Creation of an Operational Dashboard to Document Implementation of 4M’s into Primary Care in a Geriatric Patient-Centered Medical Home

Abstract

Many health systems have joined the Age-Friendly Health Systems movement to provide every older adult safe, high-quality care aligned with what matters most. Becoming an Age-Friendly Health System means that hospitals and health care systems reliably use a set of evidence-based practices known as the “4M’s” – What Matters, Medication, Mentation, and Mobility – to provide care for older, disabled and medically complex patients across all care settings. Implementing the Institute for Healthcare Improvement’s (IHI) 4M’s Age-Friendly principles into primary care is challenging because there is no best practice to identify documentation of delivery. Leveraging the electronic health record (EHR) may automate this process. Age-Friendly principles for primary care were discussed at IHI peer coaching webinars, and PDSA cycles employed among clinic staff to define each of the 4M’s for the Vanderbilt Geriatric Practice: 1) Mentation – Mini-COG and PHQ2 extracted from nursing intake, 2) Medication – extracted from medication review, provider reconciliation, 3) Mobility – extracted from activities of daily living (ADL) mobility questions in nursing intake, and 4) What Matters Most – identifying patient portal messages. A dashboard within our EPIC electronic health record (EHR) was built based on these identified fields, allowing clinician drill-down to display more detail as needed. An operational dashboard for an EHR has potential to help inform clinician delivery of 4M’s care in the primary care setting.