Upstream of Guardianship

Before the Courthouse Door

Guardianship in the United States is often described as a compassionate legal safeguard—a last resort for older adults deemed unable to manage decisions about health, finances, or daily life. But in practice, guardianship rarely begins in a courtroom.

It often begins much earlier: in a hospital room after a fall, in a medication list that has grown too long, in a missed delirium screen, in an avoidable loss of mobility, or in a care plan that never asked the most important question of all: What matters to you?

Too often, what later looks like “incapacity” is the downstream result of fragmented care.

That is why the Age-Friendly Health Systems initiative deserves recognition not only as a clinical quality initiative, but as a structural intervention with civil-rights implications. Launched in 2017 by The John A. Hartford Foundation and the Institute for Healthcare Improvement, in partnership with the American Hospital Association and the Catholic Health Association of the United States, the movement centers on a deceptively simple framework: the “4Ms” — What Matters, Medication, Mentation, and Mobility.Originally advanced through the leadership of Dr. Terry Fulmer and colleagues at The John A. Hartford Foundation, and operationalized through IHI’s implementation model, the 4Ms were designed to improve outcomes for older adults across care settings.

But they also do something more fundamental: they help preserve rights and dignity by interrupting the guardianship pipeline before crisis hardens into legal control.

That pipeline is rarely named as such, yet it is widely recognizable. A health crisis leads to hospitalization. A confusing medication regimen clouds cognition. Delirium goes unrecognized and is mistaken for permanent decline. Immobility accelerates functional loss. A rushed discharge fractures continuity. Families, frightened and unsupported, are told that someone must take charge. A petition follows. What looks like a legal necessity is often the culmination of clinical, administrative, and social failures that began upstream.

The 4Ms offer another path — one grounded not in control, but in support. 

What Matters

Start with What Matters. The Age-Friendly model asks clinicians to know and align care with each older adult’s specific health goals and care preferences, and to document and carry that information across settings. That is more than a bedside courtesy. It creates a continuity of intention that can survive hospitalization, discharge, and care transition. A clearly expressed desire to remain at home, preserve cognitive clarity, avoid unnecessary institutionalization, or retain control over daily life can shape decisions long before crisis hardens into a legal narrative of incapacity. This is not merely patient-centered care. It is a safeguard against erasure. In systems that too often mistake silence, disruption, or dependence for consent to take over, documented preferences become a form of protection: they make it harder to overwrite the person at the very moment the system is most tempted to do so.

Medication

Then there is Medication — one of the most routine and underestimated drivers of avoidable decline. Polypharmacy remains a common and too often unchallenged cause of confusion, falls, and functional loss. The 4Ms framework calls for age-friendly medication use: if medication is necessary, it should not interfere with what matters to the older adult, or undermine cognition or mobility. In practice, that means scrutinizing high-risk drugs, reducing unnecessary medications, and recognizing that poorly coordinated prescribing can make an older adult seem confused, unstable, or incapable when the system itself has produced the decline. This is not merely a clinical issue. It is a civil-risk issue. A system that clouds cognition through its own treatment choices should not be allowed to treat the resulting confusion as proof that someone else must take over.

Mentation 

Mentation may be where the stakes become clearest. The 4Ms call for preventing, identifying, treating, and managing delirium across settings. Delirium is common, dangerous, and often reversible — yet it is still too often missed, ignored, or mistaken for dementia, psychiatric decline, or some generalized notion that a person is “failing.” Depression, too, can be misread as deterioration rather than a treatable condition. That misreading is not benign. When temporary or treatable changes in cognition are recast as enduring incapacity, a reversible episode can become the basis for lasting legal consequences. A missed delirium screen does not remain a clinical oversight for long; it can become the first link in a chain that ends in substituted decision-making. Protecting mentation is therefore not only good medicine. It is a safeguard against preventable rights loss.

Mobility

And then there is Mobility, the quiet accelerant of dependency. The 4Ms framework emphasizes ensuring that each older adult moves safely every day to maintain function and continue doing what matters. Functional loss can happen with startling speed during hospitalization or illness. Days in bed can become weeks of diminished confidence, balance, and strength. Once mobility is lost, the system’s judgment can turn just as quickly: a person may suddenly be labeled unsafe at home, too difficult to discharge, or unable to perform the tasks by which others judge competence. This is how the hospital-to-guardianship pipeline hardens: preventable functional decline is recast as proof of incapacity, institutional delay is rewritten as personal failure, and a system’s inability to support discharge becomes the pretext for taking away legal agency. Preserve mobility, and you preserve more than function. You help protect the person from being redefined by a preventable decline.

Fragmentation Is Where Guardianship Is Born

The point is not that any one of the 4Ms, on its own, solves this problem. Their power lies in integration. The 4Ms are meant to be practiced together, as a coordinated set of evidence-based elements, not as isolated checkboxes. And that emphasis on integration carries a larger lesson: crisis is rarely as sudden as it appears. More often, it is the visible endpoint of smaller failures, missed signals, and preventable breakdowns that accumulated long before anyone called it an emergency.

That is precisely the insight that Pamela Teaster, Jeffrey Hall, and others have helped bring into elder-justice thinking through a public-health lens. Their approach begins with a simple but urgent question: why do we keep waiting for crisis? Its answer is a public-health framework that understands elder abuse as a preventable systems problem — one that calls for prevention at the primary, secondary, and tertiary levels: reducing risk before crisis, detecting warning signs earlier, and limiting harm once an emergency has begun.

The 4Ms and the Age-Friendly Health Systems movement offer one practical way to act on that insight. They translate that preventive logic into daily practice — not only by improving care, but by helping preserve the functional and relational conditions under which legal agency can remain intact. When care is aligned with what matters, when medications do not induce confusion, when delirium is caught early, and when mobility is protected, the system is less likely to convert preventable decline into a narrative of incapacity. That is why the 4Ms belong in this conversation. They are not just a geriatric care framework. They are a working example of how public-health prevention can be joined to rights-preserving systems change upstream.

A 2021 review of the evidence made the point clearly: the 4Ms function as an interacting whole across care domains, with better outcomes when implemented reliably and together. That is more than a clinical insight. A 2024 scoping review found that effective 4Ms implementation depends on infrastructure, collaboration, and organizational support — a reminder that preventing avoidable decline requires systems that coordinate before crisis, not after it. And a 2023 study of three early-adopter health systems identified siloed practice as a central barrier to putting the 4Ms into effect — exactly the kind of fragmentation that can turn manageable problems into the cascading failures that later harden into legal crisis.

But that insight should not stop at the clinical level. The same logic that makes the 4Ms effective — coordination, continuity, and alignment around the person rather than the institution — must extend across the wider system if avoidable guardianship is to be reduced. That means deliberate cross-sector collaboration among health care providers, aging and disability systems, housing and long-term supports, and the family and community networks that often absorb failure first. It means state aging plans that treat the preservation of legal agency as an upstream systems goal. And it means building out a No Wrong Door approach — a person-centered system of coordinated entry and navigation that helps older adults, people with disabilities, and families reach the right mix of services and supports without having to navigate a maze of disconnected programs. The Administration for Community Living describes No Wrong Door as a system that empowers people to make informed decisions, exercise control over their long-term care needs, and achieve their personal goals and preferences.

That federal backing matters. The Administration for Community Living has made No Wrong Door a central framework for helping people access long-term services and supports, and federal Medicaid guidance reinforces it as a practical structure for coordinated entry, person-centered counseling, and system alignment. In that larger architecture, the 4Ms are more than a care model. They are an upstream safeguard against the fragmentation that too often turns vulnerability into dispossession.

State multisector plans for aging now provide a concrete policy home for that work. The John A. Hartford Foundation has explicitly funded the Institute for Healthcare Improvement to develop an Age-Friendly Health Care Package for inclusion in state Master Plans for Aging, linking Age-Friendly Health Systems to broader cross-sector system design. IHI’s own state-based guidance makes the connection even more direct, urging states and regional leaders to align Age-Friendly Health Systems with Multisector Plans for Aging, and noting that in New York, leaders have already recommended integrating 4Ms care into the state’s Master Plan for Aging. In other words, the 4Ms are not only a bedside framework; they are increasingly being positioned as part of the public infrastructure through which states can scale age-friendly, coordinated, rights-preserving care.

But the importance of that broader architecture is not only administrative. It is also moral and civic. The disability rights community brings an essential corrective to this conversation. It has long argued that vulnerability is not a deviation from normal life, but one of the defining conditions of it. Human beings are interdependent; needs change, function fluctuates, and support is often what makes freedom possible. That insight cuts directly against the logic that treats dependence as a reason to transfer control. It also forces a life-course view. The crises that later get labeled “incapacity” are often the endpoint of harms and failures accumulated over time — exclusion, service fragmentation, trauma, poverty, inaccessible systems, caregiver collapse, and rights denied long before anyone is labeled elderly. Seen this way, the task is not merely to manage decline in old age. It is to build systems across the life course that preserve agency under conditions of vulnerability, so that needing help never becomes the trigger for losing personhood.

That is why integration matters so much. Guardianship is often born from fragmentation.

Remaining the Author of Your Own Life

Age-friendly care pushes in the opposite direction. It creates continuity where our institutions typically create discontinuity. That is why its implications extend beyond hospital quality metrics and care-satisfaction scores. It can help shift the default response to vulnerability away from substituted decision-making and toward coordinated, rights-preserving support.

This aligns with that broader person-centered policy direction. The 4Ms belong in the same upstream architecture as No Wrong Door: not merely as clinical best practice, but as part of a larger public ethic that says crisis should trigger support, evaluation, rehabilitation, and coordination before it triggers legal control.

That broader ethic is not only good policy. It is also closer to what a constitutional democracy should require. Guardianship is among the most sweeping civil interventions authorized by state law, often transferring control over residence, medical decisions, finances, and association to another person. When that outcome flows from preventable system failures, the problem is not simply poor coordination. It is that avoidable breakdowns are being used to justify taking away rights that should never be surrendered for want of support. The question, then, is not only whether we protect vulnerable people. It is whether we preserve legal agency, due process, and the presumption that rights should be lost only as a true last resort.

None of this means guardianship will disappear. Some people will still need formal protection. Some situations will remain truly exigent. But the difference between a true last resort and a routine default lies upstream.

And upstream is exactly where the 4Ms operate. The spread of Age-Friendly Health Systems should prompt a larger question: not only whether the 4Ms improve care, but whether they can help preserve legal agency by reducing the avoidable crises that so often precede guardianship.

In an aging society, the measure of success cannot be limited to longer life or smoother discharge. It must include whether people are allowed to remain the authors of their own lives.

The 4Ms offer a practical blueprint for that broader ambition. By stabilizing cognition, protecting function, aligning care with expressed goals, and coordinating support across settings, they can help ensure that the default response to vulnerability is support — not the surrender of rights.