Background: The Palo Alto VA Hospital has an interdisciplinary Clinical Command Center (C3) that includes “Flow” nurse practitioners (NPs) who work closely with case management, social work and primary medical teams to identify and address barriers to care and assist in discharge planning and coordination. We have created a novel collaboration between a C3 Flow [...]

Case Presentation: Planning a safe discharge from the hospital is a collaboration that includes the care team and the patient. At our VA hospital, a geriatric 4M’s (Mobility, Medications, Mentation, What Matters Most) assessment helps to determine “What Matters Most” to older Veterans as well as to connect them with the right community services (such [...]