SHM Converge Scientific Abstract ePoster Gallery-4m's Assessment Defining "What Matters Most" to Our Veterans

Pdf Summary

This case report describes how a geriatric 4Ms assessment helped guide discharge planning for a 75-year-old Veteran hospitalized with severe congestive heart failure, shortness of breath, edema, and wounds. Because hospitalization involved multiple care team handoffs and a prolonged course, the team used the 4Ms framework—Mobility, Medications, Mentation, and What Matters Most—to keep care patient-centered.<br /><br />Early in the admission, clinicians were concerned about the patient’s cognition and ability to function safely at home. Physical and occupational therapy evaluated him and initially recommended short-stay rehab (SSR). However, a 4Ms assessment on hospital day two clarified that the patient’s top priorities were to be at home and remain independent. He also stated he did not want SSR at discharge.<br /><br />His hospitalization lasted six weeks due to ongoing diuresis and cardiogenic shock, requiring a transfer to the medical ICU. A mitral clip procedure was performed during the second week, which improved his cardiac status and cognitive function, allowing him to participate more actively in decisions about his care. PT/OT reassessed him four times during the hospitalization, repeatedly recommending SSR at first. Over time, the patient continued working on mobility and consistently expressed his desire to return home with support. Eventually, PT/OT recommended discharge home with additional services once medically stable.<br /><br />The key message is that early and routine 4Ms assessments can help ensure hospitalized older adults’ voices are heard, support shared decision-making, and align discharge plans with “what matters most” to the patient.

Asset Subtitle

Desiree Haggart

Meta Tag

Author List Daniel Fang, Desiree Haggart, Marie Adachi, Sowmya Iyer

Category Clinical Vignettes

Concept CMS 4Ms Age-Friendly Care Framework

Concept 4Ms

Concept Age-friendly care

Concept Patient-Centered Care

Concept Discharge Planning

Distinguished Non-Finalist

Presenter Organization Medical Service, VA Palo Alto Health Care System

Presenting Author Desiree Haggart

Track Adult

Keywords

4Ms assessment

geriatric care

discharge planning

congestive heart failure

Veteran patient

mobility

medications

mentation

what matters most

shared decision-making

CMS 4Ms Age-Friendly Care Framework

4Ms

Age-friendly care

Patient-Centered Care

Discharge Planning