Appendix B
Appendix B — Person + Family “What Matters” Profile
Learn what the care needs to protect
Use with: Chapters 1–5 and 11, and Reference Chapter R3.
Begin with the person receiving care. Invite other people’s accounts according to the person’s preferences and appropriate authorization. The caregiver’s experience belongs in its own right, not only as information about someone else.
Build the profile through relevant conversations rather than requiring every topic at first contact. Its foundation is the person-and-family profile in the appendix plan.
B1. The profile
Field | Question or record |
|---|---|
What matters now | What would make the coming days or weeks more manageable or worthwhile? |
Identity and relationships | How does the person wish to be addressed? Which relationships and roles do they want recognized? |
Enjoyment and contribution | What do they enjoy now? What might they like to share, try, or continue? Contribution remains optional. |
The person’s concerns | Their account, using their words where recorded accurately. Distinguish a quotation from a paraphrase. |
The caregiver’s needs | What support do they want for themselves? Keep private details in a separately authorized record. |
Other accounts | Who reported or observed what, when, and in which setting? Do not merge differing accounts. |
Professional guidance | Relevant, verified guidance and its source, date, and responsible professional. Do not turn observations into diagnoses. |
Routines, culture, and beliefs | What does the person want considered? Ask; include only what is relevant and appropriately shared. |
Communication and access | Preferred spoken and written language, format, timing, assistance, and a usable nondigital route. |
Practical conditions | Transport, time, cost, environment, service availability, and other circumstances affecting the proposed support. |
Chosen involvement | Who may join which conversation or receive which information? Who has actually accepted a task? |
Unknowns and review | What needs clarification, who will address it, and when the person can correct or revisit the profile. |
Use the profile to change the offer. If someone requests a telephone conversation, identify who will arrange it. If a preferred service is unavailable, keep that gap visible rather than recording the preference as fulfilled.
B2. Shared-understanding note
After a relevant conversation, prepare only the information suitable for its intended recipients:
What we know: [verified information and its source].
What we are asking: [questions and uncertainties, attributed appropriately].
What happens next: [the action the person chose and any action accepted by others].
Who can help: [actual contact, role, availability, and alternative route].
This carries forward the Awareness chapter’s practical output. It should make the next conversation easier, not become another account the family must maintain alone.
B3. Barrier and next chosen step
For one proposed action, record what makes it worthwhile to the person; what remains unclear; what practical help or skill is needed; what concerns deserve discussion; and what they choose next. Name who can address each unresolved barrier. This adapts Chapter 3’s guide without using it as a diagnostic score.
B4. A 4Ms-informed action map
This original planning aid draws on IHI’s assess-and-act approach. It is not an IHI assessment form or a recognition checklist. Use the applicable professional guidance and involve the person in each relevant decision.
Element | What should the local plan make clear? |
|---|---|
What Matters | The person’s stated health and life priorities; the action or arrangement changed because of them. |
Medication | The current professional guidance, who is responsible for medication review/support, and what requires clinical follow-up. A list alone is not a review. |
Mentation | Relevant observations, their sources, and qualified assessment or support for thinking and mood concerns. Keep uncertainty visible; route urgent changes appropriately. |
Mobility | What the person wants to do, the assistance and environment needed for safe movement, and who provides or reviews that support. |
For each relevant row, add a named owner, agreed action, review date, and what remains unresolved. See R1, CG4–CG7; the mapping does not establish clinical effectiveness or Age-Friendly recognition.
B5. Two people, appropriately separate information
Keep the caregiver’s private account in its separately authorized record. A shared plan may record an agreed request for support without exposing private screening answers or individual-session details. Before collection, identify permitted recipients, the response owner, confidentiality limits, and the safe route when this record cannot enforce separation. Do not add private answers to this worksheet simply because both people are part of the care journey. RUSH’s separate-record example is documented publicly in R1, CG3.
Decision this tool supports: What should be explained, adapted, offered, or left for another conversation?
B6. Practical concerns and a route to help
Use only the questions relevant to the person. This is a navigation aid, not legal, financial, or clinical advice. A private matter can stay in a restricted record while the shared plan records only an agreed action.
Planning field | What to record |
|---|---|
Concern in the person’s words | The cost, work, housing, future-planning, or access question they choose to raise; source and date. |
Preferred conversation | Who they want involved, preferred language and format, and what may remain private. |
Appropriate resource | The qualified professional or service contact able to address the question. Verify the role, availability, cost, and eligibility rather than assume them. |
Accepted follow-through | Who accepts the next contact, by when, how the person will hear back, and the alternative if it cannot proceed. |
What is still open | Missing information, unconfirmed assistance, or unresolved needs. Record whether the professional conversation or actual help occurred. |