Why Asking "What Matters?" Matters

Kelseanne Breder, PhD, PMHNP-BC

Clinical Assistant Professor at NYU Meyers

Assistant Director, Behavioral Health, HIGN

The 4Ms framework promotes age-friendly care in geriatric settings by bringing clinicians’ attention to Medication, Mentation, Mobility, and What Matters to patients. This last category is particularly valuable yet often overlooked. Research has shown that asking “what matters” lowers inpatient hospitalizations and ICU stays, and increases hospice use and patient satisfaction. However, too often, clinicians have difficulty relinquishing control as a paternalistic authority and choosing instead to become partners in care (Barry & Edgman-Levitan, 2012). Learning to ask patients, “What matters to you?” takes practice and initiative, at least. But more so, it may take a change in philosophical outlook. 

Perhaps in no other healthcare setting is it more counterintuitive to relinquish clinical authority than in community settings where the aging undomiciled population is served. Persons with lived experiences of homelessness have a personal health history that stands in stark contrast to the basic expectations of our healthcare system and larger society. They live without housing and without regular access to healthcare, and many have experienced significant trauma that precipitated their homelessness or that is a consequence of living on the streets. Many undomiciled individuals have a shattered sense of trust in healthcare and socioeconomic systems, and it is difficult to engage them by the rules of the same healthcare system that has ostracized, forsaken, and forgotten them. 

As a psychiatric clinician who works with the aging undomiciled population, it is easy to think about “what should matter” to my patients from a social or clinical lens, and to assume that my priorities as a nurse overlap with theirs. Indeed, NYC’s 2022 city-wide homeless “sweeps” were conceived, in part, under this fallacy. The “sweeps” were implemented to provide undomiciled individuals access to temporary housing, financial assistance, and mental health and substance use care. Yet the sweeps largely failed to improve housing in New York City. Only 5% of individuals engaged during sweeps accepted temporary shelter, and nine months later, only 2% of individuals remained in shelters, with 0.1% in permanent housing (Office of the New York City Comptroller, 2023).

Housing First is an evidence-based alternative that has been far more successful at ameliorating homelessness, with 70% to 90% of participants remaining housed after two years (Office of the New York City Comptroller, 2023). One of the key differences between the “sweeps” and Housing First, is that Housing First policies are built upon what matters to patients. Housing First relies upon trained professionals to outreach, provide resources, and listen to patient stories. When we partner with patients and engage them in the housing process, we can understand who they are and recommend them for apartments and services that are a good fit for their lifestyles, values, and desires for the community. 

In order to understand why formerly homeless older adults stay housed, I’ve conducted qualitative interviews with older adults who have maintained housing for longer than two years. Participants reported that the resiliency strategies and survival skills that they developed during periods of homelessness are critical to their ongoing housing stability and wellbeing. Unsurprisingly, among these resilience strategies is trust. Trust is a powerful skill that helps individuals experiencing homelessness put their faith in trained professionals, pursue a plan to obtain housing, and maintain it. Yet trust is not developed overnight. Trust is not established with a homeless “sweep.” Trust is built up little-by-little through conversations in which patients’ sense of dignity is placed centerstage: through conversations in which patients are asked, in their own words, as many times as it takes, “what matters?”