Neha Pathak, MD, FACP, DipABLM: Welcome to the WebMD Health Discovered Podcast. I'm Dr. Neha Pathak, WebMD's Chief Physician Editor for Health and Lifestyle Medicine.
Today is part one of a six-episode podcast miniseries we're launching over the next year to highlight the needs of an aging population and the evidence-based models that can dramatically accelerate care improvement for older adults—which benefits all of us. Improving care for older adults to better meet their needs and maintain their independence and dignity has a positive impact on individuals, families, communities, and society as a whole, as we all benefit from the continuing contribution of older adults and from overall reductions in healthcare spending.
This week, we'll discuss the documentary Aging in America: Survive or Thrive, created by The John A. Hartford Foundation and watchable on PBS. The documentary explores the many ways our healthcare system can better serve older adults, particularly because in its current form, our healthcare system was built for 25-year-olds with broken bones, not older adults with multiple healthcare needs.
We'll unpack the science and the stakes behind the 4M Framework that's transforming healthcare across the country. We'll tackle the confusion and questions that families whisper about in waiting rooms: Who actually pays when long-term rehab tops over a hundred thousand dollars a year? How do income, zip code, and race still dictate whether an older adult thrives or declines? Why is ageism the last acceptable “ism” in healthcare?
You'll hear practical strategies so you can insist on evidence-based, dignity-driven treatment the next time an older loved one—or you—walks through the hospital door.
In today’s episode, we’re taking you inside America’s age care paradox, where life-saving technology can add years to our calendar, but outdated care models can steal quality from those years.
First, let me introduce my guest, Dr. Terry Fulmer. Terry Fulmer, a nurse scientist, is the president of The John A. Hartford Foundation in New York City, a foundation dedicated to improving the care of older adults.
Dr. Fulmer serves as the chief strategist for the foundation, and her vision for better care of older adults is catalyzing the Age-Friendly Health Systems social movement. She’s an elected member of the National Academy of Medicine and an inductee as a Living Legend in the American Academy of Nursing.
Welcome to the WebMD Health Discovered Podcast, Dr. Fulmer.

Terry Fulmer, PhD, RN, FAAN: Thank you so much. I'm delighted to be here.

Pathak: Well, we are very excited to have you and to have this conversation. But before we jump in, I’d love to ask about your own personal health discovery—particularly around the work you do to improve the care for older adults.

Fulmer: Sure. When I began my practice in Boston at the Beth Israel Hospital many years ago, what I saw was the fact that we really were making great inroads in treating critical conditions. We might have done a cardiac resuscitation, for example, and people survived that.
And we might give them chemo, but there were so many older adults who suffered because of the care. They had pressure ulcers. They became incontinent. They had episodes of delirium. And in that moment, I knew what my practice was gonna be. I saw that that was the work.
That was absolutely essential to the wellbeing and the healing of these older people, and I never looked back.

Pathak: Wow, that's beautiful.
To start off, Dr. Robert Butler’s book, Why Survive, is really highlighted throughout the film that we’re gonna be talking about today, and it really exposes viewers to the disparity in care for older adults—because we’re really seeing that the U.S. healthcare system is designed, as you said, really for acute care needs, particularly for the young, rather than really the complex chronic disease needs of older adults.
In 1982, Dr. Butler founded the first department of geriatrics in a U.S. medical school. So can you help us take a step back and explain to us what was Dr. Butler’s vision for geriatrics?

Fulmer: Sure.
So Bob Butler—I had the great privilege of knowing him—he was a visionary. He knew that in order to improve care for older adults, we really needed to change policies, change funding streams, and change education. And he did that.
His Pulitzer Prize–winning book, Why Survive? Growing Old in America, was inspirational to all of us because he just said: What is the state of care for older adults?
One chapter that stands out to me is he talked about “houses of death,” and he was talking about nursing homes. He talked about delirium. He talked about the sequelae of sarcopenia—which your audience will know is muscle wasting—and he was telling us that if you don’t get it right, people will lose all their function.
His vision was to make sure that the field was using a comprehensive, humanistic, and transformative approach to geriatric care. And he knew that geriatric medicine should be recognized as a distinct specialty, and he believed that good geriatric care required good science.
So the National Institute on Aging—which he founded and was the founding director—was brought forth to make sure that we had the science for: Why do older people get dementia? And you know how much we've advanced in our knowledge and care of dementia.
Why are older people incontinent? There's a science to it. It's not just that you're getting older and it happens to everybody—no. That’s not true. And there are treatments, for example.
So he really saw geriatric care as inherently interdisciplinary as well. He knew that you needed a team-based approach. And if ever there’s a team-based approach, it’s geriatrics.

Pathak: In the film, you profile hospitals adopting the 4M Framework: What Matters, Medication, Mentation, and Mobility.
Can you talk a little bit about the measurable outcomes that have improved most dramatically, and what do you feel still needs the most work?

Fulmer: Sure. You’re asking me a question about the topic I love the most, so thanks for doing that.
And that is—you know, we at the foundation, in partnership with the Institute for Healthcare Improvement in Boston, and the American Hospital Association, and the Catholic Health Association—have doubled down on creating a system of age-friendly care, which is based on the four pillars you just mentioned.
The four concepts of: What matters to the older person—knowing their goals and preferences. Making sure we understand what their medications are—are they under-medicated, over-medicated? What can we de-prescribe? What’s interacting? Really important.
Mobility—we have spent decades worrying about falls prevention, when in fact we should be thinking about mobility promotion. Making sure that everybody who gets hospitalized, or is in any case at rest because of therapy, gets up and moves so that they can maintain their function.
It is such a quick nosedive when an older person is not mobilized.
And then finally, their mentation—their mind, their whole mood and memory—thinking about that, and not just saying “older people get confused.”
Confusion is about as useless a word as arrhythmia. If I said to you, “I have an arrhythmia,” your first question is gonna be—

Pathak: What kind?

Fulmer: Exactly. What arrhythmia?
So if you tell me “confusion,” I’m gonna say, “What kind of confusion?” Is it acute? Is it chronic? Is it acute delirium superimposed on dementia? We know the science of this, and so we have to get this right.
So our foundation has really spent—since the 1980s—dedicated to making sure that we funded the workforce development and then models of care.
And in thinking about models of care, we know that there are some very effective models. For example, you might have been in an institution that had an ACE unit—that means Acute Care for the Elderly. Maybe they had a NICHE program—Nurses Improving Care for Health System Elders. Those are funded by The John A. Hartford Foundation.
I’m very proud of that. I wasn’t the head of the foundation at that time. They were absolutely visionary in thinking about what needed to happen.
So when we started thinking about that, we said, “Wait a minute. We have the evidence. We have the science. It’s been funded by NIA. We’ve published the papers. Why aren’t people doing it?”
And we know that there’s a great lag between science and implementation. So we went to implementation science groups—IHI—and said, “You know, can you help us?”
And so, in meetings with them, we got together experts and wanted to really help overcome that know-do gap.
And at first, we identified 90 care features in all the models that we took a look at, and then realized that we needed to distill from those 90 care features in the models—got to 13—and finally, in a room of experts, we got it down to the four essential 4Ms.
And that’s how we have come to that. It wasn’t that we decided those were good ideas—it was all science-based.
So you mentioned the What Matters—your goals and preferences, Medication, Mentation, and Mobility.
And this set has evidence. So let me give you some examples, if I may.

In the first year of the program with hip fractures using the 4Ms, Cedars-Sinai in Los Angeles saw an 11% reduction in hospital length of stay and $300,000 in direct savings.
Now you’ve got CEOs paying attention when you can improve care and reduce costs.
The Providence system in the Northwest—provider champions were trained in 12 primary care clinics for the 4Ms, and they saw a 7% decrease in hospitalizations, and the rate of screening for fall risk rocketed and really got people thinking about mobility.
There’s a small critical access hospital in Louisiana—there are many in this country—but the one we’re thinking about used the 4Ms, which resulted in a 62% decrease in hospital readmissions.
Imagine the power of that.

So there’s still a lot of work to do. Adverse events are still too high in hospitals and other settings.
But we have a new quality measure introduced by the Centers for Medicare & Medicaid called the Age-Friendly Hospital Measure, implemented this year, and it’s driving a lot of interest from hospitals in making sure they’re delivering age-friendly care.

Pathak: Your film also highlights differences in how older adults experience healthcare based on certain things that we already know promote disparities in healthcare outcomes.
So that’s income, race, geography. What have you found in terms of interventions that have proven the most effective in narrowing those types of disparities? And what is the work of the foundation to scale these types of interventions nationally?

Fulmer: I'm glad you asked that. Thank you. Because all of our initiatives have a focus on ensuring that every older adult and family caregiver gets the care they need with good outcomes. And so the age-friendly health system initiative, built in a quality framework, means that the initiative asks that all participants track their data and stratify that data by demographic characteristics to make sure that disparities based on race and other factors are detected and addressed.

Nobody wants to give disparate care. Nobody does. But we see it and we understand that we need to do a better job. So the 4Ms can be a real antidote to those disparities, and they're evidence-based: focus on what matters, using them reliably, making sure that every patient, every time, has a 4Ms request.

And you know, it's so interesting to me because our work—of course, we're focused in the United States—however, this work has gone global, and we are working in the Middle East, in Europe, in Australia, certainly with our colleagues in Asia. Why is that? It's because everything we do—it doesn't matter how you pay for it, it doesn't matter what language you speak, what religion you have—people need to be functionally intact. And so that means every individual. And the only way you can know that is to measure it.

Pathak: You're exactly right.
So what are some of the creative ways that workforce issues—in this time, particularly when we are seeing so many nurses leaving the field, so many physicians exiting the field—what is being done to address that? And what has the Geriatric Workforce Enhancement Program done to help?

Fulmer: So I want to unpack what you just talked about. Let's go back to Bob Butler. He wanted a geriatric workforce, and he wanted to ensure that every medical school had a department of geriatric medicine. That didn't happen. He wanted to increase the number of geriatricians, which has been flat at about 6,000 for the past several decades. So if it's flat, then obviously we need new creative strategies, which is our age-friendly health system approach.

It doesn't matter what discipline you are, it doesn't matter what specialty you are—everybody needs to address the 4Ms. And therefore, de facto, you are pulling in the geriatric science into your practice, and we feel really good about that. We're in over 5,000 locations of care in this country. We're in like 14 additional countries. My colleague Ronnie Snyder just got back from the IHI forum in Europe, and it's just absolutely moving so quickly because people go, "Oh, that just makes a lot of sense."

And so I think that we do have the Geriatric Workforce Enhancement Program. There are over 40 of those GWEPs, as we call them, in the United States. As a part of that program, you have to demonstrate how you are affecting 4Ms care in your work. So there it is. And not only is it about physicians and nurses, it's about nursing assistants, it's about community health workers. That's how we're going to get a common language across care settings.

Suppose I'm taking report from a nurse in a nursing home, and I'm in a unit at my hospital. If we're both talking about the 4Ms, things are going to go a lot more smoothly, and there's going to be a leveling of respect across settings. I don't have to tell you that nursing home care is considered second-class care—second-class nursing, second-class medicine. Can't we do better? By leveling this and making sure that everybody gets great care with respect. So what we're doing is we're making sure that everybody gets age-friendly care.

We do want every medical school and every nursing school to have geriatrics, but you can't just sit back and wait. You have to act now. And that's what we're doing, and we're really, really proud.

Pathak: I want to kind of pull on that thread because we have been talking mostly around hospital care, but as you mentioned, we also need to be thinking, particularly for patients as they get older, that there may be a need for long-term rehabilitation care, nursing home care. So what are some of the steps that people can take to prepare for that potential need? And I'm really thinking with regard to finances, because the additional cost can be cost-prohibitive for some.

Fulmer: Absolutely. There are very few people who have an extra $100,000 a year to spend on long-term care, which is about the cost of that care. So we, this week, released a paper in the Harvard Business Review talking about how employers can really help everybody think about what they need to prepare for when it comes to providing care for their older family members.

For the first time in history, we have more people taking time off to care for their older family members than children and babies. That's a big paradigm shift. And companies are really making sure they understand that. That paper, where I was a co-author, was led by Ken Dychtwald at Age Wave. They reported that 92% of the respondents said they wish they had more support from employers that are helping them. So that tells you there’s really a dramatic need, and caregivers want a trusted source and reliable, affordable, professional help.

We know that there are some groups doing that—Bank of America, Microsoft are really working on it. So let's all learn from that. And by the way, our major health systems need to do it too. So does Mass General have a program? Does Mount Sinai? Does Cedars-Sinai? Does Ascension? We all have to have hands on deck there.

So the cost is prohibitive. If I ask the average American, "Who pays for your nursing home care?"—it's almost a trick question because everybody thinks that Medicare pays for long-term care. It does not. Medicaid pays for 50% of nursing home beds, and it is the number one payer. Now, Medicare will pay for your post-hospitalization for a finite number of days, but after that, Americans are shocked to learn that they are on their own with payment—or to figure out who they're going to get.

How do we anticipate this for people and say, plan now, because there will come a time when you may need this?

So my heart goes out to people, and we need to do a much better job. We have really helped work with primary care and helping people understand dementia care, which is a big subset of long-term care. And then we're working on a teaching nursing home collaborative in Pennsylvania to see if we can do a test of change and see if each nursing home partnered with a nursing school can have better outcomes—better recruitment. Because it's really hard to recruit to nursing homes and to get the staff that you need. But that's not unusual because the pay is different. The whole pay scale is different between the two.

So I think that we have to really be thinking about parity, equity, respect, and what we're going to do. Increasingly, we know that there are special programs now for Alzheimer’s care and dementia care. UCLA has one of the leading programs on that. Rush is doing a special program on caring for caregivers. So I'm excited about what's going on. I know Bob would love it, and I'm sure that somehow, he sparked all of these ideas for all of us.

Pathak: Can you talk to us a little bit about what we can do to support family caregivers who have—similar to my family—become the backbone of care for older adults in the U.S.?

Fulmer: Yeah, so there are so many things we need to do, and I mentioned briefly—let me expand. Rush University Medical Center operates a program called Caring for Caregivers, and that material is available internationally. Anybody can access it, and it really helps with assessing family caregivers’ needs based on the 4Ms and helps build skills, support, planning, and most importantly, incorporates the caregivers into the team.

What they learned—their evidence—is that there's a reduction in symptoms of anxiety for the caregiver. There's a reduction in symptoms of depression, which is very prevalent in caregivers. A reduction in levels of caregiver stress.

You know, as a nurse, I often say we send them home with tubes, drips, and drains and say, "Good luck with that." It's terrifying. Or we send them home and say, "He has survived this episode of X, and now be careful and do these 12 things." Well, you get home and you say, "I don't remember what they said. Who am I going to talk to? How am I going to get help?"

Many people turn to the internet—and you know, if they turn to WebMD, we're really glad—but if they turn to some of the other content, they might not get the best support. So going to those trusted sources—the Caring for Caregivers work—is really, really important and helpful, so we recommend that.

But cultural sensitivity—I think we have a ways to go there. I really do. I think that more and more we're seeing people use interpretive services. So if you speak a different language, you might use Google Interpreter to change it, and you might get some, let's say, interpretations that are wrong. And so making sure that you're being as culturally sensitive as possible and getting that work done.

I think that more and more we're seeing telehealth and voice activation help every caregiver. Technology appears to be a real promise. Now, people also talk about the problems that come from it. Sometimes people think if you use technology, the clinician is going to abandon you. I'm positive they won’t. But I do think it’s a great complement to what we’re trying to achieve, and we really believe that tech innovation can reduce caregiver burden and improve outcomes.

So the Peterson Center on Healthcare here in New York City—and its Peterson Health Technology Institute—does this. They provide rigorous, evidence-based assessment and innovation for digital health technology. So there are trusted sources for family caregivers like you, and that’s so important.

Finally, what I’d say is I worry about social isolation for older adults who are home. And I worry about social isolation for caregivers. You can end up at home afraid to go out because you're afraid that you’ll do something that could hurt the older person or harm them. You could end up being incredibly socially isolated. So staying on top of that and asking for help—you and I don’t think of asking our primary care physician for help for social isolation, and we need to do that.

Pathak: So you mentioned the Peterson Health Technology Institute. Are there other sources that the foundation relies on to determine when a tech innovation is going to be really helpful in reducing caregiver burden, being helpful for patient outcomes for the older adult? How do you sort of navigate all of these new innovations?

Fulmer: Well, we always watch for the scientific evidence. Like everybody else, we’re scanning the literature constantly. We rely on AARP. They do an amazing job really helping us show the most effective interventions, and they really have done a great job helping us distill. And you know, that newspaper that goes out to people who are 55 and older—maybe 50 and older—gets to like 9 million people, and it’s a trusted source.

Finally, really talking to the social work team that’s available to you, your community health workers who know so much—we ask people to really also use their own self-empowerment. When you go into a clinical encounter, say, “Do you provide age-friendly care?” Because we need age-friendly care, and we demand age-friendly care.

So we have something called My Health Checklist, which is a terrific way to start that conversation and say, “Here’s my health checklist. Can we review this together?”

You have the power and the authority in the clinical encounter to say, “Before we get talking about my next MRI, I want to talk about these things.” And so I think that the documentary about Robert Butler makes a powerful case for addressing ageism in America and urges us to reshape how Americans view aging.

Over the past 20 years, we’ve seen some concrete shifts in legislation and philanthropic funding—but not enough. Our foundation is the largest foundation in the United States dedicated solely to older adults, and we welcome other foundations to outspend us. That would be great. We’d love that.

So we should all rail against ageism. We need to make sure that if somebody says, “Well, you’re old. That’s why”—that’s not the answer. You and I know that.

Pathak: You know, I think that that is really a critical point because I do think that often when you are brought into the health system—or you end up in the health system as an older adult—people look at the age on the chart and they look at the state that you're in when you come in, because clearly there is something that has made you sick. And that is not necessarily who you are. That's just you in this particular moment. And I think that that first snapshot, unfortunately, in some ways gives your care team or the folks that are seeing you this concept or the story of who you are—what your baseline is—and that is a piece of that ageism.
So I'd love if you could talk a little bit more about that.

Fulmer: It was Bob Butler who coined the term ageism. And ageism is the last acceptable ism in our country at the moment.
I often will take a look at a chart, and then set it aside, Gwen, and see the person—then come back and read. Because to your point, you know, you'll see somebody who looks like they should barely be breathing and they, Gwen, they say, "Hi, you know, I'm really looking forward to my golf game next week."
So I think that we all need to use the sources that help us with this pernicious problem. And the University of Michigan Healthy Aging poll a couple years ago showed that 93% of older adults in this national sample said they experienced everyday ageism. They showed worse health outcomes for individuals who internalized ageism.
If everybody tells you you're old and you start acting as if you know you are less worthy of this universe, well... your health will not keep up.
And finally, we've been trying to counter this with our Reframing Ageism initiative, which helps us talk about that. That's available at the Gerontological Society of America. Reframing Aging is also through the Frameworks Institute in Washington, DC, and we just love the work that they've done in helping us call it out. Call it out when you hear it, when you see it, and say, "That's ageist."
Here's an example: Why do board members have to step down at age 70 in so many corporations?
And if you are hiring, how are you gonna feel if a resume comes across your desk and somebody on it is 68 years old? You're gonna set it aside. And I'm asking people not to do that. Don't be so lazy. Learn the person.

Pathak: I know I do want to pull on one of the M's that we haven't necessarily gotten into so much, which is really about the mentation piece—particularly if there is cognitive decline, memory impairment, or dementia that's underlying. So even in the film where we meet family members that are providing around-the-clock care for elders that have memory issues or dementia—can you just help us understand a little bit more about some of the best practices for dementia care, end-of-life care, and some of the models that you've found to be most effective?

Fulmer: So the whole area of mentation is very large and very complicated, which I know you recognize. And if we were diving into that, you'd say, well, one of the things we need to make sure everybody knows is that dementia is not a part of normal aging. That when people's cognition changes, and if there's a delirium event, we should treat it as emergently as if a person had an arrhythmia, by the way.
And so it's that critical that we assess, understand, make the correct diagnosis, and then get the right care plan going in concert with the goals and preferences of that older person and family.
And don't think of cognition simply as delirium, dementia, and depression. Think about whether or not someone is lonely and how that's affecting them, and whether or not they are suffering from ageism—and that's affecting their cognition and their wellbeing.
So I think that we're seeing a lot of progress. There is a model called the GUIDE Model, which we have helped support over time and is now a part of the way in which the government is funding care, which is a 10-year opportunity to study which programs for dementia are the most successful.
But I'm very worried about delirium, because it is transient, it's easy to miss, and it can lead to a number of very detrimental outcomes—like falls, like depression, like medication problems.
For example, if you have a delirium or if you have a dementia, are you taking your medications properly? Are you thinking carefully when you go out and go for a walk about your safety and what potentially could happen?
The four M's is a set, and that's because each interacts with the other. If you are having changes in your mentation, you're likely to begin to have problems with your medication, with your mobility, and with your mentation as well. So the whole set, and thinking about them collectively, is really important.

Pathak: That is really helpful. This has been such a powerful conversation. I would love to close this episode and my time with you by asking you to speak to our audience. You've given us some examples already of how we can guide this conversation with healthcare professionals if we're not getting what we want. But can you give us a little bit more information so that someone can talk about these things in the next visit with their healthcare team?

Fulmer: Sure. So, first of all, our website at The John A. Hartford Foundation is very rich with materials and content that can help. And so is the Institute for Healthcare Improvement and the American Hospital Association. If you Google any of those and look for "age-friendly," the resources are really abundant and evidence-based and powerful. So I'd ask the audience to do that.
The other thing is a little different, and here's what I'd say: Take pride in the care you give to older adults. Name it. Call it out. Show people that, yes, by the way, you just made sure that someone's vascular system was maintained and intact, and that you reversed diabetes because you did a great job on that.
But take pride in the fact that you also made sure that that older individual did not have relapses in their function under your care. Name it. Say it. Be proud of it.
And you know what? The younger clinicians around you will emulate your behavior. We need role models who are showing that they are proud of the geriatric care that they're providing.
And I hope everybody leaves with that thought.

Pathak: Beautifully said. Thank you so much.

Fulmer: My pleasure.

Pathak: My key takeaways from this discussion are: Keep the Four M's top of mind in every encounter and in every setting within the healthcare system. Great care for older adults revolves around what matters, medications, mentation, and mobility.
Whether you're a clinician or a family member, make these four pillars the agenda for hospital rounds, primary care visits, rehab check-ins, and even home health conversations. It's really important to think proactively, not just reactively. That can be something as simple as mobility promotion—not just falls prevention.
We also learned that Medicare is not a long-term care solution. Medicare covers only short rehab stays. Ongoing nursing home care or in-home support is largely out of pocket or Medicaid-based.
That's why we talked about why it's so important to have difficult conversations with our family and loved ones early. Families, loved ones, and employers should begin financial and caregiving planning well before a crisis hits.
To find out more information about The John A. Hartford Foundation, make sure to check out our show notes.

Thank you so much for listening. Please take a moment to follow, rate, and review this podcast on your favorite listening platform.
If you'd like to send me an email about topics you are interested in or questions for future guests, please send me a note at [email protected].

This is Dr. Neha Pathak for the WebMD Health Discovered podcast.