Abstract
A need to improve the transitions of care between a small rural emergency department, a residential care facility and a primary care practice emerged early on in our work to become a level 2 accredited emergency department. One challenge is bringing together 3 partners all with distinct types of health records, unique foci of care and a variety of disciplines and workforce. This paper will focus on our journey of creating an individualized plan of care to help mitigate problems of poor communication with a focus on the 4Ms framework including: What Matters Most, Mobility, Medication and Mentation.