Using the 4M framework of the Age-Friendly Health System to improve MIPS documentation in primary care clinics: A quality improvement study.

Age-Friendly Health Systems (AFHS) commit to providing evidence-based, low-risk, coordinated care centered on what matters most to older adults, their families, and caregivers. Nova Southeastern University's South Florida Geriatric Workforce Enhancement Program (NSU SFGWEP) has partnered with primary care clinics to provide AFHS training and support to promote AFHS transformation in Broward and Miami-Dade Counties. NSU SFGWEP provides face-to-face and virtual training for AFHS and Electronic Health Record (EHR) documentation as part of the initiative. This project focuses on a group of primary care clinics in Broward County, Florida. In this paper, we evaluate the progress of AFHS transformation through six e-clinical measures that collectively provide indicators of the 4 M framework of AFHS (What Matters, Medication, Mentation, and Mobility). We used provider feedback and e-clinical measures aligned with the Center for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS) to measure clinic outcomes. From Jan 1- Dec 31, 2019, to Jan 1-Dec 31, 2020, the clinics improved high-risk medication management (0-3.71%), advanced care planning (6.79%-20.74%), and fall risk assessment (no data- 46.72%). Results demonstrate some success and ongoing opportunities to continue and expand AFHS interventions for sustainability.