in the ambulatory care setting and depression, dementia, and especially delirium in the inpatient care setting), and Mobility (ensuring functional status so older adults can achieve What Matters to them).

Consequently, while we expected that many organizations would benefit from using the 4Ms Framework, we imagined that some organizations would already have the elements well-implemented and well-practiced in their setting. In many instances, that has been the case.

However, as we talked to teams across the country, we learned that even in places where great geriatric care was being given, teams saw additional value in using the 4Ms Framework. We heard reports of increased reliability of screenings for delirium, dementia, and medication polypharmacy. We learned about reductions in polypharmacy use and other benefits from implementing the 4Ms.

The team from one Age-Friendly Health System has been so excited by their progress that they plan to submit their work for journal publication. When they applied the 4Ms, they saw significant reductions in length of stay compared to their baseline. They also reduced their total cost of care, on average by over $30,000 per patient, especially for patients who had higher discharge needs and severity of illness when compared to usual models of care delivery.

Why would health systems that were already providing a good standard of care see improvements? It comes down to reliability.

When you simplify the universe of potentially beneficial interventions down to the four “must-haves” of the 4Ms, it increases the reliability of those practices being performed for every patient, at every encounter. The 4Ms make care of older adults — which can get very complicated — more manageable. As it says in Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults:

The 4Ms identify the core issues that should drive all decision making in the care of older adults. They organize care and focus on the older adult’s wellness and strengths rather than solely on disease. The 4Ms are relevant regardless of an older adult’s individual disease(s). They apply regardless of the number of functional problems an older adult may have, or that person’s cultural, racial, ethnic, or religious background.

Assembling the Evidence

Since even teams that are providing good care for older adults can realize improvements by using the 4Ms, it’s worth highlighting a study recently published by the Journal of Aging and Health. My co-authors and I developed “Evidence for the 4Ms: Interactions and Outcomes Across the Care Continuum” to serve as a concise review and consolidation of the evidence in support of the 4Ms.

Every day, our health system leaders and frontline care teams are bombarded with information about what will make care better for people. It’s sometimes hard to determine exactly what will be most useful. This paper summarizes the evidence on how the 4Ms can help older adults live healthier, better lives, and reduce costs.

In some senses, the paper is relevant for anyone who’s invested in an older adult. It can be read and understood by caregivers. It can be helpful to primary care doctors or geriatric nurse practitioners. It can be read by folks working in inpatient service units, ambulatory service units, or clinics. The evidence in the paper can be useful to system leaders as they decide whether to become an Age-Friendly Health System. It can also be of interest to policy makers who are looking at both costs and outcomes and are seeking ways to improve the health and care of one of the fastest growing segments of our populations.

The over 2,000 care environments taking part in the Age-Friendly Health System network help us build on the evidence base for the 4Ms every day. Many had NICHE and ACE programs in place before joining the Age-Friendly initiative. Each of them is continuously learning about how to further refine the 4Ms. They provide this valuable knowledge back to us as we expand the library of ways to improve care for older adults. We regularly hear from individuals and systems who tell us they’ve been waiting a long time for the energy and focus the 4Ms have brought to care of older adults.

What else can the 4Ms teach us? Might we imagine other distillations of evidence that can help us simplify and make care reliable for other conditions and populations? Could we improve the provision of behavioral health care or heart failure care? Could we improve workforce safety? What we’re learning about how to improve care for older adults could (and should) be just the beginning.

Editor’s note: Look for more each month from IHI President and CEO Kedar Mate, MD, (@KedarMate) on improvement science, social justice, leadership, and improving health and health care worldwide.