by SSM Health
When Jo Goffinet’s mother fell in her early 70s, it set off a series of hospital stays that ended somewhere no one in the family had planned for. As Goffinet remembers it, across three hospital readmissions, no one asked her mother the question she now believes might have changed the course of her care: What mattered most to her?
The answer was simple. She wanted to go home and play with her grandchildren.
Instead, her medication list was inaccurate after each readmission. She developed delirium. She spent her days in bed in a dim room. This was a woman who loved baseball, yet she was no longer even watching it. Her family’s requests to get her sitting up in a chair went unmet. When Goffinet raised concerns that her mother would not be safe at home, the family was left to navigate the next steps on their own. Her mother moved to a nursing home and died not long after.
“I wish I knew then what I know now,” said Goffinet, MS, RN, CMSRN, a regional advanced clinical registered nurse for SSM Health. “I work in healthcare, and even I struggled to navigate her care. Can you imagine families who don’t know what to do?”
Jo Goffinet (front row, second from right), with her mother, Ruth Goffinet (front row, second from left), and family members in a family photo. Goffinet's experience navigating her mother's hospital care helped inspire her work co-leading SSM Health's Age-Friendly care efforts. Photo courtesy of Jo Goffinet.That experience helped drive Goffinet to push for a different standard of care for older adults. She now co-leads the work across SSM Health, where every adult hospital across four states has achieved Age-Friendly Health Systems recognition from the Institute for Healthcare Improvement (IHI).
The recognition, achieved this fall, is awarded to care sites that reliably provide evidence-based practices designed to improve care for older adults.
“This recognition reflects the work our teams have embedded into daily practice to provide age-friendly, person-centered care for older adults,” said Laura Kaiser, president and chief executive officer of SSM Health. “Guided by the 4Ms Framework, this approach helps ensure care is centered on the whole person, not simply the condition being treated."
The framework focuses on four essential elements of care for older patients:
Know and align care with each older adult’s health outcome goals and care preferences.
If medication is necessary, use age-friendly medications that do not interfere with What Matters, Mobility or Mentation.
Prevent, identify, treat and manage dementia, depression and delirium.
Ensure that older adults move safely every day to maintain function and continue doing what matters most to them.
In practice, age-friendly care often begins with one question: What matters most to you?
As part of the nursing admission assessment, patients may share that they want to return home and remain independent, attend a granddaughter’s wedding, or take a long-postponed trip. That answer becomes part of the medical record and care-team handoffs, helping the care team understand what success looks like for that patient.
“The patient knows we’re talking together,” said Christine Baker, PhD, RN, regional director of nursing excellence for SSM Health. “But more importantly, they know their care is being organized around what matters most to them.”
The other elements of the 4Ms help support that goal. Teams screen for delirium and work to prevent it, including by protecting sleep and adjusting the timing of blood draws so a patient at risk is not woken before dawn for a lab that can wait. Medications are reviewed at admission and with each new order against those known to pose risks for older adults. And patients are helped to move safely every day.
“Patients often believe they are in the hospital to rest, or that they are too sick to get out of bed,” Goffinet said. “Our job is to help them understand that staying active, when it is safe to do so, helps maintain strength and reduces the risk of complications.”
SSM Health’s Wisconsin ministries began the work in 2023 before the organization expanded to a unified systemwide approach. Since early 2025, an interprofessional team has worked across SSM Health to consistently embed the 4Ms into care delivery. Because IHI recognizes individual care sites rather than health systems, every eligible SSM Health adult hospital earned recognition independently.
The next phase extends age-friendly care into outpatient and clinic settings, so the conversation continues at the next appointment.
For Goffinet, that is the whole point.
“Now that we understand what age-friendly care can accomplish, we have an opportunity to help more families have a different experience,” she said. “It’s not rocket science. Why isn’t this just embedded in every healthcare system?”
Her mother was never asked what mattered most to her. Today, that question is part of the care experience for older adults admitted to SSM Health hospitals.
Age-Friendly Health Systems is an initiative of The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI), in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the US (CHA). For more information, visit www.ihi.org/agefriendly.
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