Last year's surge in hospital participation in the Age-Friendly Health Systems initiative was somewhat unexpected by insiders at the Institute for Healthcare Improvement (IHI).

“We originally thought people were going to put our program on the shelf because of all the COVID-related work,” recalled Alice Bonner, PhD, RN, FAAN, senior advisor at IHI. “We were completely wrong.”

In fact, a whopping 1,671 health care sites in the United States signed up for IHI's Age-Friendly Health Systems initiative between March and December of 2020 alone. That amounted to an 85% jump in participation in the program – or “social movement,” as IHI considers it. Today, more than 2,100 health care sites, including hospitals, outpatient clinics, convenient care clinics, and nursing homes, are recognized by IHI as participants in the Age-Friendly Health Systems movement.

If you're unfamiliar with the initiative, you're not alone. While the dizzying rush toward Age-Friendly Health Systems participation will likely enhance the care provided to older adults, many members are early in their journey toward fully incorporating the concepts throughout their organizations. One of the fundamental principles of Age-Friendly Health Systems and IHI is to start small, with one staff member and one patient on one unit. Once a care team learns how to deliver the “4Ms” on a small scale, the work is scaled and spread to other older adults, in more settings, and across other sites — until, eventually, every older adult at every care interaction is receiving truly age-friendly care, which is the overarching objective of the national initiative.

But first, the basics.

What Matters, Medication, Mentation, and Mobility

The Age-Friendly Health Systems framework has three aims: to follow an essential set of evidence-based practices, to cause no harm, and to align with what matters to the older adult and their caregivers. On a practical level, these play out in four specific areas, which are called the 4Ms: What Matters, Medication, Mentation, and Mobility (see Figure).

What Matters represents the goals of the patient and family. On the anesthesia unit level, addressing What Matters could look like a conversation with the patient ahead of surgery to identify issues of importance, or what the patient is looking to gain or avoid from the experience, Dr. Bonner advised. Medication practices ensure the medications patients use do not cause harm or interfere with What Matters to them, their Mentation, or their Mobility.

Mentation, from an anesthesia perspective, should involve deliberate inquiry into the patient's cognitive status both before and after surgery to identify any issues that could lead to delirium or other cognitive effects. Finally, choosing anesthesia agents and amounts that promote timely recovery and return to function/movement would be covered under Mobility. For more specific action, details, and references see the resources on the ASA Perioperative Brain Health Initiative website at

“The 4Ms are a framework of what we do in any setting. It also creates a standard way to communicate with one another across health care settings,” said Dr. Bonner. “Anesthesia comes in as an important player on the team. When anesthesiologists are doing a warm handover to the surgical units, a skilled nursing facility, or the community, it's important to address all 4Ms.”

“The 4Ms are a holistic framework for taking care of patients across the continuum,” said anesthesiologist Amy Lu, MD, who focuses on care pathways in her work as Associate Chief Quality Officer at Stanford Health Care. “Anesthesiologists are working with an increasingly aging population, and issues of perioperative delirium and frailty impact the 4M framework.”

Stanford Health Care joined the Age-Friendly Health Systems program in October 2016. Between 2017 and 2019, mortality for hospitalized older adults there fell from 5.8% to 2.5%, the average time to first mobilization shrank from 48 hours to 23 hours, and delirium incidence decreased from 32% to 24%, according to a case study on the Age-Friendly Health Systems website. As of May 2021, the system's geriatric trauma program was one of more than 500 sites to achieve Age-Friendly Health Systems-Committed to Care Excellence recognition.

A lifeline during COVID-19

Hospitals and health care sites that commit to putting the 4Ms into practice receive support from the IHI team as well as from others around the country on similar Age-Friendly journeys. Much of the latter occurs through membership in an Age-Friendly Action Community, where best practices for implementing the 4Ms are shared and discussed with peers at other organizations.

During the COVID-19 pandemic, action communities proved to be a lifeline for members seeking positivity and support.

“I think that's really how we got our foot in the door. People were exhausted from the pressures and challenges from COVID-19, and leaders were looking for ideas on how to support staff,” said Dr. Bonner. “They would get on these action community calls and hear about how implementing the 4M framework improved outcomes and staff morale. Participants found that the 4Ms is an accessible framework and that really resonated during the COVID crisis. Teams experienced rapport and esprit de corps with their peers, and that drove the movement.”

For organizations that prefer to work at their own pace, IHI offers an Age-Friendly Health Systems Do-It-Yourself pathway ( And for larger health systems, a Scale-Up Accelerator pathway provides guidance for leadership and point-of-care adoption of the 4Ms. Interested health systems can email for more information. You can find additional resources at

As participants ramp up their adoption of 4M practices, sites that meet requirements can achieve Age-Friendly Health Systems-Committed to Care Excellence recognition.

Opportunity for anesthesiology leadership

An upcoming ASA Monitor article will provide more in-depth, anesthesiology-specific guidance on implementing Age-Friendly practices. Although the importance of any of the 4Ms isn't exactly breaking news for any provider in this day and age, the 4Ms framework puts a handle on four elements that have the power to make or break the care of an older adult.

“The considerations in patient care involved in becoming an Age-Friendly Health System are practices that we as anesthesiologists frequently already provide to our patients during the perioperative period. It is a logical extension of the ASA Perioperative Brain Health Initiative to help implement the best patient-centered care possible during a patient's hospitalization,” said Andrew D. Rosenberg, MD, FASA, ASA's Vice President for Scientific Affairs and Professor and Chair of the Department of Anesthesiology, Perioperative Care, and Pain Medicine at NYU Langone Health and NYU Grossman School of Medicine in New York City.

Dr. Rosenberg's facility was recently recognized as an Age-Friendly Health Systems-Committed to Care Excellence organization.

“I believe taking the initiative to lead this effort on behalf of our patients is yet another excellent opportunity for anesthesiologists to work collaboratively with others in the hospital and be leaders within our institutions,” he said.

Jolynn Tumolo is an award-winning writer with more than 20 years of experience covering the health care field. She graduated summa cum laude from West Chester University, where she earned a BA in English with a concentration in journalism.