Shifting Culture Toward Age-Friendly Care: Lessons From VHA Early Adopters

Nearly 50% of living US veterans are aged ≥ 65 years compared with 18.3% of the general population.^1,2 The Veterans Health Administration (VHA), the largest integrated health care system in the US, has a vested interest in improving the quality and effectiveness of care for older veterans.³

Health care systems are often unprepared to care for the complex needs of older adults. There are roughly 7300 certified geriatricians practicing in the US, and about 250 new geriatricians are trained each year while the American Geriatrics Society expects > 12,000 geriatricians will be required by 2030.^4,5 More geriatricians are needed to serve as the primary health care professionals (HCPs) for older adults.^4,6 Health care systems like the VHA must find ways to increase geriatrics skills, knowledge, and practices among their entire health care workforce. A culture shift toward age-friendly care for older adults across care settings and inclusive of all HCPs may help meet this escalating workforce need.⁷

The Age-Friendly Health System (AFHS) 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.^8,9 AFHS uses a what matters, medication, mentation, and mobility (4Ms) framework to ensure reliable, evidence-based care for older adults (Table 1).^10,11 In an AFHS, the 4Ms are integrated into every discipline and care setting for older adults.¹¹ The 4Ms neither replace formal training in geriatrics nor create the level of expertise needed for geriatrics teachers, researchers, and program leaders. However, the systematic approach of AFHS to assess and act on each of the 4Ms offers one solution to expand geriatrics skills and knowledge beyond geriatric care settings in all disciplines by engaging each HCP to meet the needs of older adults.¹² To act on what matters, HCPs need to align the care plan with what is important to the older adult.

Hospitals and health care systems are encouraged to begin implementing the 4Ms in ≥ 1 care setting.¹³ Care settings may get started on a do-it-yourself track or by joining an IHI Action Community, which provides a series of webinars to help adopt the 4Ms over 7 months.¹⁴ By creating a plan for how each M will be assessed, documented, and acted on, care settings may earn level 1 recognition from the IHI.¹⁴ As of July 2023, there are at least 3100 AFHS participants and > 1900 have achieved level 2 recognition, which requires 3 months of clinical data to demonstrate the impact of the 4Ms.^13,14

The main cultural shift of the AFHS movement is to focus on what matters to older adults by prioritizing each older adult’s personal health goals and care preferences across all care settings.^9,11 Medication addresses age-appropropriate prescribing, making dose adjustments, if needed, and avoiding/deprescribing high-risk medications that may interfere with what matters, mentation, or mobility. The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults is often used as a guide and includes lists of medications that are potentially harmful for older adults.¹¹ Mentation focuses on preventing, identifying, treating, and managing dementia, depression, and delirium across care settings. Mobility includes assisting or encouraging older adults to move safely every day to maintain functional ability and do what matters.^15,16 Each of the 4Ms has the potential to improve health outcomes for older adults, reduce waste from low-quality services, and increase the use of cost-effective services.^11,17

In March 2020, the VHA Office of Geriatrics and Extended Care (GEC) set the goal for the VHA to be recognized by the IHI as an AFHS.^18,19 US Department of Veterans Affairs (VA) facilities that joined the AFHS movement in 2020 are considered early adopters. We describe early adopter AFHS implementation at Birmingham VA Health Care System (BVAHCS) hospital, geriatrics assessment clinic (GAC), and Home Based Primary Care (HBPC) and at the Atlanta VA Medical Center (AVAMC) HBPC.