Supporting Older Adults at Risk (SOAR): A Nurse-Led Model to Achieve Age-Friendly Care

Purpose: To describe a model of nurse-led age-friendly care in the acute care setting and associated processes and outcomes aligned with the 4Ms Framework. Method: We implemented the Supporting Older Adults at Risk Model—a novel model of care that includes primary care geriatric nurse practitioner co-management and AGS CoCare ® :HELP—and used descriptive statistics to evaluate outcomes aligned with each of the 4Ms: What Matters, Medication, Mentation, and Mobility. Results: Advance care planning conversations were documented for 81% of the selected sample, resulting in subsequent family meetings and goal-concordant care. Beers Criteria ® and anticholinergic medications were identified and reduced. Mobility goals were identified for 100% of the selected sample and mobility was maintained or improved for 46%. Addressing mentation was done in alignment with What Matters. Conclusion: Nurses are well-positioned to lead age-friendly care and drive optimal outcomes in the acute care setting, especially considering the geriatrician workforce shortage.