Age Friendly Health Systems
Project Quickstart Guide
Quality Institute
Table of Contents A quick guide to an Age-Friendly Health Systems imrpovement project
3
What is an Age Friendly Health System?
14
Access the Data
4
Aging Population Data
15
Example Project Charter and Scoping Document
5
CMS Measures and AFHS
16
Measures: Process, Balancing, and Outcome
6
AFHS Recognition
17
Workflows for Age Friendly Care
7
The 4Ms
18
Example AIM Statements
8
How to Practice the 4Ms in a Hospital Setting
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Example QI Tools
9
What Matters
20
Example PDSA Cycles
10
Medication
21
Change Management
11
Mentation
22
Project Tracker
12
Mobility
13
Forming an Improvement Project Team
What is an Age Friendly Health System? Becoming an Age-Friendly Health System entails reliably providing a set of four evidence-based elements of high-quality care, known as the “4Ms,” to all adults ages 65 and older in your system: What Matters, Medication, Mentation, and Mobility. Age-Friendly Health Systems is an initiative of 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)
Aging Population Data National Data: 61.2 million Americans were 65+ in 2024 (18.0% of the population), up from 12.4% in 2004 — Census Vintage 2024 estimates By 2030 all baby boomers will have turned 65, pushing the total to roughly 71.6 million (20.7%). By 2034, the Census projects older adults will outnumber children for the first time in U.S. history. The 85+ group is projected to nearly quadruple between 2000 and 2040 (Urban Institute analysis of Social Security Trustees data). o Those most likely to need help with basic personal care o This is the group multimorbidity and functional decline concentrate in, and it's growing fastest of all. Regional Data: Monroe County was designated an AARP Age-Friendly Community in 2024 as its 60+ population reached 25% (192,000 residents) for the first time — projected to hit 215,000 by 2030 (Monroe County Aging Alliance / AARP) Notably, 82% of county residents 65+ live in the surrounding towns rather than the City of Rochester, so suburban service capacity matters as much as urban. Common Ground Health's Sage Commission projected that by 2025 one in five Finger Lakes residents would be 65+ — and updated 2019 forecasts came in even higher than the original 2011 projections (10% higher for 65-84, 15% higher for 85+). Across the nine-county Finger Lakes region, the 65+ population grew about 50% from 1990 to 2020 (159,000 to 238,000, or 13% to 19% of the population). The Monroe County Community Health Needs Assessment projects older adults will outnumber children in the county by 2035
CMS Measures and AFHS Hospitals that participate in Medicare’s Hospital Inpatient Quality Reporting (IQR) Program are now required to report on having protocols in place to: 1. Elicit patient health care goals 2. Responsibly manage medications 3. Implement frailty screening and intervention (including cognition and mobility) 4. Assess social vulnerability (e.g., social isolation, caregiver stress, elder abuse) 5. Designate age-friendly leadership This structural measure was developed in collaboration with the Institute for Healthcare Improvement, the American College of Surgeons, and the American College of Emergency Physicians. ***The AFHS 4Ms framework provides much of the foundation for this measure *** Penalty of not participating is a significant reduction in annual Medicare payment update.
AFHS Recognition IHI recognizes clinical care settings that are working toward reliable practice of evidence-based interventions for all older adults in their care known as the 4Ms . As of September 2026, over 7,000 healthcare organizations have earned either level 1 (Participant) or level 2 (Committed to Care Excellence) recognition in the Age-Friendly Health Systems movement. More than 9.9 million older adults have been reached with 4Ms care.
Level 1 (Participant) teams have successfully developed plans to implement the 4Ms.
Level 2 (Committed to Care Excellence) teams have three months of data of older adults who received 4Ms care.
Level 1 Recognition 1.UR Medicine Finger Lakes Health 2.Noyes 3.Jones 4.UR Medicine Geriatrics Group (URMGG) 5.SOCARE Clinic: Specialized Oncology Care and Research for our Elders Clinic at Wilmot Cancer Center 6.Monroe Community Hospital 7.Eastman Institute for Oral Health
Level 2 Recognition 1.Highland Hospital 2.Strong Memorial Hospital 3.Finger Lakes Health - Living Center South & North 4.Center for Perioperative Medicine
The 4Ms
What Matters Know and align care with each older adult’s specific health outcome goals and care preferences, including day -today needs as well as end-of-life planning, and across settings of care
Medication If medication is necessary, use age-friendly appropriate medications that do not interfere with What Matters to the older adult, Mobility, or Mentation across settings of care
Mentation Prevent, identify, treat, and manage dementia, depression, and delirium across settings of care to optimize What Matters and Mobility
Mobility Ensure that older adults move safely every day in order to maintain function and do What Matters
How to Practice the 4Ms in a Hospital Setting Ask the older adult What Matters most, document it, and share What Matters across the care team Align the care plan with What Matters most Review for potentially inappropriate medication use and document it Deprescribe or avoid potentially inappropriate medications, and document and communicate changes Screen for delirium at least every 12 hours, document results, develop a care plan Ensure sufficient oral hydration Orient to time, place, and situation Ensure older adults have their personal adaptive equipment Support non-pharmacological sleep Screen for mobility limitations and document the results Ensure early, frequent, and safe mobility Institute for Healthcare Improvement ihi.org/AgeFriendly July 2019
How the Team Contributes:
Definition: Align care with each older adult's specific health outcome goals, care preferences, day-to-day needs, and end-of-life planning across all care settings. Team Participation:
Nursing Staff: Assessment: Assess Advance Care Planning (ACP) and Social Determinants of Health (SDoH) on admission. Participate in assessing "What Matters" through daily discussions. Primary Care Team (Providers): Assessment/Action: Facilitate discussions with patients/families to understand what matters most, their values, and motivators. Ensure comprehension for informed consent and collaboration. Aligning treatments with patient goals and wishes. Social Workers (SW) / Case Managers: Assessment: Conduct comprehensive ACP evaluations, especially with medical or level-of-care changes. Assess "What Matters" during comprehensive assessments. Action: Connect patients with resources based on SDoH assessments. Interdisciplinary Team (PT, OT, SLP, PCT/CNAs): Action: Collectively review "What Matters" information to align with the plan of care. Understand patient treatment goals and provide support to achieve them.
What Matters Resources
How the Team Contributes:
Definition: Use age-friendly medications that do not interfere with "What Matters," Mobility, or Mentation across settings of care. Team Participation:
Nursing Staff: Assessment/Action: Perform medication reconciliation at regular intervals. Monitor medication effects and advocate for patient safety with the care team. Pharmacists: Assessment: Participate in medication reconciliation, evaluating potentially inappropriate medications (risk vs. benefit). Assess high-risk benzodiazepine use via eRecord alerts. Action: Provide guidance for discontinuing or tapering benzodiazepines, sharing plans with the primary care team. Support clinical team in medication decision-making. Primary Care Team (Providers): Assessment/Action: Review medications throughout hospitalization, making age-friendly adjustments to align with the 4Ms. Implement or oversee pharmacist's benzodiazepine deprescribing plans. Social Workers (SW) / Case Managers: Action: Assist with financial support for medications.
Medication Resources
How the Team Contributes:
Definition: Prevent, identify, treat, and manage dementia, depression, and delirium across settings of care. Delirium: Nursing Staff: Assessment: Assess delirium (CAM, CAM-ICU; NuDESC future state). Monitor for cognitive changes. Action: Implement interventions like LIVEBAR (non-ICU) and the ABCDEF Bundle (ICU). Crucial for delirium prevention. Primary Care Team (Providers): Assessment/Action: Evaluate cognitive changes and participate in implementing interventions to treat and manage delirium. Interdisciplinary Team (PT, OT, SLP, PCT/CNAs): Assessment: Notice and communicate cognitive changes from baseline to nurse/provider. Action: Contribute to the ABCDEF Bundle (e.g., early mobility). Support patient reorientation. Depression: Clinical Staff (Nursing, Medical, Others): Assessment: Screen for depression using PHQ2, PHQ9. Action: Participate in developing and implementing a care plan to address depression. Primary Care Team: Action: Involved in ongoing management and follow-up for depression. Dementia: Occupational Therapists (OT): Assessment: Often assess dementia using MoCA. Primary Care Team (Providers): Assessment: Participate in screening with validated tools. Monitor cognitive decline to differentiate delirium from disease progression. Action: Develop treatment plans, ensuring continuity of care. Social Workers (SW) / Case Managers: Action: Provide resources and support to patients and families. Facilitate longitudinal plans with the care team and community resources. Care Team (Collaborative): Action: Develop plans for supportive care, environmental modifications, and communication strategies.
Mentation Resources
How the Team Contributes:
Definition: Ensure older adults move safely every day to maintain function and do "What Matters." Team Participation:
Nursing Staff: Assessment: Conduct BMAT (Bedside Mobility Assessment Tool) screening. Action: Promote maximal ability mobilization 3x daily. Incorporate and use safe patient handling equipment for transfers and ambulation. Physical Therapists (PT): Assessment: Conduct specialized assessments like the Egress test. Action: Develop individualized mobility plans, guide therapeutic exercises, and promote maximal ability mobilization. Provide expertise on safe patient handling equipment and techniques. Interdisciplinary Team (PCT/CNAs, OT, etc.): Action: Share responsibility for promoting maximal ability mobilization 3x daily and incorporating safe patient handling equipment, ensuring a consistent approach to maintaining and improving patient mobility.
Mobility Resources Mobility Program Website
Forming an Improvement Project Team As you establish your team to begin testing age-friendly interventions, consider the following questions: 1. Does the team represent a diversity of perspectives? Consider all the different roles within the health system that may be involved in practicing the 4Ms with older adults. 2.Additionally, is the team representative of the race, ethnicity, culture, and language diversity of the older adult population? o How do power dynamics affect the team? How might you ensure that all team members are able to actively participate in identifying and testing change ideas?
Ideal roles for project team: Geriatric Champion / Geriatric Resource Nurse
Social Worker/Case Manager/ Care Coordinator
Mobility aid / Mobility LPN
Pharmacy (if applicable)
Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults (2026)
Access the Data All the metrics you need to start an Age Friendly improvement project are easily accessible! Check out some of the dashboards below:
Age Friendly Dashboard Clinical Mobility Dashboard Delirium Reports KPI Dashboard
Example Project Charter and Scoping Document
Example Measures Process Measures
These track how well the intervention or system changes are being executed. Some examples include: Percentage of hospitalized older adults screened for delirium Percentage of older adults with a documented "What Matters" conversation within 24 hours of admission Percentage of older adults with BMAT documentation
Balancing Measures These ensure your changes aren't causing unintended Balancing Measures consequences elsewhere. Some examples include: Falls with injury Patient-reported pain levels or anxiety scores following the reduction of opioids, sedatives, or benzodiazepines
Outcome Measures These reflect the impact on the patient or system. Some examples include* : Patient satisfaction scores Length of Stay 30 day Readmissions Rate Delirium diagnosis HACs
*Ages 65+
Workflows for Age Friendly Care
Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults (Spring 2024)
Example AIM Statements Aim Statement Template for Age Friendly Care: By [date], [name of unit] will articulate how it operationalizes 4Ms care and will have provided that 4Ms care equitably for [percent of] patients 65+ years old
[Unit/Department Name] will increase percent of patient unit stays for adults age 65+ with no missing delirium screenings from 66% in August 2026 to 95% by August 2027 [Unit/Department Name] will increase rate of completed What Matters assessment for adults 65+ from 60% in January 2027 to 82% in June 2027 [Unit/Department Name] will reduce length of stay for adults 65+ from 7.2 days in October 2025 to 6 days in October 2026 by implementing the 4Ms framework [Unit/Department Name] will increase percentage of patients 65+ who are mobilized at least 3x a day from 35% to 79% by January 2028 By [Date], the [Unit/Department Name] will achieve [Target %] compliance for completing medication reconciliations within 24 hours for all patients 65 and older.
Example QI Tools
Example PDSA Cycles Confirm“What Matters” during morning interdiciplinary rounds and update documentation
Minimize vital signs checks and med passes overnight to provide a sleep promoting environment
Write a “Daily Mobility Goal” on whiteboard and work with patients to acheive
Education on nonpharmacological interventions to prevent and manage delirium
Change Management Use the ADKAR (Awareness, Desire, Knowledge, Ability, Reinforcement) template to identify where impacted groups need additional support. Create interventions with these ADKAR elements in mind.
Enter your AFHS Project into the Project Tracker!
URochester Medicine's Quality Institute Project Tracker