This article is part of State of Health, a series examining integrated care and its potential to improve Michiganders' health. It is made possible with funding from the Michigan Health Endowment Fund.

Projections show that Michigan will be the first state where residents age 65 and older outnumber those under age 18 – and as a result, issues with health care effectiveness for older adults are increasingly coming to light.

Those issues are myriad. American Family Physician reports that while older Americans represent only 13% of the population, they consume about 30% of all prescription drugs, raising concerns about prescribing appropriately and effectively for those patients. The Harvard Health Blog notes that loss of mobility has profound consequences including loss of independence, incontinence, and cognitive decline. And the Alzheimer's Association finds that only one in seven older adults receives regular, brief cognitive assessments – in contrast to the 91% who are assessed for blood pressure and 83% for cholesterol.

These and many other concerns have prompted a growing nationwide movement known as age-friendly health systems. The John A. Hartford Foundation defines an age-friendly health system as one in which every older adult gets the best care possible, experiences no healthcare-related harms, and is satisfied with their care. The foundation also notes that age-friendly health systems optimize value not just for older patients, but for their families, caregivers, and communities.

Here in Michigan, the Hartford Foundation, American Hospital Association, Michigan Health and Hospital Association (MHHA), and the Michigan Health Endowment Fund have joined forces to advance the model.

"The age-friendly health system movement is currently in 485 sites in all 50 states. Michigan is a great exemplar," says Dr. Amy Berman, senior program officer with the Hartford Foundation. "This work is based on a framework, the four M's."

The four "M"s are a set of evidence-based practices designed to create a health care continuum that causes no harm while aligning with what matters to the older adult and their family. The four "M"s are:

1. What matters: Know, and align care with, each older adult's specific health outcome goals and care preferences.

2. Medication: If necessary, use age-friendly medication that does not interfere with the other three "M"s.

3. Mentation: Prevent, identify, and treat dementia, depression, and delirium.

4. Mobility: Ensure that older adults move safely every day to maintain function and do what matters.

Berman shares the story of an acquaintance, Randall, who volunteers at the front desk of a community hospital. He often recognizes friends and neighbors among patients being admitted — and noticed that those who walked in often went home in wheelchairs, seemingly worse off. Randall told Berman that since the hospital implemented the four "M"s, more of the folks he knows are walking out of the hospital in better shape instead of worse.

"This work began in 2016 and started with the idea that there are many evidence-based models of care that we should be doing in supportive care for older adults, but less than 10% receive that evidence-based care," Berman says. "We brought together the leading experts that were doing work around all the good care that should be done."

Those experts included organizations like the Catholic Health Association of the United States and the American Hospital Association, as well as select older adults who shared their own views and experiences. Together, they crafted the four "M"s framework that is guiding health systems across the country toward improving care for elders. In Michigan, Trinity Health St. Mary Mercy Hospital in Livonia serves as flagship for the movement.

"As a health system, while we are based in Michigan, we are looking to spearhead this across multiple states in our ministries," says Carrie Hays McElroy, vice president of clinical operations/chief nursing officer with Trinity Health PACE.

Carrie Hays McElroy, vice president of clinical operations/chief nursing officer with Trinity Heath PACE.

Recognized by the Institute for Healthcare Improvement as one of five age-friendly health systems pioneers nationwide, St. Mary Mercy has had a geriatric emergency room since 2010.

"People respond very well to the care they are receiving in the ER. It centers on their needs," says Michelle Moccia, program director of senior ER at St. Mary Mercy. "The biggest outcome has been medications. Through education and giving practitioners alternate medications to use for the older adult, we are changing. Now we are prescribing medications that are more friendly to the older adult."

Michelle Moccia, program director of senior ER at St. Mary Mercy Hospital in Livonia.

Other simple differences include encouraging patients to walk instead of staying in bed and providing water bottles that make it easier to stay hydrated. According to Moccia, rolling out the four "M"s framework to the whole hospital simply took the ER's regimen one step further. She notes that asking older adults what really matters to them is vital to age-friendly care.

"When you are asking people what matters to them, there could be ultimately differences in how imaging, lab tests, or other procedures are prescribed," she says. "They may not want those things. The 'What matters?' conversation is not just about end-of-life planning."

"(When asking) what matters, we are honoring the choice of the individual and making sure we've identified their goals, following through and honoring them to the best of our ability," adds Brittany Bogan, MHHA's senior vice president of safety and quality. "It's not a focused initiative on one area. Age-friendly health systems are changing the entire continuum of care. Whether they are ambulatory at home or in a skilled nursing facility, whatever the interaction is, we're working to make it all more age-friendly."

Brittany Bogan.

People age 65 and over-represent the vast majority of hospitalizations. That, combined with the growing population of older adults, accelerates the need for more age-friendly health systems.

"This model enhances proactive communication across care settings and with the patient and their family or caregiver. That continuum of care decreases waste and prevents needless harm," Bogan says. "Applied through all of the different health care settings and spread throughout the system, it will lead to a more integrated experience for patients."

The Institute for Healthcare Improvement's goal is for 20% of U.S. hospitals to be age-friendly by June 30, 2020. To date, 14 Michigan health systems have adopted the four "M"s model, including Eaton Rapids Medical Center, McClaren Caro Region Hospital, and Sparrow Health hospitals in Carson City, St. Johns, Clinton, Ionia, and Lansing.

"This is the care that we need to deliver to every older adult," Moccia says. "Michigan is the first state where residents 65 and older will outnumber those 18 and under. We are a decade ahead of the nation. It makes sense for us to adopt this framework."

A freelance writer and editor, Estelle Slootmaker is happiest writing about social justice, wellness, and the arts. She is development news editor for Rapid Growth Media, communications manager for Our Kitchen Table, and chairs The Tree Amigos, City of Wyoming Tree Commission. Her finest accomplishment is her five amazing adult children. You can contact Estelle at [email protected] or www.constellations.biz.

Photos by Doug Coombe, except photo of Brittany Bogan courtesy of Michigan Health and Hospital Association.