The report is a product of the VA/HSR Evidence Synthesis Program.

Implementation of Age-Friendly Health Systems in Outpatient Settings: A Systematic Review

Takeaway: The Age-Friendly Health System (AFHS) initiative aims to improve care and outcomes for older adults through a “4Ms” framework (What Matters, Medications, Mentation, Mobility). This ESP review of studies (not specific to the Veteran population) found that barriers to AFHS implementation included challenges with data collection and documentation; and difficulty changing culture, engaging team members, and establishing new processes. Facilitators of AFHS implementation included buy-in; administrative support or existing infrastructure; 4Ms knowledge; and partnerships/community support. There is insufficient evidence to assess the effects of specific AFHS implementation strategies, and there is minimal evidence of the influence of AFHS strategies on outcome measures. However, using a combination of strategies to implement or increase the uptake of AFHS appears to improve some 4Ms process measures.

The Veteran population is rapidly aging and almost half of all Veterans are aged 65 or older. The Age-Friendly Health System (AFHS) initiative was launched to improve care and outcomes for older adults through a “4Ms” framework (What Matters, Medications, Mentation, Mobility) that aligns care with what matters to the patient, emphasizes age-appropriate medications, addresses dementia and psychological health, and promotes safe movement to maintain function.

In response to a request from the Office of Geriatrics and Extended Care, HSR’s Evidence Synthesis Program (ESP) Center in Providence, RI, reviewed the evidence on the barriers and facilitators to AFHS implementation in outpatient settings and the effect of implementation strategies on process, outcome, and structural measures of AFHS. ESP investigators searched MEDLINE, EMBASE, CINAHL, Cochrane, and ClinicalTrials.gov from 2015 to March 28, 2024, and identified a total of 10 eligible studies (not specific to the Veteran population) that employed 67 strategies to implement AFHS. Eligible studies reported on AFHS implementation and assessed or acted on all 4Ms.

Summary of Findings

Only one study formally assessed barriers and facilitators affecting AFHS implementation. Also, there were limited data on patient demographics.

Barriers and facilitators affecting AFHS implementation:

• Barriers to AFHS implementation included challenges with data collection and documentation; difficulty changing culture, engaging team members, or establishing new processes; lack of buy-in or knowledge of the 4Ms; patient preferences; scheduling/time constraints; and technology barriers.
• Facilitators of AFHS implementation included buy-in; administrative support or existing infrastructure; 4Ms knowledge; and partnerships/community support.

Effect of strategies to increase the uptake of 4Ms in sites with existing AFHS programming:

• Using a combination of strategies to increase AFHS uptake might improve some 4M process measures.
• No study reported results for outcome or structural measures, or results based on patient- or system-level factors.

Effect of AFHS implementation in sites without existing AFHS programming:

• A combination of implementation strategies might improve 4M process measures over time after AFHS implementation.
• No comparative study examined outcome or structural measures, or results based on patient-level factors. Only one study reported results by system-level factors.

Implications

Existing evidence on AFHS implementation strategies in outpatient settings is mostly insufficient to assess the effects of these strategies on implementation outcomes. However, using a combination of strategies to implement or increase the uptake of AFHS appears to improve some 4Ms process measures.

Limitations

The complexity of the interventions prevented the ESP team from quantitatively synthesizing findings or determining the effect of specific strategies on prioritized process and outcome measures. The review excluded some studies that described strategies to implement AFHS but reported only educational outcomes. In addition, the ESP investigators did not extract data on the pre-implementation processes that informed the specific implementation strategies.

Future Research

There is a need to standardize reporting of AFHS implementation strategies and to examine the effect of specific AFHS strategies on process and outcome measures.

Citation:

Howe R, Rieke K, Mai HJ, et al. Implementation of Age-Friendly Health Systems in Outpatient Settings: A Systematic Review. Washington, DC: Evidence Synthesis Program, Health Systems Research, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #22-116; 2025.

To view the full report, go to vaww.hsrd.research.va.gov/publications/esp/age-friendly-healthsys.cfm . (This report is available via intranet only.)

How can VA leadership work with the ESP? Nominations for systematic review topics may be submitted to the program at any time. When you submit a topic nomination form, ESP Coordinating Center staff will work with you to determine the appropriate research approach and ESP product to address your questions of interest. Topics are selected and assigned to an ESP Center based on program capacity and alignment with VA national goals.

This Management Brief is provided to inform you about recent HSR findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR Resource Center charged with disseminating important HSR findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of VA/HSR's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers; and to disseminate these reports throughout VA.

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