Care and Support With Older Adults and Their Families

The following is adapted from Age-Friendly Health Systems by Terry Fulmer PhD RN FAAN and Leslie Pelton, MPA, as Editors and Jinghan Zhang, MPH, and Wendy Huang, MHA, as Associate Editors.

The United States is aging; the number of adults over the age of 65 is projected to double over the next 25 years (Centers for Disease Control and Prevention, 2013). This has been well documented for decades, and yet our healthcare system seems surprisingly unprepared for the increasing proportion of older people brought on by the successful aging of the Baby Boomers. Meanwhile, US health expenditure is growing exponentially, increasing by 4.6% in 2019 and reaching $3.8 trillion (Centers for Medicare & Medicaid Services, 2019). Though people aged 55 and over make up 29% of the population, they are a high-need, high-cost population that accounts for 56% of health spending (Sawyer & Claxton, 2019).

Supporting an aging population is increasingly expensive, as clinical needs become more complex — approximately 80% of older adults have at least one chronic disease, and 77% have at least two (Centers for Disease Control and Prevention, 2013). Yet, many US health systems are ill-equipped to deal with the social complexity many older adults face, including, but not limited to, loss of loved ones, retirement, or relocation of residence (National Council on Aging, 2021). Our system of care treats people in silos defined by their disease processes. Older adults visit an endocrinologist for their diabetes, a cardiologist for their heart condition, and an orthopedic specialist or rheumatologist for their joint pain.

Providing excellent primary care in this fractured system is challenging; most people over 65 have three to five chronic diseases or disorders, and seldom do the experts have the opportunity to provide careful analysis across specialties. Older adults have higher rates of healthcare utilization compared to other age groups and experience higher healthcare-related harm, delay, and discoordination. They also visit emergency department four times as often as younger populations (Abrams & Milstein, 2016). The poor transitions in care and a failure to approach care in a person-centered manner result in potentially avoidable harms related to polypharmacy and falls, increased readmissions, and a greater risk of institutionalization, which further financially burden the US healthcare system.

Furthermore, the US is becoming more diverse, such that by 2030, the non-Hispanic white population will be the numerical minority. Though various ethnic and racial groups are living longer, socioeconomic disparities also bring about a disproportionate risk for adverse health outcomes compared with whites (Rowe et al., 2016). The COVID-19 pandemic has exposed these long-standing systemic disparities, as death rates have been disproportionately higher among African American, Native American, and Latinx communities. This stems from inequitable living and working conditions, higher rates of chronic medical conditions, and lower access to healthcare that predispose minority groups to worse COVID-19 outcomes (Tai et al., 2021). This highlights a need for effective care management by increasing collaboration between the older person, family caregivers, and clinicians to identify the older person’s needs and goals and implement individualized care plans to achieve higher-quality healthcare (Rowe et al., 2016).

Creating Age-Friendly Health Systems

The systems currently in place are clearly inadequate to serve an aging population’s health needs. Fortunately, we now have the tools to create Age-Friendly Health Systems. Becoming an Age-Friendly Health System entails reliably providing a set of specific, evidence-based geriatric best-practice interventions to all older adults in your health system. Such systems do so primarily through redeploying existing health system resources to achieve

• better health outcomes for this population;
• reduced waste associated with low-quality services;
• increased utilization of cost-effective services for older adults; and
• improved reputation and market share with a rapidly growing population of older adults.

The development of these groundbreaking tools began in November 2016, when The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI), in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA), set the bold aim that 20% of US hospitals and health systems would be Age-Friendly Health Systems by June 30, 2020.

The Framework: The 4Ms of Age-Friendly Care

The age-friendly care model that emerged is evidence-based and lends itself to reliable implementation in the healthcare setting. Age-friendly care can be encapsulated in the 4Ms.

The 4Ms — What Matters, Medication, Mentation, and Mobility — identify the core issues that should drive all decision-making with 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, ethnic, or religious background (Mate et al., 2018).

The 4Ms

1. What Matters

Know and align care with each older adult’s specific health outcome goals and care preferences, including, but not limited to, end-of-life care and across settings of care.

2. Medication

If medications are necessary, use age-friendly medications that do not interfere with What Matters, Mentation, or Mobility across settings of care.

3. Mentation

Prevent, identify, treat, and manage dementia, depression, and delirium across care settings.

4. Mobility

Ensure that older adults move safely every day to maintain function and do What Matters.

Each of the 4Ms is evidence-based. The innovation of an Age-Friendly Health System is the reliable practice of the 4Ms as a set (Mate et al., 2021).

Rather than asking providers to reinvent the wheel, the intention is that the 4Ms be incorporated into existing care. Much can be achieved primarily through redeploying existing health system resources to incorporate the remaining 4Ms and organize all 4Ms so that they are part of every encounter between an older adult and their caregivers.

The 4Ms provide a framework, not a program, designed to guide all care of older adults wherever they touch care and services. They are essential elements of providing high-quality care for older adults and, when implemented together, represent a broad shift by health systems to focus on the needs of older adults.

The Approach: Assess and Act

To successfully implement Age-Friendly Health Systems, there are two critical elements. First, assess every person/patient’s unique situation through the lens of the 4Ms. Second, incorporate the 4Ms into the plan of care across all settings of care.

The 4Ms were first tested with hospital-based and ambulatory/primary care-based settings with expert faculty and advisors and five pioneering health systems — Anne Arundel Medical Center, Ascension, Kaiser Permanente, Providence, and Trinity Health. The resulting Age-Friendly Health Systems: A Guide to Using the 4Ms While Caring for Older Adults is designed to help care teams test and implement a specific set of evidence-based geriatric best practices across the 4Ms in their setting (Institute for Healthcare Improvement, 2020). In convenient care clinics and skilled nursing facilities, 4Ms care is now fully underway. Staff at these locations have the goal of implementing 4Ms care in every setting.

As the US population continues to age, healthcare expenditure exponentially rises due to the failure of the US healthcare system to address the complex social and clinical needs of older persons. The bold and rapidly spreading Age-Friendly Health Systems care model emerged to provide evidence-based interventions embedded in the 4Ms framework (What Matters, Medication, Mentation, Mobility), which aims to improve health outcomes for older persons, reduce waste associated with low-quality services, and increase the utilization of cost-effective, high-value services instead.

To learn more about elderly care, you can find Age-Friendly Health Systems on Amazon.

Terry Fulmer, PhD, RN, FAAN, is the President of The John A. Hartford Foundation in New York City, a foundation dedicated to improving the care of older adults. Established in 1929, the Foundation has a current endowment of more than $650 million. She serves as the chief strategist for the Foundation and her vision for better care of older adults is catalyzing the Age-Friendly Health Systems social movement. She is an elected member of the National Academy of Medicine and recently served on the independent Coronavirus Commission for Safety and Quality in Nursing Homes established to advise the Centers for Medicare and Medicaid Services. She previously served as Distinguished Professor and Dean of Health Sciences at Northeastern University. Prior, she served as the Erline Perkins McGriff Professor and Founding Dean of the New York University College of Nursing. She received her bachelor’s degree from Skidmore College, her master’s and doctoral degrees from Boston College and her Geriatric Nurse Practitioner Post-Master’s Certificate from NYU. She completed a Brookdale National Fellowship and she is the first nurse to have served on the board of the American Geriatrics Society. She is also the first nurse to have served as President of the Gerontological Society of America, which awarded her the 2019 Donald P. Kent Award for exemplifying the highest standards for professional leadership in the field of aging.

Dr. Fulmer is nationally and internationally recognized as a leading expert in geriatrics and is also known for conceptualization and development of the national NICHE program and research on the topic of elder abuse and neglect, work that has been funded by the National Institute on Aging and the National Institute of Nursing Research. She is a Trustee for the Josiah Macy Jr. Foundation, Springer Publishing Company, the Bassett Healthcare System, and is a member of the National Academy of Medicine’s Forum on Aging, Disability, and Independence. She has served as the Chair of the National Advisory Committee for the Robert Wood Johnson Foundation Executive Nurse Fellows Program, and held board positions at Skidmore College, the Institute for Healthcare Improvement, the Geriatrics and Gerontology Advisory Committee for the U.S. Department of Veterans Affairs, and the Advisory Board for Hong Kong Polytechnic University School of Nursing. She is one of top 50 Influencers in Aging by PBS’s Next Avenue, the premier digital publication dedicated to covering issues for older Americans. Dr. Fulmer is the recipient of prestigious awards, including the American Society on Aging’s 2017 Rosalie S. Wolf Award for her body of work on elder abuse. In 2016, she received the 2016 Award for Exceptional Service to The New York Academy of Medicine for her distinguished service on the Academy’s Board of Trustees, including as vice-chair and for her active engagement in the policy work of the Academy, especially its Age-Friendly NYC initiative. She has been honored with invitations for named lectureships from noted universities. She has held faculty appointments at Columbia University, where she was the Anna C. Maxwell Chair in Nursing, and she has also held appointments at Boston College, Yale University, and the Harvard Division on Aging at Harvard Medical School. She has served as a visiting professor of nursing at the University of Pennsylvania and Case Western Reserve University.

She is a Distinguished Practitioner of the National Academies of Practice and currently an attending nurse and senior nurse in the Yvonne L. Munn Center for Nursing Research at the Massachusetts General Hospital and an attending nurse at Mount Sinai Medical Center in NYC. Her clinical appointments have included the Beth Israel Hospital in Boston, the Massachusetts General Hospital, and the NYU Langone Medical Center. She is a Fellow of the American Academy of Nursing, the Gerontological Society of America, and the New York Academy of Medicine where she served as vice-chair. She has authored over 150 peer-reviewed papers and edited 10 books.