Adherence to the Age-Friendly Care 4Ms Framework and Association with Reduced Acute Care Utilization

The Age-Friendly Health Systems (AFHS) initiative emphasizes delivery of patient-centered, goal-concordant care for older adults through implementation of the Assess and Act-On care components of the 4Ms (What Matters Most, Medication, Mentation, and Mobility) framework. Despite broad adoption, there remains limited empirical evidence linking comprehensive, encounter-level adherence to 4Ms care with meaningful clinical and utilization outcomes. This retrospective study - designed through a multisite collaboration - evaluates the implementation of a standardized, informatics-driven approach to measure adherence to 4Ms care using electronic medical record (EMR) data and examines its association with hospital outcomes. The authors analyzed 40,411 inpatient encounters among adults 70 years of age or older admitted to acute care units across an eight-hospital health system between July 2024 and June 2025. Adherence to 11 operationalized 4Ms process measures was quantified at the encounter level based on expected care frequencies (shift, day, or visit based), incorporating both Assess (knowing the patient's 4Ms) and Act-On (incorporating the 4Ms into care delivery) components. A previously developed composite adherence score was used with tiered thresholds reflecting increasing fidelity of care delivery documentation. Primary outcomes included length of stay (LOS), discharge disposition, and 30-day unplanned readmissions. Multivariable regression models with inverse probability of treatment weighting were used to adjust for confounding. Overall documented adherence to 4Ms care varied considerably: On average, 75.3% of individual shift opportunities met compliance for aligning with age-friendly care guidance; however, 67% of encounters did not meet the initial threshold of adherence requiring 100% compliance with each opportunity to Assess throughout the encounter. Only 3% of encounters achieved higher-level documentation compliance (100% Assess and ≥50% Act-On). Although certain components, such as delirium screening and medication safety, demonstrated consistently high performance, substantial variability was observed in domains including mobility goal attainment, sleep optimization, and hydration. Higher documentation adherence to 4Ms care was strongly associated with shorter LOS, with the highest adherence tier demonstrating a 41% reduction in LOS (adjusted incident rate ratio, 0.59; 95% confidence interval [CI], 0.57 to 0.60). In addition, higher adherence was associated with reduced odds of 30-day unplanned readmissions (adjusted odds ratio, 0.60; 95% CI, 0.45 to 0.79). The adjusted analyses revealed an association between higher documentation adherence and increased likelihood of discharge to postacute care facilities, most likely reflecting an interrelationship with patient complexity and functional status. These findings highlight the feasibility of a standardized, EMR-based measurement strategy for evaluating adherence to the 4Ms framework and underscore the importance of consistently documenting age-friendly care practices. Although 4Ms care was documented in only a minority of patients, reliable delivery across all care opportunities was associated with improved hospital efficiency and reduced acute care utilization, supporting its role as a scalable strategy for enhancing outcomes among hospitalized older adults. Further research is needed to define optimal pragmatic adherence definitions in relation to patient outcomes.