What Does “Age-Friendly” Care Really Look Like? A Family’s Story
As families navigate the challenges of caring for older adults, questions often arise: How do we make decisions that honor our loved one’s wishes? How do we balance safety with independence? The Age-Friendly Health Systems (AFHS) movement offers a framework to answer these questions. A recent family story shows how it can make all the difference, and how Nurse Practitioners (NPs) play a vital role in putting this approach into practice at home.
What Is Age-Friendly Health Systems?
AFHS is a national initiative launched in 2017 by the John A. Hartford Foundation and the Institute for Healthcare Improvement, in partnership with the American Hospital Association and the Catholic Health Association of the United States.
Its goal is simple but powerful: ensure every older adult receives evidence-based care that aligns with their goals and priorities, in every setting, every day.
AFHS focuses on four essential elements known as the 4Ms:
What Matters – Know and act on each older adult’s health goals and preferences.
Medications – Use age-friendly medication practices, avoiding drugs that may harm or conflict with goals.
Mentation – Prevent, identify, and manage dementia, depression, and delirium.
Mobility – Support safe movement to maintain function and independence.
AFHS has three aims:
Follow an essential set of evidence-based practices.
Cause no harm.
Align with What Matters to the older adult and their family and/or caregivers.
The Case: Meeting Mr. and Mrs. W
Mr. W was an older adult with multiple health concerns who valued comfort and time with family over aggressive medical interventions. His wife, Mrs. W, was devoted to him but beginning to experience early memory changes herself. Their adult children wanted to help but had differing opinions about the best plan for their parents.
In this emotionally charged situation, focusing on the 4Ms of Age-Friendly Care provided a clear path forward for both the family and the care team:
What Matters: The team began by identifying Mr. W’s personal goals, which are remaining at home, prioritizing comfort, and spending quality time with his wife. This shifted decisions away from aggressive interventions and toward supportive care aligned with his values.
Medications: A review of Mr. W’s prescriptions led to streamlining his regimen and discontinuing nonessential medications that increased risk for adverse drug events.
Mentation: Early signs of memory changes in Mrs. W prompted education for the family on recognizing delirium and dementia symptoms, as well as strategies to support cognitive health at home.
Mobility: Because Mr. W was deconditioned after recent hospitalizations, the team incorporated fall-prevention strategies and gentle activity to help him stay as independent and safe as possible in his own environment.
Partnering With Nurse Practitioners to Help Older Adults Thrive at Home
NPs are uniquely positioned to deliver age-friendly care in the home setting. With advanced training in both diagnosis and management of chronic conditions, NPs bridge the gap between primary care and specialty services, often catching problems early and reducing unnecessary hospital visits.
When to Involve an NP
Transitions of care (after hospitalizations or rehab stays)
Chronic disease management
Complex medication management or frequent medication changes
New or worsening cognitive concerns (delirium, dementia symptoms)
Fall prevention and mobility assessments
Advance care planning and family decision support
NP Roles in Age-Friendly Care
Conducting comprehensive home assessments using the 4Ms framework
Aligning care plans with the older adult’s personal goals
Coordinating with physicians, caregivers, and community resources
Providing ongoing education and anticipatory guidance for families
How Overture Supports These Partnerships
Overture is partnering with nurse practitioner, Dr. Kate Taylor, to strengthen support for older adults across retirement communities and home settings. In her role as a clinical consultant, Dr. Taylor advises Overture’s nursing team and caregivers on best practices in age-friendly care and helps align services with the values and goals of older adults and their families. This collaboration enhances continuity of care and equips families to navigate both routine and complex health needs with confidence.
Why This Approach Matters
Families often feel overwhelmed when navigating care for older adults. The AFHS framework, especially when paired with NP expertise, helps to:
Simplify decisions by focusing on values, not just medical tasks
Improve quality of life by reducing unnecessary hospital visits and interventions
Empower families with clear goals and shared understanding among all care team members
Lessons for Families and Referral Sources
Start conversations early about what matters most to your loved one. Don’t wait for a crisis.
Ask about NP involvement and how they can support age-friendly care at home.
Seek alignment between medical care and personal values to reduce stress and avoid unwanted interventions.
Age-friendly care isn’t about doing more or less; it’s about doing what’s right for the older adult and their family. With the 4Ms as a guide, and NPs as a trusted partner, families can navigate care decisions with confidence, dignity, and compassion.