Simplifying Complex Care for Older Adults

Simplifying Complex Care for Older Adults

Mary Tinetti, MD is the Chief of Geriatrics at Yale School of Medicine and Yale-New Haven Hospital, and co-chair of the advisory group for Institute for Healthcare Improvement (IHI’s) Age-Friendly Health Systems. At its core, an Age-Friendly Health System looks to optimize value for your loved one, the family, caregivers, and the healthcare system. An Age-Friendly Health System is looking for a win-win solution for everyone involved. Dr. Tinetti identifies the keys to providing the best care possible for older adults.

As individuals age, they amass more clinical conditions that become more complex over time. Seniors are individuals and it is important to remember each person’s outcomes, values, and desires are unique; they cannot be generalized. The healthcare team must recognize this individuality, and respond to the person’s specific needs, interests and priorities. When providers generalize or don’t take into account the variability of seniors, then there may be unintended care consequences.

The 4Ms

The “4Ms” is a part of an age-friendly approach focusing on improving the care that is complex and helping to make it more manageable. Regardless of the condition, the number of functional issues, culture, ethnicity or religious background, the “4Ms” are applicable.

  • What Matters — Acknowledges that older adults vary in what matters most to them about their health, and their health care
  • Medication – The number, types, availability/access, tolerance
  • Mentation — Mental activity. This includes the “three Ds” of the 4Ms (depression, dementia, and delirium)
  • Mobility – How well is the individual able to get around

It is important for clinicians to examine each of these areas (What Matters, Medication, Mentation, and Mobility) collectively for each individual at every interaction.

Caregiver Implications

These “4Ms” are intricate issues that are related to each other. They provide insight into some of the challenges associated with managing complex conditions. Common chronic conditions include Parkinson’s, dementia, diabetes, heart failure, and renal disease. When multiple serious chronic conditions coexist, the intricacies of clinical management become more challenging. It is important to remember that each individual is unique, and each person responds in their own special way.

Share with your provider

  • What’s important to you from a health perspective, how you “like” to live, needs, what you value, and your Advance Directive wishes
  • All medications that are taken; including over the counter, vitamins, supplements, creams, and prescriptions from other providers. Do not assume that one provider has a complete list of all the medications that are being taken
  • Feelings, being sad, “feeling blue”, forgetfulness and any strange new or unusual emotions
  • Any changes in the ability to “move”, includes changes in walking, being able to get out of bed, chair or tub, climb stairs, change in range of motion or ability to pick up items

Individuals and caregivers should remember the IHI’s Ask Me 3: Good Questions for Your Good Health that should be asked during each provider visit.

  • What is my main problem?
  • What do I need to do?
  • Why is it important for me to do this?

The Ask Me 3 questions help you to focus on the important issues that are affecting your condition at a particular time. These questions become a nice introduction to the “4Ms” that providers are beginning to utilize in care management. You are encouraged to use the “4M” as a means of reminding the provider of your “uniqueness,” and desire for the best possible care. Open the provider discussion to the “4Ms” if the provider has not done so, as they tie in nicely with any treatment, or medication change made. These questions and approach encourage and assist in improving communication with the provider. They are a framework for better understanding of the proposed treatment or medication.