SHM Converge Scientific Abstract ePoster Gallery-Integrating the Geriatric 4ms Assessment Into Inpatient Case Management

Pdf Summary

This project describes an age-friendly inpatient care model at the Palo Alto VA that integrates the Geriatric 4Ms framework—What Matters Most, Medication, Mentation, and Mobility—into case management for high-risk older Veterans.<br /><br />The hospital’s interdisciplinary Clinical Command Center includes “Flow” Nurse Practitioners who help identify barriers to care and support discharge planning. A new collaboration was created between a Flow NP and inpatient geriatrics to complete 4Ms assessments for selected hospitalized Veterans age 65 and older, especially those with complex needs or unclear discharge plans. The goal was to improve continuity, align care with patient goals, and connect patients to the right services and referrals at the right time.<br /><br />From March 2022 to January 2023, 213 high-risk older Veterans were identified, and 54 of the highest-risk patients received completed 4Ms assessments. These assessments captured functional status, patient preferences for discharge, barriers to medication adherence, and screening for mentation and mood. They also led to referrals for services such as social work, care management, physical/occupational/speech therapy, nutrition, home health, geriatrics, palliative care, home-based primary care, caregiver support, and other outpatient resources.<br /><br />The project concludes that 4Ms assessments are feasible in the inpatient setting when performed by an NP or similar team member and are useful for patient-centered, coordinated care. Eliciting “What Matters Most” helps the interdisciplinary team better match care plans to the patient’s goals.<br /><br />Future directions include expanding the approach to patients with dementia or cognitive impairment and conducting a retrospective comparison of outcomes between patients who received 4Ms assessments and those who did not.

Asset Subtitle

Desiree Haggart

Meta Tag

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

Category Innovations

Concept Geriatric 4Ms Assessment

Concept 4Ms

Concept Inpatient Case Management

Concept Medication

Concept Mobility

Distinguished Finalist

Presenter Organization Medical Service, VA Palo Alto Health Care System

Presenting Author Desiree Haggart

Track Geriatrics

Keywords

Geriatric 4Ms framework

age-friendly inpatient care

high-risk older Veterans

case management

discharge planning

What Matters Most

medication adherence

mentation screening

mobility assessment

interdisciplinary care

Geriatric 4Ms Assessment

4Ms

Inpatient Case Management

Medication

Mobility