Care Plans

IHI Standards

High-Quality Care For Aging Adults

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Care Coordination programs, such as Chronic Care Management (CCM), are designed to primarily help Medicare Beneficiaries manage their chronic conditions and provide a single source of answers to the often-complex information given by their network of primary care, hospitals, and specialists. CrossTx Care Plans used in Care Coordination Programs follow the Institute of Healthcare Improvements (IHI) evidence-based “4Ms” which are the following elements of high-quality care for aging adults:


Care Coordinators start with what matters most to the patient, including aligning care to the patients’ healthcare goals and being mindful of transitions in care, end of life care, and settings of care.


When medication is necessary, Care Coordinators can help ensure it doesn’t interfere with patients’ life goals.


This encompasses all of the mental and behavioral health for the patient. Great Care Coordinators help with the prevention, coordinating identification, and coordinating treatment for their patients.


Care coordinators collaborate with their patients to determine safe and consistent ways the aging adults in their care can continue to maintain mobility.
CrossTx is mindful of using evidence-based best methods for aging adults in our care coordination programs. Due to this, we follow the 4Ms as a framework in care planning to guide the care of older adults. This age-friendly methodology is embedded in CrossTx Care Plans to follow evidence-based elements of high-quality care for older adults.