4 M's Continuity is Crucial in Post-Acute Care Transitions

The continuity of the 4 M’s framework during hospital to skilled nursing facility (SNF) transitions is crucial for the care outcomes of older adults.

The 4 M’s approach is a set of evidence-based practices of high-quality care specific to older adults. The 4 M’s represent ‘What Matters, Medication, Mentation and Mobility,’ as part of the age-friendly health systems (AFHS) initiative.

According to an article recently published in the Journal of Post-Acute and Long-Term Care Medicine, or JAMDA, authors refer to ‘What Matters’ as knowing and aligning care with each older adult’s specific health outcome goals and care preferences. ‘Medication’ represents age-friendly medication that doesn’t interfere with what matters to the older adult, as well as their mobility or mentation. ‘Mentation’ is defined as preventing, identifying, treating and managing dementia, depression, and delirium across settings of care. ‘Mobility’ is ensuring that older adults move safely every day in order to maintain function and do what matters.

Thousands of health systems have adopted the 4 M’s framework, but implementation efforts have been largely setting-specific and approaches to achieve continuity of the 4 M’s during care transitions are still in the works.

Authors of the report state most 4 M’s practices begin with a clinical assessment resulting in an interdisciplinary care plan in the given setting. However, when a hospital-to-SNF transition occurs, it’s common to reassess the individual in the new setting and determine a new care plan to be implemented. Prior assessment results or the previous care plan actions that have been successful, typically aren’t considered.

Not following or continuing this framework into a SNF transition can lead to many threatening health challenges. For example, a patient may start a high-risk medication in lieu of continuing the safer care plan that was already working.

A geriatric clinic nurse said in the article, “We don't have a lot of control over what's being prescribed in the SNF… it is really hard to control what they're doing and what they prescribe our patients.”

“I do have a fair amount of families who will reach out to our clinic when their loved one is in a SNF for various concerns. Sometimes, it's a lack of communication, but sometimes it is, they're putting them on these meds… So, we are doing a lot of communication education on the caregiver's side as far as directing the providers actually overseeing the care.”

Another challenge area behind 4 M’s continuity is the imbalance between the greater capacity and resources for education and training around 4 M’s in acute vs SNF settings. Authors shared the inpatient settings traditionally has more ability to support implementation of initiatives like 4 M’s.

On the other hand, a nurse addressed the imbalance and told authors, “[SNFs] are there to just facilitate the resident's day, make sure that they're safe and get their medications. I would love to find a facility that was more interested in the different types of dementia, really had the staff and the activities to support patients in different fashions, but it's rare.”

The article underscores the need for post-acute protocols to assess new 4 M’s baselines and care needs in a way that considers the prior effective efforts from the inpatient setting. In doing so, SNFs can refer to the patient’s discharge summary. Though, current discharge summaries are not designed to highlight inpatient 4 M’s efforts and how they can be maintained in the SNF.

It’s encouraged inpatient providers must make a special effort to represent the 4 M’s and promote continuity of their practice in the discharge summary.

According to authors. there are 3 near-term opportunities to work toward greater continuity of 4 M’s during hospital-to-SNF transitions.

• First, hospitals could use preferred SNF partnerships to promote continuity. With the growing trend toward partnerships, these relationships can facilitate common goal sharing around 4 M’s training and education within SNFs, as well as establishing processes that promote continuity.
• Given many older patients will transition to SNFs that are not hospital partners, another strategy is to create a 4 M’s-centric discharge summary designed to avoid high-risk medication prescribing in the subsequent setting.
• Health systems could invest in establishing local training programs for post-acute care facilities focused on the 4 M’s and their continuity transitions.