From Age-Friendly Principles to Routine Care: What IHI’s 4Ms Framework Can Teach Health Care Organizations in Viet Nam
AGE-FRIENDLY CARE QUALITY
From Age-Friendly Principles to Routine Care: What IHI’s 4Ms Framework Can Teach Health Care Organizations in Viet Nam
AGE-FRIENDLY CARE QUALITY
Last reviewed: October 2026
Health care organizations rarely lack clinical guidance for older people. They have protocols for hypertension, diabetes, heart failure, medication safety, falls, dementia, depression, rehabilitation and many other conditions. The challenge is often not knowing what good practice looks like in each individual area. It is making sure that the most important elements of older-person care are considered together and reliably during routine care.
That is what the 4Ms Framework tries to make more manageable. Developed through the Age-Friendly Health Systems 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, the framework organizes age-friendly care around four elements: What Matters, Medication, Mentation and Mobility. IHI describes the 4Ms as a framework rather than a separate clinical program: the intention is to incorporate them into existing care rather than layer additional work on top of existing services.
The framework has spread widely. As of September 2026, more than 7,000 health care organizations had earned either Level 1 or Level 2 Age-Friendly Health Systems recognition, and IHI reported that more than 9.9 million older adults had been reached with 4Ms care. Fourteen participating health systems were also recognized in June 2026 for demonstrating system-wide spread of the 4Ms across multiple care settings. These figures show substantial implementation reach, but they should not be interpreted by themselves as proof that the framework improves every clinical outcome in every setting.
For Viet Nam, the 4Ms are relevant for a different reason. The country is aging rapidly, older people increasingly move between hospitals, primary care, home and community services, and national policy is expanding geriatric and older-person care. The useful question is therefore not whether Viet Nam should simply “adopt the 4Ms,” but what health care organizations can learn from a framework that tries to turn broad age-friendly principles into a small number of connected practices that influence routine care.
The 4Ms are simple, but they are not superficial
The strength of the 4Ms lies partly in their simplicity. What Matters means knowing and aligning care with each older adult’s specific health outcome goals and care preferences. Medication means that when medication is necessary, it should not unnecessarily interfere with What Matters, Mentation or Mobility. Mentation focuses on preventing, identifying, treating and managing dementia, depression and delirium. Mobility means enabling older people to move safely every day in order to maintain function and do what matters to them. IHI intends these four elements to be practiced as a set, rather than as four independent activities.
None of these ideas is new in isolation. Geriatric care has long emphasized function, medication safety, cognition and individual goals. What the 4Ms add is an organizing logic. Decisions in one area frequently affect the others: sedating medicines can impair both cognition and mobility; excessive fear of falls can contribute to immobility and functional decline; and a technically appropriate treatment can still be a poor fit if its burden prevents a person from doing what matters most to them.
That interdependence is central to the framework. Instead of approaching every geriatric issue as a separate problem, the 4Ms offer a compact way to keep several priorities visible at the same time.
What Matters has to influence actual decisions
Of the four elements, What Matters may be the easiest to misunderstand. It does not mean simply asking, “What is important to you?” and recording the answer in a medical record, nor is it limited to end-of-life decisions. IHI defines it more broadly as knowing the older adult’s health outcome goals and care preferences and aligning care with them across settings.
For one person, what matters may be remaining independent enough to cook or shop. For another, it may be maintaining sufficient mobility to participate in family life. Someone receiving cancer treatment may prioritize symptom control and time at home, while another person may accept substantial treatment burden for a chance of longer survival.
The quality question is therefore not whether the question was asked. It is whether the answer changed the care plan. If remaining mentally alert is a person’s highest priority, do medication decisions take that into account? If independent walking is central to daily life, is mobility protected during hospitalization? If returning home safely matters most, does discharge planning reflect the support actually available there?
A What Matters field that never influences a decision can easily become another checkbox. The more meaningful test is whether the person’s priorities are visible in what the care team actually does. IHI’s guidance similarly emphasizes using What Matters to shape the goal-oriented care plan, navigate trade-offs and guide communication and decision-making.
This is particularly relevant in Viet Nam, where families may play a substantial role in health-care decisions. Family involvement can be valuable, but person-centered care still requires the older person’s own wishes and decision-making role to remain visible to the extent that they are able and want to participate.
Medication is about the whole care plan, not simply the number of medicines
Polypharmacy is common in older people, but the Medication element should not be reduced to “deprescribing.” Some older people appropriately require multiple medicines. The age-friendly question is whether the medicines remain appropriate and whether the overall regimen supports rather than undermines the other Ms.
A medicine can be clinically indicated and still create problems. Sedation can interfere with mobility or cognition. Anticholinergic burden may contribute to confusion. Blood-pressure treatment may require review when orthostatic symptoms are contributing to falls. A complicated regimen can become difficult to manage when a person has visual or cognitive impairment.
IHI specifically frames Medication in relation to the other Ms: necessary medications should not interfere unnecessarily with What Matters, Mentation or Mobility. Its hospital guidance also links medication review with delirium prevention, falls, mobility and safe transitions of care.
For Vietnamese organizations, the implementation lesson is that medication review should not become an isolated pharmacy exercise. It should connect with cognition, mobility, falls, transitions and the older person’s priorities.
The 4Ms framework does not change prescribing authority, professional scope or other clinical responsibilities under Vietnamese law. Those remain governed by Viet Nam’s legal and professional framework for medical examination and treatment.
Mentation and Mobility should be part of everyday care
IHI groups dementia, depression and delirium under Mentation. Although these are clinically different conditions, they frequently interact with the rest of care. Delirium can be mistaken for dementia; depression can contribute to inactivity, poor nutrition and social withdrawal; cognitive impairment can make medication management and discharge instructions difficult; and medicines themselves can worsen mentation.
The implementation lesson is that mentation should not become visible only when psychiatry, neurology or geriatrics becomes involved. Changes in cognition or mood may first be recognized by nurses, rehabilitation professionals, family members or community workers. At the same time, brief screening should not be treated as diagnosis. A positive finding needs an appropriate route for further assessment and response.
Viet Nam’s Ministry of Health has already moved in a related direction through Decision No. 1976/QĐ-BYT, issued on 1 July 2026. The professional guidance on older-person care at home and in the community incorporates WHO ICOPE assessment of intrinsic capacity and includes cognitive and psychological domains, with identified declines linked to further assessment and care planning. This does not mean Viet Nam has adopted the 4Ms. It shows that several concerns represented in the framework are already appearing in the country’s developing older-person care infrastructure.
Mobility deserves similar attention. Preventing falls is important, but fall prevention and mobility are not the same thing. An organization can reduce one risk by unnecessarily keeping older people in beds or chairs and create another through deconditioning and loss of independence.
IHI’s Mobility element focuses on safe daily movement to maintain function and support What Matters. Its implementation guidance encourages early, frequent and safe mobility, daily mobility goals and removal of avoidable barriers to movement.
In hospitals, this may mean understanding baseline mobility, avoiding unnecessary immobilization, encouraging appropriate activity and making any change in function visible at discharge. In outpatient care, it may mean recognizing decline before a serious fall occurs. In residential care, it may mean balancing safety with autonomy and activity.
Age-friendly quality therefore asks whether clinical success was achieved without avoidable loss of function.
The goal is not four new checklists
A common implementation mistake would be to create four new forms — one for each M. That would miss much of the framework’s value.
IHI explicitly describes the 4Ms as a framework that should be incorporated into existing care rather than layered on top of it. An organization may already reconcile medications, assess falls, screen for delirium and discuss treatment goals. The first task is therefore often to understand what already exists and identify where information, action or coordination is missing.
Are all four Ms reliably covered? Is the information available to the people who need it? Does it influence the plan? Is it reconsidered when the person’s condition changes? Does it follow the older person when care moves between settings?
The difference between having activities related to the 4Ms and providing reliable 4Ms care lies largely in workflow and integration.
Evidence for the components is stronger than evidence for the whole package
The 4Ms were developed from a substantial body of geriatric evidence. An expert review summarized evidence supporting the individual components and their interactions, including goal-directed care, medication safety, mentation interventions and mobility-focused care.
Evidence about implementing all four Ms together as one health-system package, however, remains less mature.
A 2026 systematic review of outpatient Age-Friendly Health Systems implementation identified only 12 eligible studies, all conducted in the United States. Implementation of all four Ms was associated with improved process measures across the four domains, but structural and patient outcome measures were reported much less often. Heterogeneity and incomplete reporting limited conclusions about which implementation strategies were most effective and how broadly the findings could be generalized.
A separate 2026 state-of-the-science review similarly characterized Age-Friendly Health Systems as a promising integrated approach while highlighting the need for stronger evidence on outcomes reflecting older people’s lived experience and well-being.
That does not diminish the value of the 4Ms. It means the claims need to remain proportionate to the evidence. Many practices represented by the framework are supported by geriatric evidence, and thousands of organizations have demonstrated that 4Ms workflows can be implemented. But it would be premature to assume that introducing the framework automatically produces the same outcomes in every country or care setting.
For Viet Nam, that is a strong argument for local adaptation, testing and measurement rather than simple replication.
Implementation reach is not the same as effectiveness
The scale of the Age-Friendly Health Systems movement is impressive, but its recognition system should be interpreted correctly.
IHI’s Level 1 - Participant recognition means that a team has successfully developed a plan to implement the 4Ms. Level 2 - Committed to Care Excellence means that the team has three months of data on older adults who received 4Ms care.
Recognition therefore tells us something useful about implementation commitment, reach and spread. It is not, by itself, an independent clinical effectiveness assessment.
IHI also provides implementation resources for hospitals, ambulatory practices, home health, nursing homes and other settings. That breadth is relevant to Viet Nam because it shows that the framework is not tied to one department or specialty. At the same time, every setting requires its own workflow and meaningful outcomes.
Even the age threshold needs local adaptation
IHI’s standard measurement guidance for Age-Friendly Health Systems uses adults 65 years and older as the population for its 4Ms care measures.
Vietnamese law uses a different definition. The Law on Older Persons defines an older person as a Vietnamese citizen aged 60 years or older.
A Vietnamese organization should therefore not automatically copy the 65+ denominator without considering the purpose of its project. For a quality-improvement initiative explicitly aligned with Vietnamese older-person policy, beginning at age 60 may be appropriate. A resource-constrained pilot might instead start with a defined higher-risk population using age together with factors such as frailty, multimorbidity, recent hospitalization or functional decline.
The important point is not that one threshold is universally correct. It is that the denominator should be explicit, justified and appropriate to the local purpose. This is a small example of a larger principle: local adaptation begins before the first 4Ms assessment is performed.
The 4Ms and ICOPE overlap, but they are not the same framework
This distinction is particularly important in Viet Nam because WHO’s Integrated Care for Older People, or ICOPE, is now explicitly reflected in Ministry of Health guidance for care at home and in the community.
The two approaches have obvious areas of overlap. Both emphasize person-centered care, function, cognition and connecting assessment with action. Their structures and purposes, however, are different.
IHI’s 4Ms are a compact organizing framework for routine age-friendly health care. They ask whether What Matters, Medication, Mentation and Mobility are reliably considered and acted on when older people receive care.
WHO ICOPE is a broader primary-care and community care pathway. Its second edition describes four steps, basic assessment, in-depth assessment, development of a personalized care plan, and implementation and monitoring, and covers cognition, mobility, vitality, vision, hearing and psychological capacity alongside social support, caregiver support and other needs. WHO also explicitly states that its pathways should be adapted to local context.
They should therefore not be treated as competing models. ICOPE assessment of mobility and cognition can inform corresponding areas within the 4Ms; personalized care planning can also reinforce What Matters. But ICOPE includes domains not explicitly captured by the four Ms, including vision, hearing, vitality and broader social and caregiver needs.
For a Vietnamese organization interested in both approaches, the sensible goal is not to create two parallel programs. It is to identify overlaps and build one coherent workflow that minimizes duplicate assessment and reporting.
What might implementation look like in Viet Nam?
A hospital does not need to transform every department at once. A focused quality-improvement pilot could begin in one medical or surgical unit that regularly cares for older people.
The team could first map existing care. Where are the person’s goals and priorities documented? Which medication reviews already occur? How are delirium, cognitive concerns and depression identified? How is mobility assessed, protected and communicated?
The next step would be to decide how each M fits into existing workflows. What Matters might be discussed during admission or multidisciplinary review and revisited when major treatment decisions arise. Medication could build on existing reconciliation, prescribing and pharmacy processes. Mentation could be incorporated into existing clinical and nursing assessment with clear routes for response. Mobility could become part of daily care planning rather than being viewed only as a rehabilitation responsibility.
The most useful implementation question is not “Who completes the 4Ms form?” It is “Who needs to know each M, who acts on it, and how does that information change the care plan?”
Primary and outpatient settings would need a different workflow. What Matters may help when multimorbidity creates competing treatment priorities. Medication can connect with chronic disease management and pharmacy support. Mentation may be considered when the person or family reports change, while mobility can be followed longitudinally rather than only after a fall.
The 2026 outpatient review is particularly useful here because it found stronger evidence of improvements in process measures than of downstream structural or patient outcomes. A Vietnamese pilot should therefore avoid defining success merely as the percentage of encounters in which all four Ms were completed. It should also examine whether identified concerns led to action, whether the workflow was feasible and whether care became more useful to older people.
The 4Ms can support continuity across settings
One potentially valuable feature of the framework is that its language can travel with the person.
Imagine an older person whose priority is to remain independently mobile at home. During hospitalization, a medication contributes to dizziness, cognition fluctuates during an acute illness and mobility declines. Those observations should not disappear when the hospital episode ends.
The next care team needs to know what matters to the person, what medication changed, whether mentation concerns remain and what the person’s current mobility is. Used in this way, the 4Ms can become not only assessment domains but a shared language for continuity.
That fits a broader quality objective for Viet Nam: hospital care, transitions, primary care, home, community services and long-term care should not operate as unrelated quality systems.
Reliable care requires workflow, measurement and learning
Teaching staff what the four Ms mean is relatively straightforward; making them reliable in routine care is harder.
IHI’s implementation guidance moves from understanding current practice to designing or adapting workflows, delivering 4Ms care, studying performance and improving and sustaining the process. Its measurement guidance similarly focuses on whether older adults actually received care incorporating all four elements, not simply whether staff were trained.
For Vietnamese organizations, several questions follow. Can relevant information be captured within existing documentation rather than a separate form? Are responsibilities clear? Is there enough service capacity to respond when cognition or mobility problems are identified? Does information about What Matters reach the clinicians making decisions? Does important information follow the person across departments and after discharge?
If age-friendly care depends mainly on one enthusiastic geriatrician, nurse or quality manager remembering to ask, it is not yet reliable care. The workflow itself has to carry the practice.
Measurement should also go beyond completion counts. At the process level, teams can examine whether the four Ms were assessed and acted on. At the implementation level, feasibility, staff burden, fidelity, missed opportunities and reasons for incomplete care may matter. At the person level, selected outcomes might include mobility or functional change, medication-related problems, delirium, experience of care or other outcomes appropriate to the setting.
The exact measurement set should remain small enough to use. The purpose is to understand whether care became better, not to build the largest possible 4Ms dashboard.
What Matters can help orient the other three Ms
The four Ms are intended to work together, but What Matters can give the others practical direction. IHI’s own guidance places the older person’s goals and priorities at the center of care planning and encourages teams to use What Matters to navigate trade-offs among Medication, Mentation and Mobility.
Medication decisions should support rather than undermine the person’s goals. Mentation matters partly because cognitive and psychological health influence the person’s ability to participate in the life they value. Mobility supports independence and participation in activities that matter.
A technically complete 4Ms process can therefore still miss the point if the older person simply becomes the subject of four assessments.
The framework is most useful when it brings clinical care back to a simple question: Are our decisions helping this person do what matters to them as safely and functionally as possible?
What the 4Ms can teach Viet Nam
The main lesson of the 4Ms is not that Viet Nam needs another imported standard.
The framework emerged in the United States and was designed within that health-system context. Viet Nam has different legal definitions, workforce arrangements, family roles, referral capacity and developing home- and community-care structures. It would therefore be inappropriate to describe the 4Ms as a Vietnamese standard, a WHO requirement or a model that Vietnamese organizations should adopt unchanged.
What the framework offers is more practical: it shows how complex older-person care can be made easier to organize by focusing on a small number of connected priorities and embedding them into everyday workflows.
Several elements represented by the 4Ms are already reflected in Viet Nam’s emerging guidance for older-person care, particularly attention to intrinsic capacity, individualized care planning and community support. The opportunity is to examine whether the 4Ms can simplify and strengthen existing care rather than create a competing program.
For an interested organization, a reasonable next step would be to map current care against the four Ms, identify a setting where important gaps are visible, co-design an adapted workflow, test it with a defined population of older people, measure both reliability and meaningful outcomes and refine the approach before wider spread.
The useful question is therefore not whether Viet Nam should adopt the 4Ms as another imported model, but what the framework can teach Vietnamese health care organizations about making person-centered, age-friendly care reliable in everyday practice.
The answer may lie less in adding four new assessments than in ensuring that What Matters, Medication, Mentation and Mobility consistently influence the decisions organizations are already making.
That is the difference between an age-friendly principle and routine age-friendly care.
References
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Ministry of Health of Viet Nam. Decision No. 1976/QĐ-BYT issuing professional guidance on care for older people at home and in the community. 1 July 2026.