CHIRP collaborates with Case Western Reserve, CVS, and IHI on national 4M Age-Friendly Health Systems Initiative

CHIRP is pleased to consult with Dr. Mary Dolansky and her team at Case Western Reserve University Frances Payne Bolton School of Nursing in collaboration with CVS and the Institute for Healthcare Improvement (IHI) to implement the IHI Age-Friendly Health Systems (AFHS) 4Ms Framework into the 1,100 CVS MinuteClinic locations in 33 U.S. states and the District Columbia.  The initiative has been underway since 2018.


“This is a great example of where improvement meets implementation,” says Dr. Brant Oliver (Associate Professor at Dartmouth and CHIRP Director), who serves as a consultant measurement methodologist on the project. “They are simultaneously working to improve while they are implementing and are also studying the outcomes of this national effort.”


Dr. Dolansky is a national improvement and nursing leader, a professor at Case Western Reserve University at the Frances Payne Bolton School of Nursing, and serves as the senior nurse faculty advisor for the VA National Quality Scholars (VAQS) fellowship program.  She is also the director of the QSEN Institute (for quality and safety in Nursing) and the Sarah Cole Hirsh Institute (for implementation of evidence-based practice).


Click here to learn more about Dr. Dolansky, the Case Western Reserve University Frances Payne Bolton School of Nursing, the VAQS Fellowship program, the QSEN Institute, and the Sarah Cole Hirsh Institute.   


Read below for more details about the 4M Age-Friendly Project.

In June of 2020, MinuteClinic in partnership with the Institute for HealthCare Improvement (IHI) along with Case Western Reserve University Frances Payne Bolton School of Nursing, introduced IHIs Age-Friendly Health Systems (AFHS) 4Ms Framework into the 1,100 MinuteClinic locations located in 33 states and the District Columbia. The goal was to reliably provide assessments and actions related to What Matters, Medications, Mentation, and Mobility as a set. A robust implementation strategy that included professional development (orientation, monthly grand rounds, virtual clinic simulation, MinuteClinic’s internal Education Exchange, and an external resource portal), marketing and communication, Regional Age-Friendly Champions, and electronic health record (EHR) interface for documentation, dashboards, and reminders. Reliable adoption of the 4Ms Framework into every older adult patient visit demonstrated a plateau amongst the healthcare team after 6 months. An understanding of the barriers to implementation was achieved through focus groups. In an effort to address some of the barriers, a 4Ms Refresher Pilot was instituted.  The 4-week Refresher Pilot included 2 regions Senior Practice Managers (SPM), Champions, Regional Quality Leaders (RQL) and 99 providers. The implementation and evaluation strategies consisted of: pre- and post- survey questionnaires; morning huddle discussions; a post huddle recap; weekly meetings with the SPMs, RQLs and Champions; review of 4Ms completion metrics; performance metrics shared pre and post pilot program; and weekly touchpoint between the Refresher Pilot leaders. Key features of the Refresher pilot included a “team” approach, coaching the SPMs, providing 4Ms adoption data, clarifying the goal and mitigating myths. Data on the 4Ms adoption were plotted monthly on a run chart are demonstrating increased frequency of 4M completion during the beginning of the intervention period compared to baseline a trend was visualized for improvement of suggesting increased provider integration of the 4Ms as a set including assessments and acts-ons (see Figures 1 and 2). Similar gains were also observed with the delivery of 1, 2 or 3 of the 4Ms indicating that the providers were working on including all 4Ms. The Refresher Pilot coincided with the release of an Electronic Medical Record System update that reminded providers, through Best Practice Advisory reminder, to incorporate the 4Ms Framework into their older adult care.  Even with the reminder, the two regions demonstrated a positive trajectory in 4Ms assessment and acts on comparative to other regions which did not undergo the 4Ms Refresher Pilot program.  More data are needed to monitor the sustainability of the trends to confirm improvement and sustainability over time. Future inquiry into understanding regional differences would contribute important information on the need to tailor implementation strategies. The pilot revealed insight into the value of additional implementation strategies that addressed perceived barriers and the need to learn how to facilitate the trajectory of early adopters from “1” Ms integration to the full set of 4Ms.  The pilot study lead to the formation of a larger booster implementation to ensure that adults age 65 years of age and older reliably receive 4Ms care during MinuteClinic service delivery.