INQUIRY: The Journal of Health Care Organization, Provision, and Financing - New Special Collection Series on Age-Friendly Health Systems
INQUIRY: The Journal of Health Care Organization, Provision, and Financing has launched a Special Collection series on Age-Friendly Health Systems.
A new article on Age Friendly Health Systems: Pivoting from Breadth to Depth by Robert E. Burke and JAHF's Leslie J. Pelton talks about the Age-Friendly Health Systems movement's remarkable reach, with thousands of health systems now recognized as age-friendly. Having achieved this spread, the authors note that the model must pivot to depth of practice to ensure all older adults receive age-friendly care, and depth of rigor to demonstrate impact and promote sustainability. Bringing together providers, payers and researchers in a Learning Health System model supported by national regulatory and payment incentives holds the most promise for achieving transformational change.
Other papers in the Special Collection open-access series include:
Implementation of the Age-Friendly Health Systems Initiative in the Department of Veterans Affairs: 5 Years of Improving Quality for Older Veterans, Andrea Wershof Schwartz, Shivani K. Jindal, Kimberly A. Wozneak, Robert E. Burke
- The Age-Friendly Health Systems (AFHS) initiative was developed to spread principles of high-quality care for older adults using the 4Ms Framework: What Matters, Medication, Mentation and Mobility. In 2020, the U.S. Department of Veterans Affairs (VA) set a goal for the Veterans Health Administration (VHA) to become the largest integrated Age‑Friendly Health System in the country, given that nearly half of veterans are over age 65. The VA implemented the AFHS initiative at nearly all VA parent facilities over five years, spreading the 4Ms model of age-friendly care across geographic and care settings. The authors note that further study is needed on the clinical impact of and optimal implementation strategies for AFHS. The VA experience offers a promising model for health systems seeking to implement AFHS.
Embedding Two of the 4Ms Into the Electronic Health Record: One Health System’s Journey Towards Systemwide Spread of Age-Friendly Care, Anna-Rae Montano, Christine Waszynski
- The authors describe two-rapid cycle quality improvement projects that embedded "Medication" and "Mentation" into the electronic health record across seven hospital systems. Project SCREEN implemented non-interruptive decision support to reduce potentially inappropriate medications, while Project PREDICT embedded delirium prediction rule to proactively guide care for at-risk patients. These initiatives demonstrate how clinical decisions support tools integrated into existing workflows can promote system-wide delivery of age-friendly care and highlight opportunities for expanding similar tools to address the remaining 4Ms.
A Path to Better Care for Older Adults: Optimizing Medicare and Medicaid Payments Through Implementation of the CMS Age-Friendly Hospital Measure, JAHF's Leslie J. Pelton, Rani E. Snyder, Terry Fulmer and Kedar Mate
- The article introduces the CMS Age-Friendly Hospital Measure, a quality measure that launched in early 2025 as part of the Inpatient Quality Reporting (IQR) Program. Grounded in the 4Ms Framework, the measure encourages hospitals to reduce harm and improve outcomes for older adults. The paper highlights how attesting to five domains can help hospitals enhance quality, reduce iatrogenic events, and strengthen accountability through public reporting on CMS Care Compare.
Establishing First Age-Friendly Health System Tele-Palliative Care Clinic – Facilitators, Challenges, Lessons Learned to Improve Care for Rural, Older Veterans, Stephanie Hartz, Courtney McGuire Jill Steagall, Jocelyn McCauliff, Kathryn Allen Nearing
- The case study describes the VA Eastern Colorado Health Care System's efforts to establish the first telemedicine clinic recognized as an Age-Friendly Health System. Grounded in the 4Ms Framework, the clinic delivered high-quality, team-based palliative care to rural and highly rural older veterans, improving access while maintaining fidelity to geriatric best practices. The authors highlight lessons learned and call for policy changes to extend AFHS recognition to fully virtual care models that align with What Matters to patients.
A Mixed-Methods Usability Pilot of a Value-Goal Elicitation Tool in the Inpatient Setting for Older Adults Anticipating Post-Acute Care, Syama Patel, Caroline Sefcik, Marilyn Schapira, Caroline Madrigal, Katherine Ritchey, Longyi Yip, Aanand Naik, Robert Burke, et al.
- The authors conducted a mixed-methods study to assess the usability of the Health Priorities Primer Tool in hospitalized older adults likely to need post-acute care. While most participants welcomes a tool to clarify What Matters for discharge planning, many preferred facilitated, verbal administration over self-completion and offered suggestions for improving tool clarity and timing. The findings highlight the tool's promise for supporting age-friendly post-acute transitions, but emphasizes the need for simplification, clinician involvement and alignment with hospital workflows to enhance usability.
Caring for Caregivers Within Age-Friendly Health Systems: An Organizational Case Study of National Scale and Spread, Ellen Carbonell, Diane Mariani, Robyn Golden
- This case study describes the Caring for Caregivers (C4C) model developed by RUSH University System for Health to support family caregivers within the Age-Friendly Health Systems initiative. Ground in the 4Ms Framework, particularly What Matters, the model offers customizable interventions such as skill-building, therapy sessions and coordinated care planning. The authors highlight early outcomes showing reduced caregiver stress, depression and burden, underscoring the importance of integrating caregiver support into clinical care as C4C scales nationally.
Outcomes Evidence Must Keep Up with the Implementation of the 4Ms Framework to Ensure Age-Friendly Health System Transformation, James D. Harrison, Stephanie E Rogers, Benjamin Rosner, Estelle Martin, Sunny C. Lin, Jarmin Yeh, Julia Adler-Milstein
- The paper notes how the 4Ms Framework guides Age-Friendly Health Systems in tailoring care to meet specific needs and populations. As more systems adopt the 4Ms, there is a growing need for strong evidence on its impact on patient outcomes. The authors propose seven strategies to help healthcare organizations, researchers and clinicians strengthen evaluation efforts and promote evidence-based practices across the AFHS ecosystem.
Effect of Age-Friendly Care on Days at Home Post-Hospital Discharge for Traditional Medicare Patients: A Cross-Sectional Study, Kathleen Drago, Bryanna De Lima, Sophie Rasmussen, Alaina Ena, Elizabeth Eckstrom, Ella Bowman
- The authors examine whether older adults in the Bundled-Payment for Care Improvement Advanced program who received age-friendly care at a participating hospital spent more time at home in the 30- and 90-day periods after hospitalization. The analysis showed no significant differences, though sensitivity analyses revealed that patients not receiving age-friendly care were more likely to spend time in a facility within 30 days after discharge. Their findings support the importance of patient-centered and value-based care during hospital stays.
Challenges and Opportunities in Implementing a Multicomponent Dementia Caregiver Program in a Complex Healthcare System, Connor M. Warren, Laura Ellen Ashcraft, Amanda Peeples, Kirstin Manges Piazza, Octavia Goodman, Laura N. Gitlin, Judith A. Long, Robert E. Burke, Rachel M. Werner, Rebecca T. Brown
- The authors conducted interviews across six VA Medical Centers to explore how to bring the Tailored Activity Program (TAP) into VA's Age-Friendly Health Systems initiative. TAP is an intervention that helps people living with dementia reduce behavioral symptoms for people living with dementia and caregiver burden. They found four key factors that affect success which can help guide the successful rollout of programs like TAP in complex healthcare settings.
4 Steps to 4Ms: A Navigation Guide for a Hospital-Based Composite Measure of 4Ms Care and the Implications for Outcomes Assessment, Benjamin Rosner, Robert Thombley, Stephanie Rogers, Julia Adler Milstein
- The authors provide a guide for developing a hospital-based composite measure of 4Ms care. The 4Ms (What Matters, Mentation, Medication and Mobility) are central to age-friendly health systems. The guide outlines four key steps: 1) Defining the 4Ms Components 2) Develop Measurement Criteria 3) Integrate into Clinical Practice 4) Evaluate and Refine. By following these these steps, hospitals can enhance the quality of care for older adults, aligning it with the AFHS initiative.
Strategies and Outcomes of Age-Friendly Health System Implementation in Outpatient Settings: A Systematic Review, Rebecca J. Howe, Katherine Rieke, Thomas Bayer, Htun Ja Mai, Jennifer L. Sullivan, Jane A. Driver, Taylor Rickard, Thomas A. Trikalinos, James Rudolph, Ellen McCreedy, and Eric Jutkowitz
- The authors conducted a systematic review to examine how Age-Friendly Health Systems are being implemented in outpatient settings and which strategies and measures are used to assess their impact. They identified 10 studies that used over 65 implementation strategies and 98 outcome measures, most of which aligned with the 4Ms Framework. The findings highlight the need for more consistent strategy specification and standardized measures to advance from AFHS recognition to meaningful system-level impact.
Outcomes of Age-Friendly Health Systems: Return to Clinic After 4Ms Care Delivery, Grace Q. Armstrong, Heba M. Aldossary, Jessica Bingham, Lilia Pino, Anne Pohnert, Mary A. Dolansky, Nicholas K. Schiltz
- The authors conducted a study to examine the impact of the 4Ms Framework on patient return rates to clinics. Using electronic health records data, the researchers found that patients who received all the 4Ms during their visit were more likely to return to the clinic for future care compared to those who received part or none of the 4Ms. These results suggest that the 4Ms Framework enhances patient satisfaction and encourages continued use of the same health system.
Trends and Factors Associated With Extremity Fractures and Post-Acute Care Utilization of Nevada Older Adults: Insights of Age-Friendly State Planning in U.S., Soo Hwan Kang, Jay J. Shen, Yonsu Kim, Iulia Ioanitoaia-Chaudhry, Se Won Lee, Tae Ha Chung, Ian Choe, Connor Jeong, Songe Kwon, Daniel Lim, Yena Hwang, Leora Frimer, Ji Won Yoo, et al.
- The authors conducted a retrospective study of hospital discharge data in Nevada to examine post-acute care utilization trends among adults aged 65+ with extremity fractures. They found a significant decline in rehabilitation facility use from 2018 to 2021, with a corresponding increase in discharges to home with services, particularly among socially disadvantaged groups such as racial minorities, Medicaid beneficiaries and rural residents. These findings highlight the urgent need for geriatrics workforce training and policy solutions to support safe, equitable care transitions in provider shortage areas.
Age-Friendly Health Systems Integration into Rural Primary Care Clinics: A Journey of One Geriatric Workforce Enhancement Program, Leah Tobey-Moore, Katherine Scalzo, Stacie Massey, Robin McAtee
- The authors conducted a study on the implementation of the 4Ms Framework of AFHS in primary care clinics in rural Arkansas. They present research evidence to demonstrate how primary care clinics across the country can similarly enhance their services.
Assessing Equitable Adherence to the Age-Friendly Health System’s 4Ms Framework in an Academic Inpatient Setting, Julia Adler-Milstein, Robert Thombley, Sarah Rosenthal, Benjamin Rosner, Stephanie Rogers
- The authors conducted a study to identify mechanisms that may influence the 4Ms. They provide evidence that suggests that positive and negative implicit biases and comprehensive geriatrics care significantly influenced the delivery of the 4Ms.
Organizational Characteristics of Hospitals Meeting STRIDE Program Adoption Benchmarks to Support Mobility for Hospitalized Persons, Leah L. Zullig, Connor Drake, Amy Webster, Matthew Tucker, Ashley Choate, Karen M. Stechuchak, Cynthia J. Coffman, Caitlin B. Kappler, Cassie Meyer, Courtney H. Van Houtven, Kelli D. Allen, Jaime M. Hughes, Nina Sperber, Susan Nicole Hastings
- The authors conducted a study to examine how organizational characteristics of VA hospitals influence how the STRIDE Program is implemented and adopted. Their research results provide evidence of how inadequate staffing and hiring created challenges for adopting STRIDE.
This Special Collection focuses on issues of implementation and intervention effectiveness of Age-Friendly Health System (AFHS) redesign efforts, furthering the field.
Learn more about the AFHS Special Collection and go to the articles.
Learn more about the AFHS initiative.
Learn more about JAHF's co-support of the AFHS initiative.
