What We Tried

St. Vincent is part of Ascension, which is one of the first five hospitals and health systems to join the Creating Age-Friendly Health Systems initiative, using the 4M model to guide older adult care:

• What Matters – Know and align care with each older adult’s specific health outcome goals and care preferences including, but not limited to end-of-life, and across settings of care.
• Medication – If medications are necessary, use Age-Friendly medications that do not interfere with What Matters to the older adult, Mobility, or Mentation across settings of care.
• Mentation – Prevent, identify, treat, and manage dementia, depression, and delirium across care settings of care.
• Mobility – Ensure that older adults move safely every day in order to maintain function and do What Matters.

Across Ascension, the age-friendly work began by identifying and encouraging areas of the health system that are already working to improve care for older adults — including St. Vincent — to expand and share elder care initiatives with other Ascension entities. St. Vincent is currently rolling out the “4Ms” in two main ways in the ambulatory setting:

Geriatric consultations: Clinicians at St. Vincent’s Center for Healthy Aging (the Center), which is an outpatient geriatric specialty clinic, have been addressing the 4Ms as part of standard care for decades. Using the 4M framework within the Center’s geriatric consultation process provides structure and the opportunity to document the care plan as addressed by the 4Ms.

Geriatric consultations generally consist of two elements:

• A comprehensive physical exam and review of medical, psycho-social and functional history
• A patient/family conference with the geriatrician, registered nurse case manager or licensed clinical social worker to discuss findings, provide education and align recommendations to what matters to the patient

Geriatricians developed a simple template in the Center’s electronic health record (EHR) to guide their assessment. The template has a section for each of the 4Ms along with a few suggested prompts to consider while evaluating the patient. The case manager uses the same template to talk with the patient about the physician’s recommendations, essentially creating a care plan.

The traditional exam approach had been more problem focused and involved assessing the various biological systems (e.g., gastrointestinal, neurological). In comparison, the 4M template is centered around the goals (i.e., the patient’s own priorities, mentation, mobility, medication management), with the physicians and case managers determining what medical, functional and psychosocial problems may be interfering with the patient’s ability to achieve these goals.

Information is also collected from patient and families/caregivers before the geriatric consultations, which is particularly helpful in preparing for visits with patients who have dementia and related conditions. A form is mailed to the patient’s home, which asks what matters to the patient as well as specific questions related to the other 3Ms. For example, the form asks whether a lack of mobility is interfering with the patient’s goals.

Medicare wellness exams: The Center only sees a small percentage of the older adults served by the St. Vincent system. To impact more patients, the health system is structuring annual Medicare wellness exams — which Medicare covers and encourages beneficiaries to get — around the 4Ms. The St. Vincent nursing group that is dedicated to conducting these exams enthusiastically agreed to pilot a 4M approach.

A multidisciplinary team, which included nurses, geriatricians, quality improvement staff and others, redesigned the EHR documentation template for Medicare wellness exams around the 4Ms. With this approach, a longitudinal plan of care for older patients based on the 4Ms, can be continually addressed and updated when patients return each year.