Background: The age-friendly hospital implements an evidence-based “4M” framework (what matters most, medication reconciliation, mentation and mobility) to minimize harm among older adults. Clinical outcomes of patients who receive bundled 4M’s care delivery remains a knowledge gap. We determined if the incremental benefit of more M’s was associated with reduced discharges to post-acute care facilities.
Methods: We assembled a prospective cohort of patients admitted to an Acute Care for Elders (ACE) unit April-August 2021 at an academic medical center. Patients were included if they were admitted to the geriatric medicine service where the 4M’s improvement implementation initiative was underway. Participants were excluded if they were discharged in < 24 hours, transferred to another unit, discharged on hospice, or died. The primary predictor included the number and type of “M” received. Patients were counted as having received what matters most care if the provider asked, documented, and aligned the plan of care with the patient’s priorities. Patients were counted as having received medication care if the pharmacist reconciled their medications, educated, and deprescribed or dose escalated when appropriate. Patients were counted as having received mentation care if screened for delirium ≥ 1.5 times per hospital day. Patients were counted as having received mobility care if mobility scores improved. The primary outcome was discharge to a post-acute care facility.
Results: There were 261 patients with a median age of 80 years (IQR 76-86), 58% female, and 15% non-white. Median hospital length of stay was 5 days (IQR 3-7) with 7.7% rehospitalizations. Thirty patients (11.5%) had at least one positive delirium screen. The median delirium screens completed were 8 (IQR4-13). The median discharge mobility score was 6 (IQR 3-7). Discharge to post-acute care was 45.6% overall, 21% for those who received what matters most care, 72.3% for those with complete medication reconciliation/deprescribing, 84.9% with delirium screening greater than once per day, and 58% for those with improved mobility scores. The odds of discharging to a post-acute care facility was 2.6 higher (CI 1.4-4.8) in participants who received mentation care compared to those who did not. The odds of discharging to post-acute care was not associated with care delivery of any of the other 3M’s. The odds of discharging to a post-acute care facility was also not statistically significantly associated with the number of M’s received (0-4) during index hospitalization.
Conclusions: The 4M’s of geriatric care are rooted in evidence-based practices. Our early work demonstrates that the incremental benefit of bundled 4M’s care is not associated with reduced discharge to post acute care facilities. More work is needed to examine other patient and system factors at play.