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

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.

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.

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.

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.