What Matters Most Only Matters If It’s Available

The 4Ms Framework defines “What Matters,” but if it's not available when decisions are made, it doesn’t guide care.

By Scott Brown, President & CEO

The U.S. population aged 65 and older is projected to grow from approximately 61 million in 2025 to nearly 84 million by 2050, an increase of more than one-third over the next 25 years (U.S. Census Bureau, 2023). This shift will place increasing pressure on a healthcare system that’s already struggling to manage complex, high-need populations across multiple care settings.

In response to this expanding demographic, the Age-Friendly Health Systems movement has brought important clarity to how care should be delivered for older adults. The 4Ms Framework—What Matters, Medication, Mentation, and Mobility—offers a practical approach for aligning care with patient goals. Led in large part by the John A. Hartford Foundation and the Institute for Healthcare Improvement, this work has helped move the industry toward more consistent, person-centered care (Institute for Healthcare Improvement [IHI], n.d.).

 Graphic courtesy of Institute for Healthcare Improvement (IHI)

There’s little debate about the value of this approach. MyDirectives’ focus primarily centers on “What Matters,” and the challenge isn’t whether “What Matters” should guide care decisions—it’s whether our healthcare system is equipped to ensure that patient goals of care and preferences are actually available when and where medical treatment and intervention decisions are being made.

Advance care planning (ACP) is an important mechanism through which “What Matters” is documented. Through advance directives, POLST forms, out-of-hospital DNR orders, and the designation of a healthcare agent, patients are able to express their goals of care, treatment preferences, and values in a structured and clinically relevant way. Over time, healthcare organizations have made meaningful progress in encouraging these conversations and increasing documentation rates.

However, documentation alone isn’t sufficient. Studies have shown that ACP is intended to ensure care aligns with patients’ values and preferences, but ACP’s effectiveness depends on documentation being accessible and available when and where needed (Sudore et al., 2017). Guidance from the National POLST Collaborative also emphasizes that POLST forms are only effective when they’re immediately available to those responsible for making and carrying out treatment decisions (National POLST Collaborative, n.d.).

A persistent and often overlooked gap remains between capturing patient preferences and making them accessible across care settings, and the consequences of this gap are significant. When ACP documents exist but aren’t available during critical moments—particularly during emergency department visits, transitions between care settings, or when EMS, emergency care teams, and community paramedicine organizations are responding in the field—clinicians are forced to make decisions without the benefit of knowing the patient’s wishes. When that information isn’t accessible, it becomes a barrier to delivering patient goal-concordant and medical order-concordant care.

Consider a common and difficult scenario. An older woman has worked with her doctor to complete a POLST form indicating that she doesn’t want aggressive interventions or attempts at resuscitation, and that she doesn’t want to go back to the hospital. Her preferences are clear, she’s discussed them with her family, and they’ve been documented appropriately. 

Yet when EMS arrives in response to an emergency call, they’re expected to know that her POLST form is taped to the refrigerator door. Otherwise, that documentation isn’t available to them. If she goes into cardiac arrest, then in the absence of actionable instructions to the contrary, the default is to proceed with full resuscitative efforts. They perform chest compressions, fracturing ribs. They perform other aggressive interventions that may be clinically appropriate in the moment, but that are entirely inconsistent with the woman’s expressed and documented wishes. Then they transport her to the hospital emergency room. She suffers. Her family suffers. The emergency medical team suffers.

Situations like this aren’t the result of a lack of communication or a failure of clinical intent. They reflect a structural limitation in how our healthcare system manages and exchanges critical patient information. When medical treatment, intervention, and hospitalization preferences aren’t accessible at the point of care, they can’t meaningfully influence decision-making.

ACP shouldn’t be viewed solely as a program or an intervention. It functions, more accurately, as a form of clinical infrastructure. Like other foundational elements of healthcare delivery, it must be designed to operate reliably across all points of care, during transitions, and in time-sensitive situations. This requires systems that ensure ACP documentation is interoperable, accessible across care settings, embedded in clinical workflows, and available to all members of the interdisciplinary team, including those delivering care outside of traditional clinical environments.

The 4Ms framework has provided an essential foundation for improving care for older adults. Its emphasis on “What Matters” is both appropriate and necessary. At the same time, realizing its full potential requires more than alignment around shared principles. It requires the underlying systems and infrastructure to ensure that patient preferences are consistently available and actionable.

As healthcare continues to evolve toward greater accountability for outcomes and patient-centered care, the ability to reliably access and apply what matters most to patients will become increasingly important. The next phase of progress will depend not only on continuing to encourage ACP discussions, but on ensuring that what has already been documented can be used effectively wherever and whenever care decisions are being made.

About the Author

Scott Brown is President and Chief Executive Officer of MyDirectives, the leader in digital advance care planning. He co-founded the company in 2007 and has led its growth as a nationwide platform for documenting and sharing care preferences across healthcare settings. A strong advocate for interoperability and person-centered care, he is a co-editor of HL7 implementation guides for advance care planning and a reviewer of C-CDA standards, helping ensure care preferences are accessible and actionable at the point of care.

Before founding MyDirectives, Scott practiced international corporate, securities, and mergers and acquisitions law in Paris and Dallas.

References

U.S. Census Bureau. (2023). National population projections tables: 2023 national population projections. https://www.census.gov/data/tables/2023/demo/popproj/2023-summary-tables.html

Institute for Healthcare Improvement. (n.d.). Age-friendly health systems: Guide to using the 4Ms in the care of older adults. https://www.ihi.org/partner/initiatives/age-friendly-health-systems 

National POLST Collaborative. (n.d.). POLST: Portable medical orders for seriously ill patients. https://polst.org

Sudore, R. L., Lum, H. D., You, J. J., Hanson, L. C., Meier, D. E., Pantilat, S. Z., Matlock, D. D., Rietjens, J. A. C., Korfage, I. J., Ritchie, C. S., Kutner, J. S., Teno, J. M., Thomas, J., McMahan, R. D., & Heyland, D. K. (2017). Defining advance care planning for adults: A consensus definition from a multidisciplinary Delphi panel. Journal of Pain and Symptom Management, 53(5), 821–832.e1. https://doi.org/10.1016/j.jpainsymman.2016.12.331