Facilitators and Barriers to Implementing the 4Ms Framework of Age-Friendly Health Systems: A Scoping Review

Background: This scoping review explored the evidence in the peer-reviewed published journal literature to identify the facilitators and barriers to implementing the 4Ms Framework of Age-Friendly Health Systems in inpatient and outpatient clinical settings. Methods: Our search strategy focused on primary and secondary data sources that described the barriers and facilitators of incorporating the 4Ms Framework in clinical settings. We focused on older adults 65 years and older and followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-SCR). Results: The evidence analyses of the 19 identified articles revealed six facilitator themes and five barrier themes to implementing the 4Ms Framework of Age-Friendly Health Systems in inpatient and outpatient clinical settings. The most recurring facilitator theme was embedding the 4Ms Framework into routine clinical practice with clinical pathways and designated personnel. The most frequently reported barrier theme was the lack of clinicians’ buy-in. Conclusions: Future research may translate the findings of this scoping review into a facilitator and barrier checklist or a “reality-check” measure to monitor the progress of the journey of embracing the 4Ms Framework in outpatient or inpatient clinical settings. This study was not registered.


Introduction
The Institute for Healthcare Improvement's (IHI) 4Ms Framework of Age-Friendly Health Systems includes four components: (1) knowing "What Matters" to each person; (2) preventing, identifying, treating, and managing "mentation" issues; (3) supporting "mobility" needs; and (4) necessary "medication" [1,2].Despite the benefits of age-friendly health systems on older adults' health outcomes, there is limited evidence on improving health-system-level and community-level metrics to support the implementation and sustainability of age-friendly health systems [3].A recent interview study [4] explored the insights of adopting the 4Ms Framework in three health systems that were early adopters of the Framework and found that the common barriers to implementing the IHI's 4Ms Framework included disengaged physicians, siloed implementation efforts (which led to problems with collaborations and scaling), and challenges in implementing "What Matters" in a meaningful way during clinical encounters [4].A frontline culture change to sustain the 4Ms implementation is warranted.Successful efforts are dependent upon effective top-down communication, redesign of the healthcare system's infrastructure to provide effective and tailored care to older adults, and provision of clinical education and support [4].To our knowledge, no scoping review studies have examined the facilitators and barriers when implementing the IHI's 4Ms Framework.In light of the existing knowledge gaps [3,4], the Alzheimer's Association (AA) recommended the adoption of the IHI's 4Ms Table 1.Keyword search syntax and search strategy for the two library databases (Ovid-MEDLINE and EBSCOHost-CINAHL databases).
1. 4Ms 2. "Age-Friendly Health Systems" 3. 4 M Framework 4. 1 or 2 or 3 5.Limit 4 to (English language and "all aged (65 and over)") Notes: This search strategy was put together with the help of a professional librarian to ensure a comprehensive search of keywords and MeSH terms.
The following databases were searched: MEDLINE-Ovid and EBSCOhost.The initial search was performed between 8 September 2022 and 13 December 2022, with five updated searches on 17 March 2023, 28 April 2023, 20 June 2023, 10 August 2023, and 10 January 2024.We hand-searched references of the included articles and used the snowball method to identify relevant papers.No gray literature was included in the complementary searches.
As for the selection of evidence sources, the first two authors screened the citations and articles against the preset inclusion criteria described in the "eligibility criteria" section.We applied the same approach to identify articles for inclusion in the initial and updated searches.First, we screened the titles and abstracts of all retrieved articles from the library databases and removed the duplicates.Next, we retrieved the remaining articles' full texts and reviewed them for relevance according to the research question, assigning a score of either 0 (not relevant) or 1 (relevant).We then discussed conflicts and discrepancies between interrater scores to resolve them.The overall interrater reliability Kappa score was calculated to be 0.708 (standard error = 0.089, p < 0.001) using the Statistical Package for the Social Sciences (SPSS) [9].All citations were imported or manually entered using Endnote X9 reference manager [10].
We extracted the following preidentified data from the final included articles: author names, title and date of publication, study type, design, data collection methods, study setting, sample size and description, outcome measures used, findings, and facilitators and barriers to the implementation of the 4Ms Framework.For each selected study, the first two authors extracted and coded the data for facilitators and barriers as described in each included article.All data were compiled into a table using Microsoft ® Word Version 16.28 for Mac [11].
We appraised each included article's characteristics and methodological quality using the JBI critical appraisal tool for quantitative studies (e.g., randomized clinical, prospective, retrospective, and cross-sectional studies) [12].The JBI critical appraisal tool evaluates the rigor, trustworthiness, relevance, and potential for bias in study designs, conduct, and analysis [12].See Supplementary Materials Tables S1-S5 for the critical appraisal data of the included studies using the JBI critical appraisal tools for study designs.
We analyzed the findings from the included articles to identify the barriers and facilitators of implementing the 4Ms Framework.The first two authors met weekly via the Zoom online meeting site to review codes and themes from the data analyses.Conflicting themes were resolved by discussion.

Selection of Evidence Sources
We identified 130 articles from the two databases (n = 122) and by the hand-searching/ snowball method (n = 8).Of these 130 articles, 26 were duplicates, resulting in 104 articles to be further screened.After screening the title and abstracts, we excluded 16 articles, leaving 88 for which we retrieved and assessed the full texts for eligibility.After screening the full texts, we excluded 69 articles, leaving 19 for data extraction and final review.Full-text articles were excluded from final screening for the following reasons: (1) no discussion of the implementation of the 4Ms Framework, (2) not based on collected data, (3) the article was not written in English, or (4) the article was not an original study (i.e., discussion paper, editorial, commentary, essay, or dissertation) (Figure 1).
full texts and reviewed them for relevance according to the research question, assigning a score of either 0 (not relevant) or 1 (relevant).We then discussed conflicts and discrepancies between interrater scores to resolve them.The overall interrater reliability Kappa score was calculated to be 0.708 (standard error = 0.089, p < 0.001) using the Statistical Package for the Social Sciences (SPSS) [9].All citations were imported or manually entered using Endnote X9 reference manager [10].
We extracted the following preidentified data from the final included articles: author names, title and date of publication, study type, design, data collection methods, study setting, sample size and description, outcome measures used, findings, and facilitators and barriers to the implementation of the 4Ms Framework.For each selected study, the first two authors extracted and coded the data for facilitators and barriers as described in each included article.All data were compiled into a table using Microsoft ® Word Version 16.28 for Mac [11].
We appraised each included article's characteristics and methodological quality using the JBI critical appraisal tool for quantitative studies (e.g., randomized clinical, prospective, retrospective, and cross-sectional studies) [12].The JBI critical appraisal tool evaluates the rigor, trustworthiness, relevance, and potential for bias in study designs, conduct, and analysis [12].See Supplementary Materials Tables S1-S5 for the critical appraisal data of the included studies using the JBI critical appraisal tools for study designs.
We analyzed the findings from the included articles to identify the barriers and facilitators of implementing the 4Ms Framework.The first two authors met weekly via the Zoom online meeting site to review codes and themes from the data analyses.Conflicting themes were resolved by discussion.

Selection of Evidence Sources
We identified 130 articles from the two databases (n = 122) and by the hand-searching/snowball method (n = 8).Of these 130 articles, 26 were duplicates, resulting in 104 articles to be further screened.After screening the title and abstracts, we excluded 16 articles, leaving 88 for which we retrieved and assessed the full texts for eligibility.After screening the full texts, we excluded 69 articles, leaving 19 for data extraction and final review.Full-text articles were excluded from final screening for the following reasons: (1) no discussion of the implementation of the 4Ms Framework, (2) not based on collected data, (3) the article was not written in English, or (4) the article was not an original study (i.e., discussion paper, editorial, commentary, essay, or dissertation) (Figure 1).

Synthesis of Results
As for the content analysis and the process of data charting, we extracted data from the final selected articles based on preidentified data items: author(s), title and date of publication, study type and design, materials and methodology, data collection methods, stage of the care continuum on which the study focused, setting, barriers or facilitators, limitations, and lessons learned.Table 3 includes the summary of the evidence of the included studies (Table 3 can be found after the references due to the length of the table ).
Based on the summary of the evidence in Table 3, we used the 4Ms Framework of Age-Friendly Health Systems to guide the synthesis of results and to organize the findings (i.e., the descriptive content analysis and descriptive results of the review synthesis).In other words, the first two authors analyzed the findings in Table 3 to identify the barriers and facilitators of implementing the 4Ms Framework.For each selected study, the first two authors extracted and coded the data as barriers and facilitators of implementing the 4Ms Framework.The main themes were then developed based on the identified codes (subthemes) related to barriers and facilitators (as shown in Tables 4 and 5).All data were compiled into a table or spreadsheet using Microsoft ® Word Version 16.28 for Mac [11] for manuscript preparation purposes.The first two authors met weekly to review and refine codes and themes from the data analyses, and conflicting themes were resolved by discussion during the weekly meetings.Table 4 describes the facilitator themes and related subthemes to implementing the 4Ms Framework.Table 5 presents the barrier themes and associated subthemes to implementing the 4Ms Framework as reported in all included studies.
As part of the content analysis, we carefully recorded each identified code (i.e., quantifying the observed codes as yes = present, no = not present) using Microsoft Excel.We matched the identified codes (subthemes) with the corresponding themes.Then, we generated the frequency of each main theme and summarized the findings in Table 6.Each article may be cited to more than one facilitator or barrier theme.In other words, Table 6 includes only the main themes of the identified facilitator and barrier themes (i.e., the number of included articles for each identified theme), as stated in Tables 4 and 5.A cross-sectional qualitative study using a semi-structured questionnaire.Intervention: not applicable.
Not applicable.
The 4Ms Framework offered a compelling conceptual framework for advancing age-friendly care.However, implementation was complex and fragmented.
Each health system took varied implementation approaches with a different implementation order for each of the 4Ms.None of the sites implemented all components of the 4Ms at one time due to the number of activities and disciplines involved.
The common strategies that facilitated the 4Ms implementation success and supported frontline culture change were: (1) continuous communication from leadership promoting the 4Ms as a priority, (2) engagement across multiple disciplines, (3) adopting EHR templates for understanding clinical workflows, promoting adherence to standardized 4Ms process and reporting, (4) the use of peer coaching and clinical champions who attended unit meetings and clinical huddles, providing hands-on support and clinical education, and ( 5) incorporating compliance incentives.The researchers identified three common barriers to the implementation of the 4Ms: (1) physician disengagement due to the perception of the 4Ms as not being their work responsibility, (2) siloed implementation efforts across settings within a health system, which limited synergies and scaling of the 4Ms Framework, and (3) difficulty in knowing how to implement "What Matters" meaningfully.After the 4-week geriatric mini fellowship training, primary care providers were 1.7 times more likely to screen for fall risk and 3.6 times more likely to discuss fall risk.Primary care providers were also 5.8 times more likely to assess patients aged 65 and older for orthostatic blood pressure.
Regarding high-risk older adult patients, participating primary care providers were 4.1 times more likely to discuss fall risk and 6.3 times more likely to assess orthostatic blood pressure than their peers who did not receive the education.During the intervention period, 69% of new patients received a mobility screening (an increase from 55% during the preintervention period), 85% had a mental examination (increase from 82%), 85% consulted with their pharmacist to manage their medications (no change from preintervention period), and 69% had "What Matters" to the patients addressed (decrease from 85%, mainly due to failing to upload intake notes to electronic medical records).The 4Ms intervention resulted in an improvement in medication adherence, simplification of medication regimens, and a reduction in hospitalizations and readmissions.Online survey responses.
Over 90% of the clinicians stated that older patients needed a different approach than younger patients, and 50% said they "always" considered the patient's age when providing care.About 60% of the clinicians were either not currently using the 4Ms Framework of Age-Friendly Health Systems in their practice settings (40%) or were unaware whether their practice settings were adopting the 4Ms Framework (20%).
The healthcare team's lack of familiarity with the 4Ms and lack of time during the visits were two common barriers for clinicians and their teams to address the 4Ms.Physicians and physician assistants found the mentation component in the 4Ms Framework to be the most challenging one to address with older adults.Nurse practitioners found the medication component the most challenging one to address.The mobility component was the least challenging for all these primary care clinicians.About 30% of the clinicians were not asking their older patients "What Matters" for alignment with their care plans.The "What Matters" metric was met with documentation discussing prognosis and end of life care.
The "Medication" metric was met if no high-risk medications were active on an individual patient's current medication list.
The "Mobility" metric was met if a fall risk screening tool was completed within the last year.
The "Mentation" metric was met if depression and cognition screenings were completed within the last year.
Five hundred and seventeen (15.3%) patients received care, including all 4Ms.Advance care planning discussions occurred more often with females than males and with English speakers than non-English speakers.
Females were more likely to use at least one high-risk medication than males.Patients with an activated electronic patient portal account were more likely to use high-risk medications than the ones with an inactive account.Individuals with an active electronic patient portal account were more likely to have cognitive screening than the ones without an active account.The intervention resulted in a statistically significant improvement in fall efficacy for older adults.Thus, there was no statistically significant change in the self-assessment of health-related quality of life levels.Frequency of weight-bearing on postoperative day 1.
Frequency of delirium.
The age-friendly intervention reduced delirium frequency by 26% for patients on the intervention unit compared to 35% on other units (not statistically significant, p = 0.055).There was an 84% frequency of day 1 postoperative weight-bearing for patients in the intervention unit versus 72% in other units (statistically significant, p = 0.003).There was no change in the median length of stay in the intervention unit.Twenty-four peer-reviewed journal articles were included in the synthesis.
The evidence indicates that the 4Ms Framework was feasible in the rural Australian context.There were more reviewed studies on mobility and mentation, with fewer reviewed studies relating to medications and "What Matters".Over one-third of the reviewed studies solely focused on mobility; 4 focused on fall prevention as the intervention.
Table 4. Facilitator themes on implementing the 4Ms Framework of Age-Friendly Health Systems.

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Alignment between the 4Ms Framework component of mobility and clinical practice [21,23,25,27] Table 5. Barrier themes on implementing the 4Ms Framework of Age-Friendly Health Systems.

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Limited numbers of staff to support 4 M Framework implementation [25] Lack of clinician awareness [4,18,23] • Lack of knowledge of the 4Ms Framework of Age-Friendly Health Systems [18,23]

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Lack of knowledge of community resources [18] • Lack of clarity regarding implementation of the 4Ms [4,18] Table 6.Summary of the identified facilitator and barrier themes on implementing the 4Ms Framework.

Facilitators
As shown in Table 4, we identified the following themes as facilitators to implementing the 4Ms Framework: (1) frequency of patient participation in age-friendly care, (2) aligning the health system's mission with the 4Ms Framework, (3) infrastructure readiness to embrace the 4Ms Framework, and (4) and embedding the 4Ms Framework into routine clinical practice with clinical pathways and designated personnel.Table 6 summarizes that the most frequently mentioned facilitator theme was embedding the 4Ms Framework into routine clinical practice with clinical pathways and designated personnel (11 articles, 57.9%), followed by infrastructure readiness to embrace the 4Ms Framework (9 articles, 47.4%).
The facilitator theme of embedding the 4Ms Framework into routine clinical practice with clinical pathways and designated personnel included six subthemes: (1) adopting geriatric syndrome screening before introducing interventions; (2) alignment between the entire 4Ms Framework or part of the 4Ms Framework and clinical practice; (3) alignment between the 4Ms Framework component of "What Matters?" and patients' interests in improving health; (4) alignment between the 4Ms Framework component of mentation and clinical practice; (5) alignment between the 4Ms Framework component of medication and clinical practice; and (6) alignment between the 4Ms Framework component of mobility and clinical practice.Within this facilitator theme, the most often recurring subthemes were the alignment between the 4Ms Framework component of "What Matters?" and patients' interests in improving health (e.g., giving older adults a choice [18]; discussions with patients regarding goals, preferences, priorities, their knowledge about their situation, and what brings the patient comfort during difficult moments [27]; adding facilitating questions regarding "What Matters" to intake paperwork [28]; having designated healthcare providers and processes (through combined home and telehealth visits within geriatric emergency departments [EDs]) to address "What Matters" and identify unmet care needs [29]; and incorporating a "What Matters" conversation guide tailored for ED settings to ascertain fears or concerns about the patient's healthcare needs and identify the outcomes patients most want [24]) (Table 4).

Barriers
Table 5 shows the identified five barrier themes on the implementation of the 4Ms Framework, which were (1) patients unable to actively participate in age-friendly care; (2) lack of infrastructure readiness to embrace the 4Ms Framework in clinical practice; (3) lack of clinicians' buy-in; (4) challenges in incorporating the 4Ms components in clinical practice; and (5) lack of clinician awareness.As shown in Table 6, the most frequently reported barrier theme was the lack of clinician's buy-in (eight articles, 42.1%), which included six subthemes: (1) clinicians' concerns about adding extra burden and steps during clinic visits; (2) lack of time to learn about the 4Ms Framework; (3) limited time to implement the 4Ms Framework; (4) lack of full buy-in from clinicians and health systems in eliciting older adults' goals and values (i.e., "What Matters?"); (5) limited published literature on adoption of the 4Ms Framework; and (6) siloed implementation efforts across settings within a health system leading to limited synergies and scaling of the 4Ms Framework.Within this barrier theme, the most common barrier subtheme was limited time to implement the 4Ms Framework (e.g., limited time available for implementation of the 4Ms [18,25]; limited time available to participate in the monthly grand round [13]; and limited available time during medical visits [23]) (Table 5).

Discussion
In this scoping review, we explored the evidence in 19 data-based, peer-reviewed journal articles to identify facilitators and barriers to implementing the 4Ms Framework of Age-Friendly Health Systems in inpatient and outpatient clinical settings.We identified four facilitator themes for implementing the 4Ms Framework: (1) frequency of patient participation in age-friendly care, (2) aligning the health system's mission with the 4Ms Framework, (3) readiness of health system infrastructure to implement the 4Ms Framework, and (4) and embedding the 4Ms Framework into routine clinical practice with clinical pathways and designated personnel, as the most frequently mentioned facilitator theme.These facilitators were geared toward health-system-level policy and technological and personnel infrastructure readiness.These findings were consistent with previous research [4] that implementation success required redesigning the healthcare system infrastructure along with needed clinical education and support [4] We also identified five barrier themes: (1) patients unable to actively participate in agefriendly care; (2) lack of infrastructure readiness to embrace the 4Ms Framework in clinical practice; (3) lack of clinicians' buy-in, as the most frequently mentioned barrier theme; (4) challenges in incorporating the 4Ms components in clinical practice; and (5) lack of clinician awareness.Our findings were consistent with previous interview studies [4] that identified the common barriers to implementing the IHI's 4Ms Framework as mostly related to clinicians' attitudes toward the benefits of adopting the 4Ms Framework (i.e., disengaged physicians) [4] In summary, our findings revealed many significant system factors (e.g., infrastructure readiness) that may hinder or support the implementation of the 4Ms Framework of Age-Friendly Health Systems [4,[13][14][15][16][17][18][21][22][23][24][25][26][27][28][29][30].As an example, a recent review [33] around the implementation of the streamlining framework (for streamlining cancer multidisciplinary meetings) in the United Kingdom's national health system identified similar system issues.This review suggested several strategies to overcome challenges to its implementation (e.g., securing buy-in from key clinician and administration stakeholders, desiring clearly defined management approaches that include triage, assessment of cancer case complexity, the roles of clinicians and clinical staff, and acknowledging that the standard of care cannot be universally applied without the consideration of the variations across hospitals and clinics) [33].Another review [34] summarized the enablers of chronic disease prevention and management for the Aboriginal people in Australia (e.g., culturally acceptable and safe services, patient-provider partnerships, primary healthcare service attributes, and clinical care pathways).This review emphasized the need to enable place-based partnerships across patients, providers, and policymakers to develop strategies that align with local community priorities as another system factor [34].Further in-depth research is warranted to comprehend these identified system issues of implementing the 4Ms Framework.It is critical to link these identified system issues to a broader health systems literature and what that means for the ongoing development and implementation of the 4Ms Framework (e.g., using implementation science frameworks to guide review studies and studies that collect primary data [33]).

Study Strengths and Limitations
The main strength of this scoping review was summarizing the facilitators and barriers of implementing the relatively new IHI 4Ms Framework in a hospital or outpatient clinic setting.As a limitation of this scoping review, we excluded the studies that focused on healthcare providers' education or training-related interventions.This exclusion narrowed the scope of this review to a focus on implementation-related matters in clinical settings.

Conclusions
The evidence analyses of the 19 original peer-reviewed articles revealed a total of six facilitator themes and five barrier themes to implementing the 4Ms Framework of Age-Friendly Health Systems in inpatient and outpatient clinical settings.The most frequent recurring facilitator theme was embedding the 4Ms Framework into routine clinical practice with clinical pathways and designated personnel [18,24,[27][28][29].The most frequently reported barrier theme was the lack of clinician buy-in [13,18,23,25].Future research may translate the findings of this scoping review into a facilitator and barrier checklist or a "reality-check" scale to monitor the progress of the journey of embracing the 4Ms Framework in outpatient or inpatient clinical settings.

Supplementary Materials:
The following supporting information can be downloaded at: https: //www.mdpi.com/article/10.3390/nursrep14020070/s1,Table S1: Critical appraisal of the included analytical cross-sectional studies using the Joanna Briggs Institute critical appraisal tools for study designs; Table S2: Critical appraisal of the included qualitative research using the Joanna Briggs Institute critical appraisal tools for study designs; Table S3: Critical appraisal of the included systematic reviews and research syntheses using the Joanna Briggs Institute critical appraisal tools for study designs; Table S4: Critical appraisal of the included studies reporting prevalence data using the Joanna Briggs Institute critical appraisal tools for study designs; Table S5: Critical appraisal of the included studies reporting prevalence data using the Joanna Briggs Institute critical appraisal tools for study designs.

Table 2 .
Summary of the included studies by types.

Table 3 .
Summary of the evidence of the included studies.
(1)re was low adoption of(1)training for older adults and family caregivers on the patient portal, (2) an electronic medical record portal for long-term care facilities, and (3) being able to electronically send information to long-term care facilities.Adler-Milstein et al., 2023[4]† Study Purpose: this qualitative study conducted interviews to assess the implementation of the 4Ms Framework in early-adopter health systems.Approaches to and experiences with 4Ms Framework implementation (e.g., facilitators and barriers) were explored.Setting and Country: academic and non-academic inpatient and outpatient clinical settings in the USA.Sample Population: N = 29 stakeholders at 3 health system sites (21 from an inpatient setting and 8 from an outpatient setting).Among these 29 stakeholders, 22 were frontline clinicians (e.g., physicians, nurses, pharmacists, physical therapists, and social workers), and 7 were those in administrative or leadership positions.Data Source: semi-structured interviews from stakeholders in three healthcare systems: Anne Arundel Medical Center, Maryland; University of Utah; and University of California, San Francisco.
Breda et al., 2023 [27] † Study Purpose: this quantitative study determined the outcomes of adopting the 4Ms Framework in an integrated inpatient and outpatient program specifically for geriatric fracture patients.Setting and Country: inpatient acute care hospital in the USA.Sample Population: N = 1598 patients aged 65 years and older with fractures; 746 managed by a Geriatric Fracture Program (GFP) physician, and 852 managed by non-GFP physicians.Data Source: electronic medical record.