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Improve Health of Seniors With 4-Pronged, Age-Friendly Strategy

Analysis  |  By Christopher Cheney  
   May 29, 2019

To boost quality and reduce costs, an IHI initiative calls on clinical teams to focus on four evidence-based elements when caring for older adult patients.

An Institute for Healthcare Improvement (IHI) initiative to promote age-friendly clinical care for older adults is taking hold nationwide.

The number of Americans over age 65 is expected to double to nearly 100 million by 2060. With multiple chronic conditions and high costs of care at end of life, older adults have relatively higher healthcare costs compared to younger Americans. In 2010, citizens over age 65 were 13% of the population but accounted for 34% of healthcare spending.

IHI's Age-Friendly Health Systems initiative launched in early 2017. Now, 350 healthcare organizations including more than 125 health systems are implementing the effort in whole or in part.

Four-pronged intervention strategy

The main component of the IHI initiative is an evidence-based framework called the 4Ms:

  1. What matters to the patient: With a potentially dramatic impact on medical decisions, determining what matters to patients may be the most momentous of the 4Ms, says Kedar Mate, chief innovation and education officer at Boston-based IHI. "Improving medical decision-making is a key element of attaining value. Of all the interventions, the first M—what matters—gets you to high value as defined by the patient. It gets you to services that offer value in the patient's eyes."
  2. Medication: Managing medications is crucial for achieving therapeutic benefits and avoiding adverse drug reactions, which cause harm and costly complications. Annual costs in the United States associated with adverse drug reactions have been estimated at $30 billion, according to a December 2013 article in the Journal of Pharmacology & Pharmacotherapeutics.
  3. Mentation: Addressing delirium in the inpatient setting generates significant mentation benefits, Mate says. "Delirium is extremely common among older adults in inpatient settings, and it is extremely costly both on the human cost side with complication rates and lengths of stay, and the financial side. Length of stay is often 20%–30% longer with delirium."
  4. Mobility: Maintaining mobility also generates clinical and financial benefits, he says. "The data on functional impairment is stark. If you have a patient with one or two chronic conditions, then you add on functional impairment, the cost of care roughly doubles. Functional impairment is a big impediment in older adults' lives in achieving what matters to them, and it costs us a ton of money as a society."

In consultation with geriatricians and healthcare organization leaders, IHI selected the 4Ms after dissecting 17 evidence-based clinical practice models for older adults.

"To get to four things felt doable to folks. It felt conceivable for health systems to adopt, and achievable in a relatively short period of time for the average practitioner in the clinical service environment," Mate says.

Anne Arundel Medical Center benefits from 4M framework

At Anne Arundel Medical Center, asking older adult patients what matters to them has been a primary driver in adoption of the IHI initiative, says Barbara Jacobs, RN, chief nursing officer of the Annapolis, Maryland–based health system.

"We've changed our discharge plans and the way we interact with a patient and a family by asking that fairly simple question. We need to know what the patient wants in terms of the plan of care," she says.

Like most patients, many older adults want to go home after an inpatient stay, and Anne Arundel discharge teams have stepped up efforts to honor this desire, Jacobs says.

"If we don't ask patients where they want to be after discharge, we are not going to have a successful discharge. We have to work with patients if they say they want to go home. We can set up that support. It's a learning moment for us—listening to the patient."

Anne Arundel is pursuing all 4Ms, and a mobility intervention stands out, she says.

The main campus of the health system has an inpatient floor that specializes in care for older adults, the Acute Care for the Elderly (ACE) Unit.

At 11 a.m., medically cleared patients are encouraged to participate in "ACErcise," which features wheelchair-based exercises and walking. The age-friendly session has become a significant socialization event. "The patients enjoyed the togetherness, so the activity evolved into the opportunity to eat together. It has been very popular," Jacobs says.

The value of mobility is undeniable, she says. "If a patient stays moving, their chance of getting home is much better, which is where most people want to go."

Age-friendly care impact

Anne Arundel is implementing multiple age-friendly efforts simultaneously; so, it's difficult to gauge return on investment, but gains are expected, says Executive Vice President of Integrated Care Delivery and COO Maulik Joshi, DrPH.

"The age-friendly best practices are based on research and evidence that the interventions make a difference in outcomes. For us, we are strongly focused on quality and investing in quality. It can be hard to prove, but these best practices have been directly related to readmissions, patient satisfaction, length of stay, and other crucial outcomes," he says.

Anne Arundel is confident there will be clinical and financial gains from age-friendly efforts, Joshi says. "The evidence is incredibly profound. This is not weak evidence. We know mobility and medication management have a huge impact."

Jacobs says the value is apparent. "It's not like you are out on a limb with something that has barely been tested. It is palpable. You can see that this kind of care is better."

The early results at healthcare organizations participating in the IHI initiative are promising, Mate says.

"It didn't surprise us that the 4Ms improved the health of populations—they were derived from models that improved the health of seniors. And it didn't surprise us that patients were more satisfied when they were asked about what mattered to them and more satisfied when caregivers paid more attention to their mobility. What surprised us is that the 4Ms lowered costs significantly."

To help health systems, hospitals, and clinics track the financial impact of age-friendly efforts, the IHI initiative includes ROI calculators for the inpatient and outpatient settings.

In case studies conducted by IHI, two organizations reported significant ROI on their age-friendly activities, Mate says:

  • Ascension-affiliated St. Vincent Medical Group, Indianapolis: In an ambulatory setting where 4M care is being added to annual Medicare wellness visits, $600,000 of additional benefit was generated on a $3 million investment.
  • Hartford Healthcare-affiliated Hartford Hospital in Connecticut: The academic medical center implemented a delirium management program that generated a $3.6 million return on a $2.4 million investment in the program.

"If you want to figure out how you deliver higher-value care, then an age-friendly system is a good place to start," Mate says.

How healthcare organizations can implement the 4Ms

IHI published a list of steps for health systems, hospitals, and clinics to implement age-friendly care into their organizations:

  1. Learn about age-friendly health systems
  2. Inform IHI of your interest in participating
  3. Identify an age-friendly champion
  4. Send IHI a letter of commitment from a senior leader
  5. Introduce clinical teams to the age-friendly framework
  6. Describe how your healthcare organization will apply the 4Ms
  7. Share your description of the 4Ms with IHI
  8. Share the count of patients who are receiving age-friendly care with IHI for at least three months

Christopher Cheney is the CMO editor at HealthLeaders.


The number of Americans over age 65 is expected to double by 2060.

A national IHI initiative launched two years ago to improve the care of older adults.

A fundamental step in treating older adults is determining what matters to them in their care plan.

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