Health system approaches and experiences implementing the 4Ms: Insights from 3 early adopter health systems

Abstract

Background Redesigning the healthcare system to consistently provide effective and tailored care to older adults is needed. The 4Ms (What Matters, Mobility, Medication, and Mentation) offer a framework to guide health systems' efforts to deliver Age‐Friendly care. We use an implementation science framework to characterize and assess real‐world implementation experiences with the 4Ms across varied health systems. Methods With expert input, we selected three health systems that were early adopters of the 4Ms and engaged in different implementation support models through the Institute for Healthcare Improvement. We conducted 29 semi‐structured interviews with diverse stakeholders from each site. Stakeholders ranged from hospital leadership to frontline clinicians. Interviews covered each site's approach to and experiences with implementation, including facilitators and barriers. Interviews were recorded, transcribed, and deductively coded using the Consolidated Framework for Implementation Research. We characterized each site's implementation decisions and then inductively identified overarching themes and subthemes with supporting quotes. Results Health systems varied in their implementation approach, including the implementation order of each of the 4Ms. We identified three overarching themes: (1) the 4Ms offered a compelling conceptual framework for advancing Age‐Friendly care, but implementation was complex and fragmented; (2) complete and sustained implementation of the 4Ms required multidisciplinary and multilevel leadership and engagement; (3) strategies that facilitate implementation success and support frontline culture change included top‐down communication and infrastructure alongside hands‐on clinical education and support. Common barriers are siloed implementation efforts across settings that impeded synergies and scaling; disengaged physicians; and difficulty implementing What Matters in a meaningful way. Conclusions Similar to other implementation studies, we identified multifactorial domains impacting 4Ms implementation. To achieve Age‐Friendly transformation, health systems must plan for and attend to multiple phases of implementation while ensuring that the work coheres under a unified vision that spans disciplines and settings.

Developing electronic health record‐based measures of the 4Ms to support implementation and evidence generation for Age‐Friendly Health Systems

“…(The Implementation Team has not yet defined standardized care practices for What Matters component. Additional description of UCSF Health's 4Ms implementation and level of maturity can be found in prior work 5 and in column 3 of Supplementary Table S1.) As part of implementation, the Implementation Team developed a limited set of EHR-based process measures (e.g., delirium and mobility screening compliance), which they track internally through custom EHR reports.…”

“…To achieve standardized practice within a particular health system, the work of implementation necessitates, in the mobility example, selecting, and then promoting compliance with, a single mobility assessment tool, specified frequency of assessment, location of associated documentation, follow-up actions to be taken, and how to evaluate progress toward mobility goals. [5][6][7] As with any implementation of new care processes, measuring the level of adherence is critical to inform current state and assess the impact of efforts to promote routine practice. With widespread adoption of electronic health records (EHRs), 8,9 there is an opportunity to use EHR data, including EHR audit log data that tracks actions users take while in the EHR (e.g., reviewing data), to develop granular measures of 4Ms process adherence.…”

Facilitators and Barriers to Implementing the 4Ms Framework of Age-Friendly Health Systems: A Scoping Review

“…Despite the benefits of age-friendly health systems on older adults’ health outcomes, there is limited evidence on improving health-system-level and community-level metrics to support the implementation and sustainability of age-friendly health systems [ 3 ]. A recent interview study [ 4 ] explored the insights of adopting the 4Ms Framework in three health systems that were early adopters of the Framework and found that the common barriers to implementing the IHI’s 4Ms Framework included disengaged physicians, siloed implementation efforts (which led to problems with collaborations and scaling), and challenges in implementing “What Matters” in a meaningful way during clinical encounters [ 4 ]. A frontline culture change to sustain the 4Ms implementation is warranted.…”

“…A frontline culture change to sustain the 4Ms implementation is warranted. Successful efforts are dependent upon effective top-down communication, redesign of the healthcare system’s infrastructure to provide effective and tailored care to older adults, and provision of clinical education and support [ 4 ]. To our knowledge, no scoping review studies have examined the facilitators and barriers when implementing the IHI’s 4Ms Framework.…”

“…To our knowledge, no scoping review studies have examined the facilitators and barriers when implementing the IHI’s 4Ms Framework. In light of the existing knowledge gaps [ 3 , 4 ], the Alzheimer’s Association (AA) recommended the adoption of the IHI’s 4Ms Framework of Age-Friendly Health Systems; however, health systems and clinics need evidence on how the implementation of the IHI’s 4Ms Framework has better supported the health and well-being of people aged 65 years and older by providing older-adult-friendly clinical encounters (e.g., offering Medicare beneficiaries free annual wellness visits to access preventive services in ways that make sense to older adults) [ 5 , 6 , 7 ].…”