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

Area of Science:

• Geriatric Medicine
• Nursing Care Models
• Healthcare Quality Improvement

Background:

• Older adults represent a growing population requiring specialized care.
• The acute care setting presents unique challenges for geriatric patient management.
• A shortage of geriatricians necessitates innovative care delivery models.

Purpose of the Study:

• To describe a novel nurse-led model for age-friendly care in acute settings.
• To evaluate processes and outcomes using the 4Ms Framework (What Matters, Medication, Mentation, Mobility).
• To demonstrate the potential of nurses in leading geriatric care initiatives.

Main Methods:

• Implementation of the Supporting Older Adults at Risk Model.
• Inclusion of primary care geriatric nurse practitioner co-management and AGS CoCare®:HELP.
• Descriptive statistics used to analyze outcomes aligned with the 4Ms Framework.

Main Results:

• 81% of patients had documented advance care planning conversations, leading to goal-concordant care.
• Identification and reduction of high-risk medications (Beers Criteria®, anticholinergics).
• 100% of patients had mobility goals identified; 46% maintained or improved mobility; mentation addressed in alignment with patient priorities.

Conclusions:

• Nurses are pivotal in leading age-friendly care within acute care settings.
• The implemented model demonstrates positive impacts on key geriatric care domains.
• This approach offers a viable solution to address the geriatrician workforce shortage and improve care quality.