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Related Concept Videos

Documentation in Long-Term and Home Healthcare Setting01:29

Documentation in Long-Term and Home Healthcare Setting

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Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
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Traditional Level Of Health Care System01:26

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The levels of care describe the services provided in the healthcare system. Accordingly, there are six levels of the traditional healthcare system in the US: preventive, primary, secondary, tertiary, restorative, and continuing healthcare. A nurse must understand how the healthcare industry organizes and provides services within these levels of care.
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Restorative care is provided once a patient has been discharged from a healthcare facility and requires additional services. The additional services include home care, rehabilitation programs, and extended care. Restorative care centers help the patient regain their previous level of functioning or acquire a new level of functioning due to the incapacitating effects of a disease or a disability. It aims to assist patients in enhancing their quality of life by encouraging independence,...
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Peripheral Artery Disease (PAD) is characterized by narrowed arteries that diminish blood flow to the extremities. Effective management of PAD requires an interprofessional approach involving various healthcare professionals. The critical aspects of interprofessional care for PAD patients focus on risk factor modification, drug therapy, exercise therapy, nutrition therapy, critical limb ischemia care, and interventional radiology and surgical procedures.The primary treatment goal for PAD...
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Specialized care provided over an extended period is called tertiary care. Usually, a primary or secondary care physician will refer a patient to tertiary care. A patient's maximum physical and mental function is restored in tertiary care, which is caused due to the impact of a chronic illness or condition. Tertiary care aims to achieve the highest level of functioning possible while managing chronic illness. For example, a patient who falls and fractures their hip will need secondary care...
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The discharge summary is crucial as it enables a smooth transition from a healthcare facility to a patient's home or another care setting. This critical document facilitates seamless continuity of care, ensuring patients receive the necessary support and attention.
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Updated: Jan 14, 2026

Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit
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Post-Hospitalization Outcomes for Veterans Receiving Age-Friendly Health Systems 4M Care.

Thomas A Bayer1,2, Malisa Barber1, Christopher Halladay1

  • 1Transformative Health Systems Research to Improve Veteran Equity and Independence Center of Innovation (THRIVE), Providence VA Healthcare System, Providence, Rhode Island, USA.

Journal of the American Geriatrics Society
|October 17, 2025
PubMed
Summary

Age-Friendly Health System (AFHS) care, including the 4Ms (What Matters, Medications, Mobility, and Mentation) assessment, reduced 30-day readmissions for Veterans. This study supports implementing AFHS evidence-based practices in inpatient settings.

Keywords:
agedage‐friendly health systemshospitalization

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Area of Science:

  • Geriatric Medicine
  • Health Services Research
  • Quality Improvement

Background:

  • The Age-Friendly Health System (AFHS) initiative promotes the assessment of the 4Ms (What Matters, Medications, Mobility, and Mentation) in healthcare.
  • While the 4Ms are evidence-based, limited data exist on outcomes for patients receiving comprehensive 4Ms assessment.

Purpose of the Study:

  • To evaluate the impact of inpatient AFHS care, specifically the 4Ms assessment, on key health outcomes for Veterans.
  • To determine if AFHS care influences 30-day readmission rates, emergency department (ED) visits, and mortality.

Main Methods:

  • Retrospective matched cohort study of Veterans admitted to six VA medical centers from January 2022 to December 2024.
  • Used electronic health records to identify Veterans with documented 4Ms assessments and matched them with controls without complete 4Ms assessment.
  • Propensity score matching was employed, considering facility, admission timing, demographics, and comorbidities. Outcomes analyzed included 30-day readmission, ED use, and mortality using Kaplan-Meier and Cox proportional hazard models.

Main Results:

  • The study included 2420 Veterans receiving 4Ms care and 4688 matched controls.
  • AFHS care incorporating the 4Ms was associated with a significantly reduced hazard for 30-day readmission (HR 0.67).
  • No statistically significant differences were observed in 30-day emergency department visits (HR 0.95) or mortality (HR 1.02) between the groups.

Conclusions:

  • Inpatient AFHS care, including the 4Ms assessment, is linked to decreased 30-day readmission rates among Veterans.
  • The findings suggest that implementing AFHS evidence-based practices in inpatient settings can improve patient outcomes.
  • Further research may explore the specific mechanisms driving the reduction in readmissions.