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 [...]

Background: The age-friendly hospital implements an evidence-based “4M” framework (what matters most, medication reconciliation, mentation and mobility) to minimize harm among older adults. Clinical outcomes of patients who receive bundled 4M’s care delivery remains a knowledge gap. We determined if the incremental benefit of more M’s was associated with reduced discharges to post-acute care facilities. [...]

Background: Asking patients “what matters” to them is one of the 4 evidence-based elements of care developed by the Age-Friendly Health Systems initiative to improve the care of older adults, and the question “what matters most” has been extended to other settings. We conducted a study to assess the frequency and categories of responses to [...]

Background: The elderly population is growing rapidly and those aged 65 and older comprise nearly 40 percent of hospitalized adults. As the population continues to age, this number is expected to rise. Promoting age-friendly care has been at the forefront of many health systems’ goals. Purpose: Our Hospital Medicine Group’s Orthopedic Hospitalist co-management program set [...]

Background: The Institute for Healthcare Improvement’s Age-Friendly Health Systems (AFHS) initiative calls for providers to ensure that older adults move safely to maintain daily function. However, studies show that about a third of hospitalized older adults have bed rest orders, most of which are not medically indicated. Therefore, at our 537-bed community teaching hospital, we [...]

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 [...]

Background: The fragmented US healthcare system leads to high rates of errors, especially for older patients. In 2017, multiple health institutions collaborated to create an age-friendly framework, named the 4Ms. To help ensure reliable care, the 4Ms framework consists of what matters, medications, mentation and mobility (1). Beginning in 2025, CMS will require hospital reporting [...]