What Matters: Learning From Patients to Transform Age-Friendly Care

The 4Ms Framework for Age-Friendly Care represents an advancement in geriatric health care, offering structured approaches to addressing What Matters, Medication, Mentation, and Mobility (^{Fulmer et al., 2022}). Although it has been adopted by many health systems across settings, including the emergency department (ED) and in-patient setting, the framework still leaves unfinished work to achieve fully patient-centered care. The current article examines an ED visit followed by a hospitalization of Mr. R at an academic medical center with recognition for age-friendly care in the ED and inpatient settings (^{American College of Emergency Physicians, n.d.}; ^{Institute for Healthcare Improvement [IHI], n.d.}). We interviewed Mr. R—a participant from an age-friendly communities project—who agreed to share his story for our reflection on age-friendly care. His story reveals opportunities to pursue the 4Ms in a way that centers genuinely on listening to older adults alongside the focus on evidence-based practices supporting improved outcomes for older adults.

Mr. R's Perspective About His Hospital Experiences

At age 81 years, Mr. R, a formerly unhoused Black man, had never been hospitalized, not even at birth. He made the significant decision to call an ambulance to seek emergency care for dizziness and weakness. After arriving at the ED, he waited on a gurney for 18 hours before being admitted to the hospital, where he had a 10-day stay and was, ultimately, diagnosed with Legionnaires' disease, a treatable type of pneumonia. His expectation of the hospital was simple: “They would tell me fairly quickly what was wrong with me.” From the beginning, Mr. R believed he explained his symptoms and needs to providers clearly. A false-positive tuberculosis test created initial confusion about room requirements, which was “very frustrating” because it further delayed his admittance to inpatient care. Throughout his stay, Mr. R demonstrated what he thought was a sophisticated understanding of his own body and medical needs. For instance, he understood drug interactions and tried telling providers: “You need to make sure that you're getting the right medications and they're not conflicting with one another.” Yet, he believed his input was consistently ignored.

He observed poor communication; redundant testing, including duplicate computerized tomography scans; and repeated nighttime disturbances despite his explicit requests for rest: “If you say, as a patient—‘I don't want you coming to see me at 2 o'clock in the morning, don't come’—but they come anyways, that's very disturbing and, boy, it pisses you off.” Tired of repeating himself with each new staff shift, he wrote his preferences on the whiteboard for visibility to all providers. Still, he believed his input was ignored: “I'm expressing what I need, and it doesn't seem to matter to you. Only thing you can think of is your training and what you know. You're not taking into account I know some things that you don't know.”

The situation deteriorated when Mr. R's physical mobility was compromised by monitoring equipment, restricting his basic movements. His need for bathroom independence was continually dismissed until he desperately ripped off the mobility-limiting tethers: “Having to need to go to the bathroom—you can't do this; you're all tied down—it's very frustrating for a person.” When he soiled himself, he believed providers expressed visible dismay, further undermining his dignity. Providers attributed his distress to low blood oxygen, possibly causing fluctuating confusion or delirium. When his frustrations escalated, providers feared his behaviors could be harmful to himself or others. He was restrained to his bed, and providers called his emergency contact, who verified his baseline cognitive functioning. Mr. R believed his treatment was due to his race: “Let's be realistic here. This is a White man's world.”

These were not isolated incidents but a cascade of events that undermined the interplay of independence, dignity, and autonomy that were meaningful to Mr. R. After 10 days and antibiotic treatment, Mr. R was discharged. He is currently healthy, living in the community, and has not been rehospitalized.

Reimagining the 4Ms Through Mr. R's Case

What Matters: The Foundation of All Care

Mr. R's story reveals that assessing and acting on what matters to older adults is foundational to delivering age-friendly care and challenging to deliver reliably throughout a clinical care episode. Engaging in conversations about what matters is vital for older adults and their caregivers, especially for those hospitalized older adults experiencing temporary delirium, confusion, or cognitive impairment during acute illness because it can help ensure their personal values and preferences are understood, reduce anxiety and distress, and aid in more effective decision-making during their vulnerable state. These discussions enhance the implementation of the other three Ms by focusing on the individual's life context and priorities, linking them to care impacts, self-management, and decisions they find acceptable (^{DeBartolo et al., 2021}; ^{Laderman et al., 2019}).

Mr. R believed he clearly communicated what mattered to him: identifying his diagnosis, getting treatment and rest, and maintaining his independence. A systematic assessment and ongoing discussions about his health goals would have documented his preferences and guided his care plan. This approach would have acknowledged Mr. R's expertise about his own body and needs, reducing his perceptions of potential bias. His whiteboard notes would have been integrated into his care plan, facilitating seamless communication about his stated priorities between shifts and preventing repeated disruptions to his rest.

Medication: Recognizing Knowledge

When older adults have experience managing their health conditions, their medication knowledge should be valued as essential to safe prescribing, regardless of temporary cognitive fluctuations that may occur during acute illness. What mattered to Mr. R was sharing his understanding of medication safety, but his insights were overlooked, representing a missed opportunity for collaborative care.

In Mr. R's case, instead of the current focus on assessing for and deprescribing/avoiding prescribing high-risk medications for older adults, an age-friendly medication review ideally would have engaged him as a partner in decision-making (^{Fulmer et al., 2022}). Providers would have conducted collaborative medication reconciliation, thoroughly explained prescriptions, and incorporated his knowledge about how they would affect him.

Mentation: Honoring Personhood

Age-friendly care should recognize that older adults' cognitive capacity may fluctuate during acute illness, while still maintaining their core personhood, fundamental values, comfort needs, emotional responses, and capacity for participation in care decisions. By understanding what matters to each individual, providers can better distinguish between situational distress—such as Mr. R's frustration—and temporary cognitive fluctuations that may affect certain decisions but leave other capacities intact.

Mr. R expressed that his frustrations stemmed from unmet needs and perceived unfair treatment based on his race, which mattered to him. These feelings align with studies indicating that Black patients are more likely than their White peers to experience unfair or disrespectful treatment by health care providers due to their race (^{Artiga et al., 2023}; ^{Lesser et al., 2022}).

Equity in age-friendly care means reliably assessing and acting on the 4Ms regardless of race, ethnicity, language, sexual orientation, gender identity, or social and economic circumstances, which includes understanding and addressing existing inequities in care for all older adults, particularly those from historically marginalized groups (^{Southey & Henriquez Garcia, 2023}). Providers could have addressed Mr. R's concerns about potential racial bias while explaining that their clinical assessments suggested that his mental state appeared compromised, possibly due to delirium. This approach would have framed his resistance to mobility restrictions as a response to perceived threats to his autonomy, rather than behaviors necessitating restraint. Validating his feelings while providing transparency about their medical reasoning supports the effective delivery of care to identify, treat, or manage potential delirium by respecting and responding to the person's values and experiences. Preventing adverse outcomes requires age-friendly care that recognizes the impact of bias and systemic racism on health, as well as acting on culturally responsive, person-centered approaches that eliminate inequities and sustain care consistent with the 4Ms (^{Southey & Henriquez Garcia, 2023}).

Mobility: Preserving Autonomy

Mr. R's need for bathroom independence and freedom of movement were fundamental to his dignity. An age-friendly mobility assessment would have prioritized his functional independence while ensuring his safety. By understanding what matters to him, providers could have used mobility-friendly monitoring that effectively addressed his needs. Proactive accommodations of his mobility needs and desires would have prevented his attempts to remove monitoring equipment.

Older adults' preferences about their physical autonomy should guide care planning, not be overridden by provider assumptions about safety or compliance. Knowing what matters to patients fosters care delivery by aligning safety measures with patient autonomy, thereby preventing situations such as the use of restraints in Mr. R's case. This unfortunate last resort highlights the critical need for solutions that honor safety and autonomy, ensuring that care planning is patient-centered and respectful of individual dignity while actively working to cause no harm (^{Fulmer et al., 2022}; ^{Southey & Henriquez Garcia, 2023}).

Learning from Patients

Mr. R's experience reveals how dignity can be stripped when protocols overshadow personalization and respect. His case underscores the need to distinguish more clearly between adverse outcomes that could have been prevented by following a 4Ms protocol versus those that occur despite following a 4Ms protocol because it did not go far enough to address known and suspected inequities to ensure patient-centered care (^{Southey & Henriquez Garcia, 2023}). Age-friendly care transcends mere implementation of the 4Ms—it involves recognizing each older adult as a knowledgeable partner with valuable insights about their own needs. Achieving this partnership approach necessitates a cultural shift in health systems to identify whether some groups, based on their sociodemographic characteristics, are more or less likely to receive age-friendly care that aligns with their preferences and needs and to form authentic partnerships with older adults, using adaptive communication that respects personhood throughout cognitive changes.

Providers should take time to understand patients and respond to individual needs using best practices, which requires structural changes in staffing, workflow, and performance metrics to prioritize person-centered outcomes. These structural changes include training nurse leaders and frontline nurses to perform comprehensive 4Ms assessments and deliver holistic age-friendly care, addressing complex geriatric syndromes and attending to what matters across the full spectrum of social determinants of health (^{Fulmer et al., 2021}).

The 4Ms framework provides excellent guidance for implementation (^{DeBartolo et al., 2021}; ^{Fulmer et al., 2022}; ^{IHI, 2020}; ^{Laderman et al., 2019}; ^{Southey & Henriquez Garcia, 2023}). However, without intentional commitment to valuing what matters to each older adult, age-friendly care risks becoming a mere checklist rather than a guiding philosophy. Mr. R's willingness to share his story illuminates a path forward. For continuous quality improvements, we should ask ourselves: Are we truly listening to the voices of those we serve?

References

American College of Emergency Physicians. (n.d.). Geriatric emergency department accreditation(GEDA) program. https://www.acep.org/geda

Artiga, S., Hamel, L., Gonzalez-Barrera, A., Montero, A., Hill, L., Presiado, M., Kirzinger, A., & Published, L. L. (2023, December 5). Survey on racism, discrimination and health. Kaiser Family Foundation. https://www.kff.org/report-section/survey-on-racism-discrimination-and-health-findings/

DeBartolo, K., Saret, C., & Webster, P. (2021). How to have conversations with older adults about “what matters”:Aguide for getting started. Institute for Healthcare Improvement. https://www.ihi.org/sites/default/files/2023-10/AgeFriendlyHealthSystems_How-to-Have-Conversations-with-Older-Adults-About-What-Matters.pdf

Fulmer, T., Pelton, L., Zhang, J., & Huang, W.(Eds.). (2022). Age-friendly health systems:Aguide to using the 4Ms while caring for older adults. Institute for Healthcare Improvement. https://www.johnahartford.org/resources/view/book-age-friendly-health-systems-a-guide-to-using-the-4ms-while-caring-for-older-adults

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Institute for Healthcare Improvement. (n.d.). Age-friendly health systems recognition. Institute for Healthcare Improvement. https://www.ihi.org/partner/initiatives/age-friendly-health-systems/recognition

Institute for Healthcare Improvement. (2020). Age-friendly health systems: Measures guide. https://www.ihi.org/sites/default/files/2023-09/IHIAgeFriendlyHealthSystems_MeasuresGuide.pdf

Laderman, M., Jackson, C., Little, K., Duong, T., & Pelton, L. (2019). “What matters” to older adults:Atoolkit for health systems to design better care with older adults. Institute for Healthcare Improvement. https://241684.fs1.hubspotusercontent-na1.net/hubfs/241684/Age-Friendly/Guides%20and%20Tool-kits/What%20Matters%20Toolkit%20revised%202024%2002%2020.pdf

Lesser, S., Zakharkin, S., Louie, C., Escobedo, M. R., Whyte, J., & Fulmer, T. (2022). Clinician knowledge and behaviors related to the 4Ms framework of age-friendly health systems. Journal of the American Geriatrics Society, 70(3), 789–800. 10.1111/jgs.17571 PMID: 34837381

Southey, C., & Henriquez Garcia, L. (2023). Focusing on equity at every step of your age-friendly health system journey. Institute for Healthcare Improvement. https://241684.fs1.hubspotusercontent-na1.net/hubfs/241684/Age-Friendly/Guides%20and%20Toolkits/Focusing%20on%20Equity%20at%20Every%20Step%20of%20Your%20Age-Friendly%20Health%20Systems%20Journey.pdf

The authors thank Mr. R for his willingness to speak with them about his care experiences and share his perspective as a patient for this article. The authors also thank Estelle Martin, Jade Christey, and the Age-Friendly Health Systems Research Council for their intellectual support to strengthen this article.