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Deploying the 4Ms to Improve Outcomes and Health Experiences for Older Adults

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Anne Arundel is rolling out inexpensive improvements that are positively impacting older patients.

The Issue

More than 45 percent of patients admitted to Anne Arundel Medical Center (AAMC) are ages 65 and over, and we expect that percentage to increase as Baby Boomers age. We’re located in Annapolis, MD, near Chesapeake Bay, which attracts a lot of retirees. While AAMC has taken a number of steps to improve outcomes for older patients, including opening a geriatric inpatient unit, we believe more needs to be done. Too many older Americans suffer from falls, inappropriate medication use, delirium and other avoidable harms.

What We Tried

AAMC volunteered to be one of five pilot organizations in the Creating Age-Friendly Health Systems initiative focusing on the 4Ms:

  • Identify and pursue what matters to patients.
  • Determine any unnecessary or potentially harmful medications.
  • Ensure mentation by ensuring proper hydration and nutrition and managing dementia, delirium and depression.
  • Maintain mobility by encouraging patients to be active.

We began by educating the nurses and other staff on AAMC’s geriatric inpatient unit about the initiative. Staff enthusiastically embraced the concepts and identified a number of ways to roll out the 4Ms, including the following:

Integrating 4Ms into shift reports. Nurses and patient care technicians are using the 4Ms to help guide patient handoffs between shifts. This was a simple adjustment to the nursing reports since the 4Ms reflect the traditional head-to-toe assessments nurses conduct.

Incorporating “what matters” into the EHR and whiteboards. We added a section to our electronic health record (EHR) that reminds staff to learn and document what matters to the patient. We also replaced the small whiteboards in patient rooms with larger ones that older patients can read more easily. Front and center on the boards is a section to document “what matters” to the patient.

Team rounding is also helping to drive this mindset. During team meetings, physicians, nurses and care managers discuss how to prioritize each patient’s preferences and needs. For instance, what mattered to one patient was having her dog with her. Since her dog was well-behaved and small, we were able to grant her request and believe she recovered faster than she would have without her pet.

Daily exercise sessions. Now patients are brought together for a 40-minute group session that is part physical therapy (PT), part social gathering. The sessions end with a challenge: “Walk back to your room.” The first day a patient may only walk 10 feet, but most can walk to their room by the third day.

Our patients progress faster in group PT than individual therapy, and family members love the approach. Our patient care technicians also help ensure patients maintain mobility. Physical therapists place orders specifying how many feet a patient needs to walk that day, and the technician is responsible for helping the patient meet that goal.

Impact

The pilot on our geriatric inpatient unit began in Summer 2017. By late 2017, we had documented significant improvements, including the following:

Length of stay (LOS). By paying more attention to what matters to patients and ensuring care was coordinated, we were able to reduce average LOS on the pilot unit by 26 hours.

Patient satisfaction. On the pilot unit, patient satisfaction has increased since the pilot began.

By the end of 2018, we intend to spread the 4Ms to a total of nine inpatient units and the ED at AAMC as well as 25 private assisted living facilities.

Tips

You don’t have to spend a lot of time thinking about how to improve care for older adults. Seek ideas from staff on how to roll out the 4Ms, and wonderful things can happen.

The Creating Age-Friendly Health Systems initiative is sponsored by the John A. Hartford Foundation, the American Hospital Association, and the Institute for Healthcare Improvement.

Lillian Banchero

Profession: Nurse

Organization Background

Anne Arundel Medical Center

Organization Name: Anne Arundel Medical Center

Location: 2001 Medical Pkwy, Annapolis, MD 21401

Organization Type: Hospital

Organization Model:

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