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

Thousands of health systems have adopted the 4 Ms 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 4 Ms 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 4 Ms practices. Drawing from the authors' insights and 5 exploratory interviews at 3 health systems that implemented the 4 Ms in the inpatient setting, we describe a set of current-state challenges when trying to extend specific inpatient 4 Ms practices (eg, deprescribing of high-risk medications) as well as the nuanced understanding of the individual's clinical trajectory developed during an inpatient stay.