AAA/D-SNP Care Coordination and Integration Using the Age Friendly Health Systems’ 4Ms Framework

July 31, 2023

The 4Ms include What Matters, Medications, Mentation, and Mobility, and aim to make care of older adults more manageable by identifying the core issues that should drive all decision making in their care. It is a clear, simple framework that advances healthy aging. Over the past few years, the state of Indiana's Family and Social Services Administration (FSSA) developed a vision for their state of improved care coordination for high-risk individuals, integrating Area Agencies on Aging (AAAs) coordination with Medicare Advantage (MA) Dual Eligible Special Needs Plans (D-SNPs), using the 4Ms Framework. 

Indiana leveraged the principles of the 4Ms Framework into efforts the state was implementing to advance Age-Friendly programs to achieve an overarching goal to improve care integration for older adults and individuals living with disabilities. Beginning in 2021, the state of Indiana began an initiative to require D-SNPs to coordinate care with AAAs for the dually eligible individuals both entities serve, integrating health and social services for the whole person and focusing on what is important to them. The 4Ms Framework has enabled Indiana to move forward with successful approaches to advance Age-Friendly principles for dually eligible individuals. This model may be replicated in additional states to improve care coordination across the country and continue to improve care for older adults and high-risk populations. 

Looking forward, to continue promoting the 4Ms Framework for integrating care coordination services across Medicare and Medicaid, the following considerations are at the forefront:

  • Assess each state for their unique situation and policy landscape. 
  • Understand, across the country, levels of business acumen of AAAs as well as progression toward Medicaid managed long-term services and supports (MLTSS) and Medicare-Medicaid integration models. 
  • Find champions to bring the 4Ms Framework into the states’ vision for care coordination and healthy aging program policies and structures. 
  • Leverage the 4Ms Framework for trainings and build buy-in on the implementation of the 4Ms Framework. 
  • Investigate opportunities for how the 4Ms Framework could be evaluated and documented. 
  • Consider ways to further frame the 4Ms Framework approach as the integration of clinical and social care. 

This report outlines research conducted by Altarum and Altarum Medicare-Medicaid Services for States (AMMS) regarding the efforts that Indiana FSSA has undertaken and similar work that is occurring in other states, such as Ohio. The findings from interviews with key leaders lay out specific aspects of successful approaches to this integration and potential for replication and scalability in other states. The recommendations for future efforts will inform strategies to broaden the potential impact of the 4Ms Framework to improve care of older adults across the country. 


Helen Dawson
Project Manager
Sarah Barth
Executive Director, Medicare-Medicaid Services for States