Implementing the Age-Friendly 4Ms+ Framework in a Vulnerable Population at a Safety-Net Hospital

On account of the growing proportion of older adults in the United States, thousands of health systems have implemented the Age-Friendly Health Systems' (AFHS) 4Ms framework - What Matters, Medication, Mentation, Mobility - to optimize older adult care. Safety-net hospitals serve a vulnerable older adult population characterized by adverse social determinants of health and often operate with limited financial resources. The objective of this article is to describe the process of implementing the 4Ms framework, plus two additional Ms - Malnutrition and Mal-Care Transitions - into the inpatient services of a major Southeastern safety-net hospital. The authors outline barriers, challenges, and resources applied during this process. Additionally, they present initial clinical outcomes for an inpatient cohort cared for in the most recent 2 years. An AFHS work group composed of relevant departmental heads, geriatricians, and key staff members was established to champion the design and employment of the 4Ms framework. Subcommittees were formed for each of the four Ms. Each committee developed and applied frameworks, workflows, protocols, tools, and modifications to the electronic health record to implement their respective M. A stepwise approach was developed to spread practices across inpatient units in the hospital through a combination of tests using a Plan-Do-Study-Act approach, while the creation of data dashboards and reporting workbenches permitted longitudinal monitoring of performance and documentation compliance in near real time. The authors describe adherence to the 4Ms over a 2-year period. From March 2024 to March 2026, 4647 inpatient encounters with 3427 patients (mean age of 79.3 years, 58% female, 64% African American, mean Katz functional score of 5.8) occurred on units that implemented the 4Ms framework as a set. Adherence in the AFHS units reached 100% on 5 of 14 care protocols and over 90% on an additional 5. AFHS units performed particularly well with the implementation of What Matters (74%), Mentation (98% delirium screening), and Mobility (96% functional capacity assessments). Adherence with other mobility-related assessments and medication-related practices was also high. This study shows the feasibility of implementing and sustaining the AFHS framework with high adherence to the 4Ms in a large safety-net hospital with a diverse and vulnerable older adult population.