The population of the United States is aging --and aging fast. According to the U.S. Census Bureau, from 2010 to 2020, the population aged 65 or older experienced its largest-ever 10-year numeric gain, increasing by 15.5 million people. By 2020, this demographic accounted for 16.8% of the total population. A report from the U.S. Department of Health and Human Services’ Administration on Aging put this percentage at 17.3% in 2022 (57.8 million people) and projects the percentage will rise to 22% by 2040 (see sidebar #1).
As expected, most older adults have worse health than their younger counterparts. In 2022, 24% of adults aged 65 and older reported their health as fair or poor, compared to 19% of adults aged 50 to 64, according to the Administration on Aging report. In addition, most older Americans have at least one chronic condition, with many having several.
Clinicians and healthcare organizations will need to develop strategies for delivering care to meet the diverse health needs of these many older adults. One strategy is the Age-Friendly Health System, which is designed to improve the care of older adults. The system is an initiative of the John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI) in partnership with the American Hospital Association and the Catholic Health Association of the United States. The goal is to provide evidence-based care in every setting where nurses, advanced practice registered nurses (APRNs: nurse practitioners and clinical nurse specialists), and other clinicians interact with older adults.
Following the precepts of the Age-Friendly Health System can facilitate the ability of nurses and APRNs to apply evidence-based care, which can not only help their patients but also help themselves avoid litigation related to factors such as missed or wrongful care. It’s also essential for clinicians to understand the scope of healthcare needs for older patients.
Care needs
The Administration on Aging report notes that 90% of people 65 years or older take at least one prescription medicine, and 33% have a disability. According to a study by Boersma and colleagues, who examined 2018 data, the prevalence of multiple chronic conditions was highest among adults aged 65 or older who had both Medicare and Medicaid (76.9%) and lowest among those with Medicare only (excluding Medicare Advantage) (58.5%).
At the same time, older adults may struggle to pay for care, which can add additional stress that affects their health. The average out-of-pocket healthcare expenses were $7,640 in 2022, a 47% increase since 2012 ($5,118), according to the Administration on Aging report.
Those in current healthcare systems often struggle to effectively care for older adults. The Age-Friendly Health System can facilitate the provision of quality care.
Age-Friendly Health System
The Age-Friendly Health System has three aims:
- follow an essential set of evidence-based practices,
- cause no harm,
- and align with what matters to the older adult and their family caregivers.
The framework of the system consists of providing four evidence-based elements of high-quality care, referred to as the “4Ms”: What Matters, Medication, Mentation (including mood), and Mobility (see sidebar #2).
The IHI has recognized 5,211 hospitals, practices, and long-term care organizations as Age-Friendly Health Systems Participants.
The framework can be applied to all older adults, regardless of racial, ethnic, or religious background. Benefits include optimal care for patients, improved patient satisfaction, and optimized value for patients, families, caregivers, healthcare providers, and the organization. However, the framework must be thoughtfully implemented; otherwise, it can create unnecessary work and burden clinicians.
CMS weighs in
The Centers for Medicare & Medicaid Service (CMS) has added an Age-Friendly Hospital Measure to its Inpatient Quality Reporting Program. The measure assesses a hospital’s commitment to improving care for patients aged 65 years or older who receive services in the hospital, operating room, or emergency department.
Five domains are included in the measure, which started in FY2025. Annually, hospitals will need to state whether they have protocols in place to 1) elicit patient healthcare goals, 2) responsibly manage medications, 3) implement frailty screening and intervention (including for cognition and mobility), 4) assess social vulnerability (e.g., social isolation, caregiver stress, elder abuse), and 5) designate age-friendly leadership.
Even if a hospital responds 'no' to one or more of the domains, it still meets the reporting requirements. Failure to report will affect Medicare payments as of FY2027.
Nurse’s role
Nurses play a pivotal role in promoting, implementing, and sustaining an Age-Friendly Health System (see sidebar #3). (And even if their organization doesn’t have a formal program, nurses can follow the 4Ms.)
The nurse’s role begins in nursing schools, where faculty can instruct students about the framework. For example, Herbert and Sibley have written about how they used simulation to help students integrate the 4Ms into their practice.
Frontline nurses can deliver care based on the 4Ms. For instance, Pettis writes that they can collaborate with other members of the care team to ensure that an older adult’s care aligns with their needs and preferences. Emery-Tiburcio and colleagues note that frontline nurses can also involve family caregivers, who can provide valuable insights and are often responsible for managing the care plan after hospital discharge.
In addition to frontline nurse activities, APRNs with prescriptive authority can deprescribe high-risk medications and the overall number of medications when appropriate.
Nurse leaders can promote the Age-Friendly Health System framework in their organizations and help drive its implementation. For example, Pohnert and colleagues have described how American Organization of Nurse Leaders competencies were applied to implement the 4Ms in CVS MinuteClinics.
Most importantly, all nurses can advocate for an age-friendly approach to care.
Many resources related to an Age-Friendly Health System are available on both the John A. Hartford Foundation and IHI websites to support nurses in their efforts. These include implementation guides for various settings, guidance on creating the business case (including inpatient and outpatient ROI calculators), and case studies.
Supporting older adults
Nurses can play a pivotal role in promoting and implementing the Age-Friendly Health System framework to ensure that the growing population of older adults receives the highest quality care. In addition, following the 4Ms can help nurses avoid litigation by encouraging the delivery of comprehensive, evidence-based care.
Cynthia Saver, MS, RN, is a medical writer in Columbia, MD.
Sidebar #1
Key facts about older adults in the US
A few statistics from the 2024 Administration on Aging report highlight the scope of the aging population.
- More than 1 in every 6 Americans is 65 years or older.
- Between 2012 and 2022, the number of Americans 60 years or older increased by 29%.
- In 2022, 88,988 people were 100 or older, which is more than double the 1080 number of 32,194.
- By 2030, all Baby Boomers will be over 65, and by 2050, all Baby Boomers will be over 85.
- By 2040, about 78.3 million people will be 65 or older, more than twice as many as in 2000 (35 million).
- By 2040, approximately 13.7 million people will be 85 years old or older, more than double the 6.5 million in 2022.
Source: Administration on Aging, U.S. Department of Health and Human Services. 2023 profile of older Americans. 2024. https://acl.gov/sites/default/files/Profile%20of%20OA/ACL_ProfileOlderAmericans2023_508.pdf
Sidebar #2
Age-Friendly Health System Framework
As shown below, the framework consists of the “4Ms” — What Matters, Medication, Mentation, and Mobility.
Source: Institute for Healthcare Improvement. Age-friendly health systems. n.d.
Sidebar #3
Integration of the Age-Friendly Health System Framework
The Institute for Healthcare Improvement has developed a guide that includes six steps for integrating the 4Ms into care delivery, including action items for each step.
- Understand your current state. Sample action item: Determine languages, races/ethnicities, religious and cultural preferences for patients aged 65 years and older.
- Describe care consistent with the 4Ms. Sample action item: Develop a plan that includes addressing gaps in current practice.
- Design or adapt your workflow to deliver care consistent with the 4Ms. Sample action item: Develop process flow diagrams or value-stream maps of daily care.
- Provide care consistent with the 4Ms. Sample action item: Test key actions and modify as needed.
- Study your performance. Sample action item: Observe care delivery.
- Improve and sustain care consistent with the 4Ms. Sample action item: Apply MOCHA (measurement, ownership, communication, hardwire the change, assess the workload) to help identify areas that need focus.
Steps two through six align with the Plan-Do-Study-Act cycle.
Source: Institute for Healthcare Improvement. Age-friendly health systems: Guide to using the 4Ms in the care of older adults in hospitals and ambulatory care practices. 2024.
References
Administration on Aging, U.S. Department of Health and Human Services. 2023 profile of older Americans. 2024. https://acl.gov/sites/default/files/Profile%20of%20OA/ACL_ProfileOlderAmericans2023_508.pdf
Boersma P, Black LI, Ward BW. Prevalence of multiple chronic conditions among U.S. adults, 2018. Prev Chronic Dis. 2020;17:E106.
Centers for Medicare & Medicaid Services. Hospital inpatient quality reporting (IQR) program: Summary of FY 2025 IPPS/LTCH PPS final rule change. 2024. https://www.qualityreportingcenter.com/globalassets/2025/01/iqr/03.-hiqr_summary-of-fy-2025-final-rule-program-changes_vfinal_508.pdf
Centers for Medicare & Medicaid Services. Medicare and Medicaid programs and the Children’s Health Insurance program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and policy changes and fiscal year 2025 rates; quality programs requirements; and other policy changes. 42 CRF Parts 412, 413, 482, 485, 495, and 512. 2024. https://www.federalregister.gov/documents/2024/05/02/2024-07567/medicare-and-medicaid-programs-and-the-childrens-health-insurance-program-hospital-inpatient
Emery-Tiburcio EE, Mack L, Zonsius MC, et al. The 4Ms of an Age-Friendly Health System. Am J Nurs. 2021;121(11):44-49.
Herbert VM, Sibley S. Addressing 4Ms of Age-Friendly Health Systems for older adults in family nurse practitioner education through simulation-based learning. Clin Sim Nurs. 2022;64(10-15).
Institute for Healthcare Improvement. Age-friendly health systems. n.d. https://www.ihi.org/networks/initiatives/age-friendly-health-systems
Institute for Healthcare Improvement. Age-friendly health systems: Guide to using the 4Ms in the care of older adults in hospitals and ambulatory care practices. 2024.
Pettis J. Nursing leading the way to age-friendly care using the 4Ms model. Geriatr Nurs. 202;41(2):195-197.
Pohnert AM, Dolansky MA, Patterson A. Implementing and leading the Age-Friendly Health Systems 4Ms framework in nursing practice: a competency based approach. Nurs Lead. 2025;23(1):62-66.
The John A. Hartford Foundation. Age-friendly health systems. n.d. https://www.johnahartford.org/grants-strategy/current-strategies/age-friendly/age-friendly-health-systems-initiative/
The John A. Hartford Foundation. CMS approves new 2025 age-friendly hospital measure. 2024. https://www.johnahartford.org/resources/view/cms-passes-new-2025-age-friendly-hospital-measure
U.S, Census Bureau. 2020 census: 1 in 6 people in the United States were 65 and older. 2023. https://www.census.gov/library/stories/2023/05/2020-census-united-states-older-population-grew.html