Over the past 10 years, the Age Friendly Health Systems project has transformed the care of older adults in healthcare settings across the country.1 Leaders at participating organizations have spearheaded projects that improve the care of older adults using a new framework called the 4Ms – What Matters, Mentation, Medications, and Mobility.1 Since the initiative’s implementation, more than 3,000 health systems have joined and incorporated the 4Ms in varied ways to address their systems’ needs.2

The geriatric education community also recognizes that the 4Ms concept elevates core geriatric principles, but few studies demonstrate the impact of incorporating the 4Ms into geriatric curricula. One medical school created an online elective to teach 4Ms in patient assessments, care planning, interprofessional practice, and process improvement.3 A residency program designed an interactive, longitudinal, case-based workshop focused on the Ms.4 Both initiatives improved student and resident knowledge,3,4 and self-efficacy4 in caring for older adults.

In our hospital, a team of an attending physician and at least one internal medicine resident performs inpatient geriatrics consults. The faculty adopted the 4M curriculum to teach comprehensive geriatric care as part of this rotation. The attendings standardized the approach in several ways: introducing the 4Ms during orientation; requiring learners to use preset electronic health record templates that include the 4Ms; and encouraging residents to include each of the 4Ms in their clinical presentations and patient discussions.

Outcomes and Impact

Improving Consult Etiquette and Becoming Effective Consultants

Resident learners previously reported difficulty knowing how to provide support to primary services without the attending physicians’ help framing a patient’s geriatric specific concerns. By applying the 4Ms framework, learners were able to identify patients’ underlying geriatric problems.

Consults for safe discharges necessitated cognitive evaluations and decision-making capacity assessments. Consults about delirium required medication reconciliations. Consults for frequent falls needed mobility assessments and goals of care consults involved conversations about what mattered to the patient, their family, or surrogate.

The Geriatric attendings found that by requiring residents to comprehensively evaluate their consult patients using the 4Ms framework, residents were better able to identify and describe the often-subtle geriatric issues related to consult questions.

Providing Comprehensive Geriatric Care

Many learners previously found performing comprehensive geriatric assessments to be an insurmountable task. They tended to focus on a specific concern and missed valuable information essential to the care of older adults. Since implementing the 4Ms, learners report they can evaluate and manage geriatric syndromes more holistically.

When assessing what matters, residents learned to identify frailty, existing supports, surrogacy, care access, social determinants of health, and advance care planning preferences. When assessing mentation, residents learned to identify issues related to dementia, delirium, depression, and sleep disorders. When assessing medications, residents learned to recognize polypharmacy, and concerns of nutrition, incontinence, or constipation. When evaluating mobility, they learned to evaluate falls, dizziness, sensory impairment, gait, risk for future falls and injury, and complications of immobility, such as generalized deconditioning, and pressure ulcers.

The Geriatric attendings recognized in using these 4Ms assessments, residents were better able see the patient holistically and cite complexities that could make it difficult for the patient to thrive.

Identifying and Managing Appropriate Care Transitions

One dilemma learners and hospitalists face is in identifying the best patient disposition in complicated clinical scenarios. With the initiation of the 4Ms framework, learners were able to effectively plan discharges and organize care transitions.

When evaluating what matters, learners identified patient priorities, feasibility in the discharge level of care, and, when appropriate, options for comfort focused care. When evaluating mentation, learners screened for cognitive deficits that could influence the patients’ ability to care for or advocate for themselves. When reviewing medications, learners identified discrepancies in medication lists and shared changes with patients, families, and outpatient clinicians as necessary. When considering mobility, learners gathered information about current functional status and support systems including community resources.

The Geriatric attendings observed that after evaluating the 4Ms, residents recommended more comprehensive, care concordant discharge plans.

Learner Satisfaction

After implementing this educational initiative, the attendings revised the optional MedHub survey sent to residents at the completion of the rotation. From the initiation of the change, approximately 62 residents rotated on the inpatient geriatrics service from 7/2021-9/2023, and 47 evaluations were completed. Overall, residents reported satisfaction with the curricular changes. Thirty-five residents (74%) reported that using the 4Ms improved their understanding of geriatric concepts, 39 residents (83%) reported that they were confident in formulating plans of care using the 4Ms, and 33 residents (70%) reported that they would use the 4Ms in their future practice.

Conclusion

As the population ages, the Age Friendly Health Initiative will become essential to daily clinical practice. By using real time, case-based teaching on hospitalized patients, trained providers can effectively teach future SGIM clinicians about the 4Ms framework and prepare them for Age Friendly practice. With appropriate education, any SGIM provider can create patient-driven geriatric care plans and become Age Friendly clinicians.

References

  1. Age friendly health systems. What is an age friendly health system? Institute for Healthcare Improvement. https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx. Accessed May 15, 2024.
  2. Adler-Milstein JR, Krueger GN, Rosenthal SW, et al. Health system approaches and experiences implementing the 4Ms: Insights from 3 early adopter health systems. J Am Geriatr Soc. 2023; 71(8): 2627-2639. doi:10.1111/jgs.18417.
  3. Severance J, Ross S. Teaching medical students to incorporate the 4Ms of age-friendly health systems across the continuum of care. Innov Aging. 2022 Dec 20;6(Suppl 1):34–5. doi:10.1093/geroni/igac059.130. PMCID: PMC9765584.
  4. Phillips SC, Hawley CE, Triantafylidis LK, et al. Geriatrics 5Ms for primary care workshop. MedEdPORTAL. 2019;15:10814. https://doi.org/10.15766/mep_2374-8265.10814.

Issue

Topic

Geriatrics/Palliative Care, Medical Education, SGIM

Author Descriptions

Dr. Whitesides (lwhitesides@mfa.gwu.edu) is an assistant professor of Geriatrics and Palliative Medicine at George Washington (GW). Dr. Lodhi (tlodhi@mfa.gwu.edu) is an assistant professor of Geriatrics and Palliative Medicine at George Washington (GW). Dr. Prather (cprather@mfa.gwu.edu) is an associate professor of Geriatrics and Palliative Medicine at George Washington (GW). Dr. Alchalabi (talchalabi@mfa.gwu.edu) is an assistant professor of Geriatrics and Palliative Medicine at George Washington (GW).

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