February 4, 2022

Age-Friendly Health Systems: Dr. Terry Fulmer & Leslie Pelton

According to the US census bureau, the US population over the age of 65 is expected to nearly double over the next 30 years. From 43.1 million in 2012 to an estimated 83.7 million in 2050. These demographic advances, however extraordinary have left our health systems behind as they struggle to reliably provide evidence-based practice to every older adult at every care interaction. 

Age-friendly Health Systems is an initiative of the John A. Hartford Foundation and The Institute for Healthcare Improvement in partnership with The American Hospital Association and The Catholic Health Association of the United States, designed age-friendly health systems to meet this challenge head-on.

Here’s my conversation with Dr. Terry Fulmer and Leslie Pelton about the new book, Age-Friendly Health Systems, enjoy.

Welcome to The Author Hour Podcast, I’m your host Benji Block and today, we’re honored to be joined by Dr. Terry Fulmer and Leslie Pelton. Terry, you’re the president of the John A. Hartford Foundation and you guys just came out with a tremendous resource of book, the title is Age-Friendly Health Systems: A Guide to Using the 4Ms While Caring for Older Adults.

Welcome to both of you, welcome to Author Hour.

Terry Fulmer: Thanks Benji, we’re happy to be here.

Benji Block: It’s fantastic to get to chat with both of you. Today, let’s start here. Maybe each just provide a bit of context on the work you guys are doing and how you ended up where you are and what you’re doing now.

Terry Fulmer: Thanks, Benji. I can start and Leslie will certainly have a lot to add. We are so excited about our age-friendly health system movement. We call this a movement because we are determined to make sure that all care is age-friendly throughout our country and around the world. We think about age-friendly care because all of us have known a family member, a friend, have heard stories about an older person who did not have the good experience with their healthcare system, whether it was in the hospital, in the nursing home, in their community and we are absolutely convinced that our age-friendly health system work will catalyze our system into age-friendly care.

Leslie Pelton: I would add, Terry, that we’re so excited and you can see this in the forward of our book by Dr. Dan Barwick, how many health systems have taken up this call and have joined the age-friendly health system movement and adopted the core of evidence-based care that’s best for older adults. We can talk a little bit about how much the movement has grown and why we think it has grown and I would just underscore to say, the purpose of this book is to be a guide for people who want to join the movement.

Benji Block: I’m excited to dive into some of that. Let’s go here first, as this movement is developing, when do you guys realize we should put this in book form so that many can have it as a resource? I know you’re both busy, so choosing to take on a project like a book is no small thing but give us some of the background on why that was the right time to release and write this resource.

Terry Fulmer: Thanks, Benji. The first thing I also want to say to everybody listening is that it’s very clear that the greatest success story of the 20th century is longevity. If you were born in 1900, you live to be about 40 years old, fast forward to hundred years, you live to be about 90 years old. There it is, longevity, something to be really excited about, and yet, the care that goes along with longevity is not acceptable currently and that’s why we began our age-friendly health system conversation in 2015.

Why a book now? Because we have collected the evidence. Thanks to IHI, we have beautiful materials and we just knew that a book form — we want to have as many formats as possible so that this content is accessible to everyone who wants to join our work.

Leslie Pelton: I would say that the age-friendly health system movement isn’t really just about getting people to provide the right and the best care to older adults, so much as tapping into what people already know is the right care for older adults and that’s so many providers want to be able to deliver to older adults and will continue to provide as many on-ramps as are available that will enable providers’ care teams to deliver the kind of care that they know is the best care for older adults.

We have many different ways for providers and care teams to get involved in the movement and the book is one important aspect of that for sure.

Benji Block: Love it. For this resource and for this book, is it meant to be read as just a front-to-back experience? Is it meant more as a reference guide that people go back to, how do you imagine people using this?

Terry Fulmer: I think that we’re going to see people use it both ways and for those who really haven’t heard us talk about this and we’re pretty dramatic about the way we get our monthly thing out, you might want to do front to back but for those who say, “Wait a minute, what did they say about a business plan?” and they’ll just go to that chapter.

Again, these beautiful materials that have been on the IHI website and will continue to be are in book accessible form now thanks to the great partnership with all of you.

Leslie Pelton: That really reflects, Terry, the movement and the intent to decide behind the movement which is that we know that great care and part of the core, being age-friendly health system, that kind of care is being provided some places in with some older adults in just about every health system. The work of the movement is to ensure that that evidence-based care is provided reliably to all older adults and we really want health systems, we want providers to be able to start wherever they’re at in this journey.

They may be really good at making sure that they understand what matters to older adults and really feel like they’ve got that down but what they’re struggling with is, what is the safe way to provide medication to older adults when they need it? Well, they can flip to the chapter that’s focused on medication if that’s an area that they know they have growth in.

Benji Block: Yeah, I like the potential of it being both and obviously getting the full context, the way it’s written, it’s engaging. You’re covering a lot of content that is also obviously extremely practical and needs to be applied but yeah, great reference guide potentially but also, could totally read it front to back and enjoy it that way as well. Let me ask you a personal question to the two of you. When you think of how both of you ended up in this space of giving your life and your time to improving care for older adults. Why is this such a passion to each of you and where did that passion kind of come from, where did it get its beginnings?

Terry Fulmer: Leslie, you go right ahead and I’ll follow you.

Leslie Pelton: I believe that societies, our systems, it should be judged in many ways by how we serve the most vulnerable and older adults, we know inadvertently are being harmed in our health systems. This is an opportunity for health systems to organize around what matters to older adults and to provide reliably, the right care for older adults and if we can get that right for the most vulnerable in our health systems, the most vulnerable in our communities, then we are doing, I think the right and important work.

Of course personally, my mother, my grandmother and carrying up out what happens to them, understanding how overwhelming the health system can be. I just shared with our team the other day that my mother, 83-year-old mother, is just recovering from COVID, and my sister and I were able to use the 4Ms every day to keep her one, at home, to keep her really clear about what matters to her, her connection to her community and her loved ones and we were able to keep that at the center of her care and we really used the 4Ms to manage her care and to manage her care with her primary care physician as well. I can see the effect and the impact of the 4Ms.

Terry Fulmer: I love that, Leslie, and knowing you and how wonderful you are, I can only imagine how much that meant to your mother and your family. For me, I am a nurse as I mentioned, Benji. My first job was in a hospital, where I observe something fairly quickly and that was in 1975 and what I saw was that we were really good at saving people.

If they came in and their heart had stopped, they had a cardiac arrest, we could bring them back. If they had kids or — boy, we were at them with the chemotherapy but heaven help you, if you were a frail old person who came in with dementia because you had pneumonia. Then, you are not an interesting patient and I would say to the physicians, “Mrs. So-and-So isn’t eating, what shall I do?” and they’d say, “Do whatever you want, that’s not our problem.”

They weren’t bad people, they were good people, they were fundamentally saying, “That’s not something that I am responsible for” and I said, “Oh, I’ve got it, this is absolutely the essence of what I do” We began programming, we started another program called Niche, which works very closely with our age-friendly health system initiative but I’ve had free reign in the middle of this very complex health center to create and to say, “Wait a minute, I know what we need to do for this older person, I know how to keep them mobile, how to make sure that they don’t have any skin breakdown, that they’re eating so that they don’t…” There are statistics that say if you leave a hospital and you’re older, you will have lost weight.

That’s not good for older people, so it just struck me then. Every day, I think about it and I practice most recently over the holiday season and there it is again. I just would say that we know how to do this, we have this geriatric science, we just have to put it into practice reliably. That’s why, when I started this conversation, I went straight to the Institute for Healthcare Improvement and Leslie’s whole team there, she mentioned Don Barwick and I want to give a shout out to Kedar Mate, who is the current CEO and an amazing leader in this work, a physician who is just so thoughtful about his work. 

Each of us come to it, Kedar often tells the story about his grandparents and I tell the story about my patients and you just heard Leslie tell the story about her mother. This is personal work and we’re going to get it right.

The 4M’s: Matters, Medication, Mentation, & Mobility

Benji Block: Yup, I love heading a personal side. Obviously, you guys have your up-close situations that lead to then to the development of some of this work but provide then moving from personal to more of a, just context that at a large scale, right? I am not in any sort of healthcare profession but I know this is an area that is much talked about and the need for improvement. I’d love to know some of the numbers and the larger-scale context for what you’re thinking about as you think of what we’re facing when it comes to care for the elderly.

Terry Fulmer: I’m going to start with one phrase and that is, we’re facing opportunity. Do not let people use terrible phrases like silver tsunami, we’re trying to stamp that out in this country. We are so fortunate to have longevity in this country and so we’re reframing aging, we are trying to stamp out ageism, which is a terrible thing where people make judgments about you because your hair is grey and so we start with that philosophy and regarding numbers, I mean, I’m going to turn it over to Leslie who is a numbers maven.

Terry Fulmer: I want to say too, that what you just talked about around ageism, Terry, it’s so important. It’s actually frighteningly embedded into our health systems, right? If an older adult is in the hospital, I’ll share another personal story, when my mother-in-law was in the hospital, she was in her late 70s and she was having surgery and she became delirious in the ICU. Literally, the nurse said to my husband and I, “Don’t worry about this, this is normal, this happens to all older adults who come to us after surgery.”

It’s not true. First of all, it is in 40% of the time, delirium is preventable with older adults and what we’ve learned is the long-term harm to older adults, not just the psychological harm and the trauma because delirium is remembered afterward but also, how it contributes to cognitive decline over time to depression is really profound and yet again, we say, “This is what happens to older adults.” That is ageism and the 4Ms are designed to ensure that our systems cannot act in a way that is ageist, right? 

We are saying, when an older adult is in the hospital, you need to screen them for delirium at least every 12 hours, so that we can catch this early and do something about it because we can do something about it. Then, the other thing that Terry said when you were talking about early in your career, Terry, you talked about the complex medical system. Well, medical systems have become only more complex, right? 

Then, we overlay COVID and the chaos really, that that has created in so many ways in our health system and part of the purpose of this guide and of the 4Ms fundamentally is to create an accessible framework that really can bring comfort and guidance during chaos. We actually found that the movement grew more during COVID, especially during 2021 than in prior years which is really phenomenal, saying people in a complex medical system overlay a pandemic, care teams, providers need a framework to hold on to and to guide their care and guess what? Families, we need it too, right?

Benji Block: Yup.

Terry Fulmer: It gives us, it organizes us in a complex, chaotic environment to ensure that we are delivering the right care and doing that in a way that counters the ageism that we might fall back on.

Benji Block: You know, we’re talking about reframing age and moving away from ageism before we jumped online, I mentioned to you both that I grew up overseas in Africa and East Africa and one of the main takeaways I have from the 10 plus years living over there was their respect for the elderly. 

There is an immense amount of respect for those that are along in years, where if you are elderly in the room, older in age, you get the seat of power, you get a lot of questions asked your way, there’s a specific way of even saying hello. You say [inaudible 0:16:08.8], you bow your head, you don’t make eye contact immediately because it’s a sign of respect.

I think of a lot of those things often Stateside because there’s an opposite, we over-romanticize youth and there’s just a lot to be learned there. Thank you, guys, for hitting on that. I think it’s vitally important, I hope it’s mass adopted and I know this movement is going to kind of help propel that. I just wanted to throw that in before we move on here.

Let’s do this for the next few minutes, would you just walk us through the 4Ms at a high level, what is contained within them and what you’re thinking about? Just walk us through the four?

Terry Fulmer: Sure, and Benji, thank you for that story, that’s powerful and I can only welcome that kind of change for us as we think about the number of older people in the way in which they become pretty invisible. Leslie, do you want to walk through the 4Ms?

Leslie Pelton: I do. Benji, before I do, I want to because we’ve been talking ageism, I want to make sure that I also name racism and the intersectionality here. We have our original aim of the movement, it has been updated to ensure that we are focused on the equitable application of the 4Ms and I’ll dive deeper into the 4Ms but I really want to call out that this movement at its core is about making sure that the whole spectrum of older adults, right? 

You think, 65 can be very different from 90, right? There’s a whole experience that differs across the age spectrum and the same across race and ethnicity and we are integrating that into the movement and ensuring that health systems that we’re working with are stratifying their data, our learning as they apply the 4Ms to watch and ensure that those are being applied equitably across race and ethnicity I just want to call that out. All right, I would love to dive into the 4Ms a little bit by way of an introduction.

Terry Fulmer: We could do, you one, me one.

Leslie Pelton: All right, sounds good. That means I get to start with ‘what matters’ and to some which I’m thrilled to do because we sometimes call this the keys to the kingdom and the 4Ms are a connected circle, we begin with what matters, we go through all the 4Ms and we come back to what matters, they’re all interrelated. As I said, the purpose of the 4Ms is to create an evidence-based framework of the best care for older adults and that has to start with what matters, right? 

That has to begin with understanding what does an older adult experience as bring happiness and meaning to their lives and a large scale and at a very focused way when an older adult is in the hospital, what is it that is important to them to be addressed when they’re in with the primary care visitor or they’re at CVS mini-clinic for a convenient care clinic visit, what is it that they want out of this visit, right? We need to stat there and not bring our own assumptions to that. So that’s what matters is asking and acting on what is important to the older adult and to their family caregivers.

Benji Block: Can I ask one follow-up question there, Leslie? Obviously, you’re wanting to ask what matters most, how does that differ from what maybe is currently asked right now? What’s the mindset shift to get people to what matters?

Leslie Pelton: What the current state is understanding what is medically wrong and very often, what is medically wrong with one part of your body. You’re coming in with hip pain, maybe you’re even in a conversation about having a hip replacement. The conversation might be about the hip replacement, right? You’re going to go, you’re going to either arrive on Tuesday, it’s going to be early in the morning, you’ll be home by late Tuesday night, this is the care team talking to the older adult.

Forgetting to ask, why is it that you want to have your hip replacement? What is it that you’re looking forward to being able to do? Because that’s a real shift, right? Bringing the older adult back to the center of the conversation and the center of the care, what matters to them. By the way, it’s actually really useful for the care team to understand why this hip replacement is so important to the older adult because as you’re going through the challenges of navigating the health system with the hip replacement, the rehab, if we know what matters to the older adult, we can help to motivate them, to keep them focused and use that to help sustain them through this medical journey.

It’s a reorientation from what’s wrong with one part of your body or medically, what’s wrong with your body right now to what matters to you, what feels healthy to you, what feels important to you?

Benji Block: That’s fantastic. Thanks for clarifying that fantastic transition. Number one, what matters, number two is medication, right, Terry?

Terry Fulmer: Right, it is and Leslie, that was beautifully said. Medications, I don’t know any person who does not expect to get a prescription at the end of a visit and that just can’t be. We have overprescribed beyond belief and in our age-friendly health system work, what we really want to do is to look, is the medication necessary, does one prescriber know what the other one has been giving you? Are they using age-friendly medications? 

There’s something called the Beers Criteria that’s been in the literature for many years. Mark Beers was a dear friend of mine when we were both at Harvard Medical School and I will tell you that the Beers Criteria are a safe way of giving medications. We give people guidance about the medications that do not interfere with what matters to you, your mobility, or your mentation, which will talk about in a minute but if you are on there on medications, you could become groggy, you could lose your balance, you could become sleepy or you could become agitated, so getting those medications right is so critical to an age-friendly 4M framework because if you get the meds wrong, it will hurt your mobility. 

You won’t be able to express what matters and your mentation, good memory, are likely to be affected, so we try to de-prescribe, make sure that the medications are age-friendly, and re-evaluate whether people are in the right dose. People gain weight, lose weight, they have other disorders, sometimes you might be on a number of cancer medications and nobody knows that because you’re talking to your arthritis doctor, that’s what’s we’re talking about. 

So we are really excited to really help people focus in and get that right and I want to also, Benji, say this work is about every setting of care, so our nursing homes will be so benefited from thinking about the 4Ms in exchanging that content across the care settings but let me turn it over to Leslie for mentation. 

Leslie Pelton: Mentation is the health of the mind and Terry just gave great examples of how medication can impact the health of our mind and how knowing what matters can help a care team enable an older adult to stay oriented and sustain the health of the mind and when we think about mentation, we really break it into three parts. One is delirium, which is a more transient impairment that I mention, cognitive impairment or dementia and then the third is depression. 

In an age-friendly health system, we take the time to understand what the health of the mind is with an older adult. We normalize a conversation about talking about the health of the mind. Dr. Donna Fick from Penn State, who is one of our advisors and faculties and member really guide in this movement, talks about normalizing a conversation between an older adult, their family caregiver, and their provider about the health of our brains just the way we talk about the health of any of our other organs, our heart and our lungs, right? 

There is a lot of fear both on the side of the older adult, the family, the providers to talk about the health of the mind, right? There’s some trepidation about it and so we are with the 4Ms and normalizing a conversation about the health of the mind so that it’s not skipped over when we’re thinking about and working with an older adult in their health and wellbeing. It’s really making sure that we screen and understand the health of one’s mind and then we provide inputs and connections and activities that can improve the health of the mind. 

Yes, occasionally that may be moving to a medication M for somebody who’s depressed but it also may be moving to the mobility M, right? How can helping somebody mobilize and get out of their home or get out of bed and walk down the hall, how can that improve the health of their mind and their mentation? 

Benji Block: Then the fourth one is mobility here you just mentioned by you, Leslie. Terry, talk about what is all contained in mobility? 

Terry Fulmer: Sure. Well, mobility is again, just an absolutely critical feature in feeling well and working in a 4M framework with the age-friendly health system effort. We have for many years talked about falls prevention to the point where we’ve frightened some older people about the fact that they should be not moving and that’s not a good thing to do. The message is be mobile, ensure that you move safely every day to maintain your function, and do what matters to you. 

Amy Randall has done a spectacular job developing their mobility team, which can be their nursing assistants and their nurses and the physical therapy team to make sure that everybody in that hospital gets up and has the opportunity to move around every day while they are in the institution, which happens to be a hospital. Nursing homes do a great job with this as well, certainly during COVID and the pandemic, we’ve had staffing shortages. 

We’ve had an array of serious interference if you will with the way we need to do this work but getting – keeping people mobile, you know that if you don’t move for a while not only do you lose your muscle mass but it’s just not comfortable and then [inaudible 0:26:40.8] so keeping people strong, there’s a phenomenon called sarcopenia and that’s a medical term for muscle loss and the only way you prevent sarcopenia is by moving. 

Bob Butler again, who is the head of the National Institute on Aging and wrote that fabulous book called, Why Survive?: Being Old In America, which won a Pulitzer Prize, reminded us that mobility and the ability to keep yourself active is important every time and just if you haven’t been mobile for a while, it is never too late to start. We know that mobility is good for — certainly it is good for brain health, good for cardiovascular health. 

Really important to circle again through the 4M framework in affecting each of these. Anybody who has been immobile for a while is going to be isolated and depressed. 

Leslie Pelton: I was going to go full cycle back to what matters from mobility. I am thinking about a story that I heard from one of the nurses in an age-friendly health system hospital and she talked about — she told the story about an older gentleman who was in the hospital and they were having a very hard time in helping him to mobilize. In this case, the care team was quite motivated and he was not feeling motivated to do so and they had a what matters conversation with him when he first came in. 

They knew that one of the things that was very motivating for him, what really mattered to him was being able to get home so he can be with his dogs and so, they started the conversation about getting up and being mobile. They started focusing it on helping him to get ready to go home and to be able to act on what matters to him, to be back home with his dogs. The whole, the 4Ms – 

Terry Fulmer: This means he was walking his dog, right, Leslie? 

Leslie Pelton: That’s right, he wanted to be home walking his dog, that’s right. As an aside, I will say the nurses also went out and got the dog and brought the dog to him. 

Benji Block: Fantastic, oh my gosh. 

Leslie Pelton: That is above and beyond age-friendly and that’s above and beyond but boy, that was this thing in acting on what matters to them really profound, right? 

Benji Block: I have a feeling that was probably slightly selfish too, they just wanted a dog around you but — 

Terry Fulmer: All the nurses out there who do these extraordinary things every day, they have superpowers and it’s fabulous. 

Leslie Pelton: Isn’t that true? I hope we’ll talk about the impact on the workforce of an age-friendly health system. We’ll go where you want to go next. 

Benji Block: Yeah, no, I totally think we should go there. I was going to say, I think I was in a conversation yesterday but definitely this week where a similar story, a lady was having trouble with mobility and the nurse went above and beyond, printed a picture of her grandchild, and taped it to the walker so that every time she walks she remembers why she is getting mobile again. Obviously, I am new to the 4Ms and all of that but it is so perfectly fits in with what you’re going after here. 

Terry Fulmer: That’s a great image, great image.

Supporting The Community

Benji Block: Talk to us a little bit, Leslie or Terry, whichever on the impact it does have on the staff and what you see not just obviously helping the person that needs to get better or needs to continue to improve in these areas but actually on the healthcare workers. 

Terry Fulmer: I would start by saying that when you join the age-friendly health system movement, you become a part of a community and it’s such a gift. It is almost like a family where all of us are encouraging each other. It’s what I try to call as all teach all learn, which Leslie will talk more about but I am going to take it right down to the practice level and I worked at a hospital over the holidays.

There is nursing shortages and I had the great privilege to go in and help give care. When you talk about the 4Ms and age-friendly, it’s so accessible intellectually to very busy nurses who say, “Those four things, yeah, I got it. I can do that. I can focus on that.” It provides focus and it’s parsimonious in that you can’t have 12 new things to do every day. You have to streamline what you’re talking about when you are thinking about quality improvement and safety in any setting. 

When I go into a facility and start talking about this work, I say, “I want to make this simple for you.” And so that reduces the burden on the staff who are saying, “Oh my god, here comes another project” and some people call it Projectitus. Who is it — who says that, Leslie? It’s a friend on the committee? 

Leslie Pelton: Yeah, it’s a comment right? I mean, especially in our large health systems, the VA and CVS mini-clinic, right? 

Terry Fulmer: Yes and I do want to give a shout out to the American Hospital Association and Catholic Health Association, who have been absolute devote partners with us since the day we started and we’re really pleased that they were also able to help us with our book and [want to] thank them for everything they’re doing to keep acting communities alive, which we’ll also probably talk about but to come back to it. What I have also learned from Leslie and Maureen Bisognano at IHI is about joy in work. Leslie, do you want to wrap those together? 

Leslie Pelton: Yes, I am so glad you brought that up. I will, full disclosure, say that at the start of this movement, I was fully focused on the meaning to the older adult and I very quickly started receiving calls, emails from providers who said, “This movement, the 4Ms, it’s changed everything for me. It’s helped me grow professionally, it’s brought joy in work back to me. It’s giving me permission and a reminder to put what matters in the older adult back at the center of care.” 

I am thinking about a physician who is part of the University of California health system who showed up at in-person meetings when we have those with tremendous enthusiasm for the 4Ms. He had made a badge to put on his badge about being an age-friendly 4Ms champion and so he came to our meeting, he learned deeply about the 4Ms. He started practicing them with older adults and then he jumped into learning about the business case. 

He used the 4Ms in an age-friendly health system to understand what matters to his health system and to understand how he could talk about age-friendly care and the 4Ms as moving forward what mattered to a health system and then — so this was about I’d say a two-year journey with him. Last month, we were on the phone with him and he said that age-friendly health systems and the 4Ms enabled him to bring the attention of his executive leadership to the care of older adults. 

It was this incredible journey, that is just an example of one person’s journey but then, overlay the pandemic and how hard it is for providers and care teams whose heart and professional whole lives are about doing what’s right for people and there’s again, all this complexity and so much strain on the system but what we see, what they tell us is that they are coming back to the 4Ms as a way for them to do what matters to them as providers. 

It is bringing them back the joy in work and returning wellbeing to the providers. I know UA Banner Heath in Tucson has measured this and looked at not just higher patient satisfaction scores with patients who receive age-friendly care but higher provider satisfaction scores and health systems desperately need right now a way to ensure that our providers are cared for and are able to keep showing up to work, right? 

We need people who could keep showing up to work and providing this incredibly important care as Terry did over the holidays and the 4Ms is a means for that to happen. 

Benji Block: Yeah, when it is such an interesting time for the whole system and there is extra stress added on, I can see the value of what matters and the clarity around the 4Ms being so beneficial for all sides, right?

Terry Fulmer: Yes and Benji, lest you think we have no sense of humor, I’ll tell you my story about my friend, Ellen Flaherty, who is a spectacular nurse leader. She was president of the American Geriatric Society and she is six years into this work. She said to her team one day the 4Ms and they made her a t-shirt that said, “4Ms” and it said, “Martinis, Manhattans, Mojitos, and Margaritas.” 

Benji Block: That’s the right 4Ms, that’s your second book right there.

Terry Fulmer: You know, you need relief every now and then and so they are doing spectacular work and they do it with their sense of humor. I also want to give a shoutout to my friends at Bassett Medical Center at Cooperstown, New York, and thank them for the fact that they are engaging with New York State, our hospital association of New York State has an action community on age-friendly health systems because the state government said that 50% of our institutions would be age-friendly in two years from now. 

So the hustle is on, we are trying to beat Massachusetts where Leslie lives and so Bassett, welcome aboard and New York State Hanis, thank you for your incredible work and for everything that the state is doing to get this work embedded into our state as we create a master plan for aging like California has. 

Leslie Pelton: Also Bassett represents a very rural health system serving a pair of rural population and I just want to point out that one of the reasons why the movement has grown as much as it has is because we do create a lot of space for local context for our providers, the care teams to get really clear about what the 4Ms are and then to provide those in a way that works in their context with their technology, with their workflows, with their culture. 

What we’ve seen is that that enables adoption in rural settings, in urban settings, in everything and everything in between. 

Terry Fulmer: The veteran’s administration, where our Indian health services are. 

Leslie Pelton: Absolutely, we now have age-friendly health systems in every state in the country and we know through our recognition process that over one million one hundred thousand older adults payer has been shaped by the 4M, so the reach is very, very real. We also — 

Terry Fulmer: Also in 30 countries. I am very proud of IHI. 

Benji Block: That reach is incredible and really, I mean this book is another catalyst, right? Just another step in the journey and so we’re really thrilled for this to get out into the world. As we start to wrap up, anything left that you guys want to highlight about this resource and what people can expect, and then we’ll give practical ways for the people to stay connected to the work. 

Terry Fulmer: Sure. Leslie, do you want to tell about the book and the context of our action communities? 

Leslie Pelton: The Institute for Healthcare Improvement is really privileged and the movement is really privileged to have the support of The John A. Hartford Foundation and that support enables us to provide many different ways for people to join the movement. Many different ways for people to learn how to practice the 4Ms, starting small and then scaling it up across their site of care, across their health system and one of the ways that people can learn is through this book. 

Another way and I would say the way that many, many health systems have learned about adopting the 4Ms is through what we call an action community. Terry talked about this movement being a family, this is one part of the family, these action communities. At The Institute for Healthcare Improvement and our partners, The American Hospital Association provide sprints if you will about six months when teams from different health systems can come together and learn how to practice the 4Ms. 

At the end of that, they are able to be recognized as age-friendly health systems and it is really a journey where the teams start very small. They may start with one older adult, what do the 4Ms look like with one older adult? They practice it and then they scale that up over the course of the action community to reach five, 25, 125 older adults and they learn from expert faculty about the 4Ms and really importantly, they learn from each other. 

They accelerate their adoption of the 4Ms by learning from each other. For example, we find that there are some health systems that are really comfortable with asking what matters, and perhaps they are struggling with how to screen for delirium in the mentation M and so then they teach each other. The health system that is really comfortable with asking what matters teaches their colleagues how to ask what matters. 

That health system can pick that up and then they don’t have to learn from scratch themselves how to practice and how to ask what matters and so, there’s this all teach all learn and then expert faculty that are available for support and teaching and The Institute for Healthcare Improvements team that is available to create, to really bring the science of improvement, how can we really have a science around moving from one older adult to five to 25 to 125 older adults. 

These action communities are offered twice a year, the spring in 2022 IHI is offering an action community, which you can learn about on ihi.org/agefriendly. Again, with the generous support of The John A. Hartford Foundation, these are available at no cost to join for a health system. 

Benji Block: Fantastic. 

Terry Fulmer: I love that Leslie and let me underscore my gratitude as the president of the foundation with the support of our trustees who all have their own stories and their own narratives and who have come to this with extraordinary passion as well and without trustees approving grants where you can get this type of work done, philanthropy matters and that’s a true, true gift. 

Also, as Leslie pointed out, we have faculty from around the country and around the world who are just all in saying, “How can I help? What do you need me to do?” This is making a difference and so to all of you on our faculty, our advisory boards, the organizations that are working with us. This would never happen without you and I am just so grateful and especially to The John A. Hartford Foundation and just as a little factoid here, The John A. Hartford Foundation, our funding came from the generosity of the AMP grocery store heirs, which is John and George Hartford and they started a foundation in 1929. 

In the 80s, we started focusing on geriatrics in the geriatric workforce and improving care for older adults and to the trustees’ credit, they have stayed the course and they are a national force for good.

Benji Block: Wow. Well, I really appreciate the time today. Terry and Leslie, thank you for being here on Author Hour and for providing this resource. Just tell us real quick what’s the best way, I know what we can get the book on Amazon and I will plug that here in a second but what is the best way for people to stay connected to the work you guys are doing online and the best place to maybe stay connected with you. 

Terry Fulmer: Go ahead, Leslie. 

Leslie Pelton: People who want to stay connected to the movement, you can go to ihi.org/agefriendly and there’s all sorts of doorways that you can enter through. I suggest that you join an action community and start to learn and do with the 4Ms. 

Terry Fulmer: As Leslie loves to say, never worry alone. If you are doing your work and you need help, just call us because we are the most accessible people you’ll ever meet. 

Benji Block: Wonderful. Well again, the book is called, Age-Friendly Health Systems: A Guide to Using the 4Ms While Caring for Older Adults. Leslie, Terry, thank you for being on Author Hour today.

Terry Fulmer: Thanks, Benji.

Leslie Pelton: Thank you, Benji. 

Terry Fulmer: Really nice to meet you and thank you. 

Leslie Pelton: Such a pleasure.