Lost in Transition: Missed Opportunities for the 4Ms to Support Post-Acute Care Transitions.

Abstract

Thousands of health systems have adopted the 4Ms framework, a set of evidence-based practices specific to older adults, as part of the Age-Friendly Health Systems (AFHS) initiative. However, implementation efforts have largely been setting-specific and approaches to achieve continuity of the 4Ms during care transitions are nascent. Transitions from hospitals to skilled nursing facilities (SNFs) are one type of care transition that would greatly benefit from continuity of 4Ms practices. Drawing from the authors' insights and 5 exploratory interviews at 3 health systems that implemented the 4Ms in the inpatient setting, we describe a set of current-state challenges when trying to extend specific inpatient 4Ms practices (eg, deprescribing of high-risk medications) as well as the nuanced understanding of the individual's clinical trajectory developed during an inpatient stay. We also offer concrete opportunities, such as developing 4 Ms-centric discharge summary templates, to address the challenges. With the large investment in AFHS transformation and associated efforts to implement the 4Ms framework in all care settings used by older adults, it is critical to raise awareness of the specific obstacles to promoting continuity of successful 4Ms practices during care transitions and work to overcome them. Our insights from hospital-to-SNF transitions offer a starting point.