TY - JOUR
KW - Aged
KW - Geriatrics
KW - Home Care Services
KW - Humans
KW - Patient-Centered Care
KW - Primary Health Care
KW - Workforce
KW - Health Promotion
KW - Older adult
KW - primary care liaison
KW - Social Determinants of Health
KW - what matters
AU - J. Kim
AU - V. Pacino
AU - H. Wang
AU - A. Recher
AU - I. Jain
AU - V. Mone
AU - J. Ma
AU - M. J. Spurgin
AU - D. Jeffrey
AU - S. Mohring
AU - J. Potter
A1 - 
AB - Assessing and addressing social determinants of health can improve health outcomes of older adults. The Nebraska Geriatrics Workforce Enhancement Program implemented a primary care liaison (PCL) model of care, including training primary care staff to assess and address unmet social needs, patient counseling to identify unmet needs, and mapping referral services through cross-sectoral partnerships. A PCL worked with three patient-centered medical homes (PCMHs) that are part of a large integrative health system. A mixed-methods approach using a post-training survey and a patient tracking tool, was used to understand the reach, adoption, and implementation of the PCL model. From June 2020 to May 2021, the PCL trained 61 primary care staff to assess and address unmet social needs of older patients. A total of 327 patients, aged 65 years and older and within 3-5 days of acute-care hospital discharges, were counseled by the PCL. For patients with unmet needs, support services were arranged through community agencies: transportation (37%), in-home care (33%), food (16%), caregiver support (2%), legal (16%), and other (16%). Our preliminary results suggest that the PCL model is feasible and implementable within PCMH settings to address unmet social needs of older patients to improve their health outcomes.
AD - Department of Health Service Research & Administration, University of Nebraska Medical Center, 984350 Nebraska Medical Center, Omaha, NE 68198, USA.; Department of Health Service Research & Administration, University of Nebraska Medical Center, 984350 Nebraska Medical Center, Omaha, NE 68198, USA.; Department of Health Service Research & Administration, University of Nebraska Medical Center, 984350 Nebraska Medical Center, Omaha, NE 68198, USA.; Nebraska Medicine Nebraska Medical Center, Omaha, NE 68198, USA.; Department of Health Service Research & Administration, University of Nebraska Medical Center, 984350 Nebraska Medical Center, Omaha, NE 68198, USA.; Department of Health Service Research & Administration, University of Nebraska Medical Center, 984350 Nebraska Medical Center, Omaha, NE 68198, USA.; Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE 68198, USA.; Department of Internal Medicine, Division of Geriatrics, Gerontology and Palliative Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA.; Department of Internal Medicine, Division of General Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA.; Department of Internal Medicine, Division of General Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA.; Department of Internal Medicine, Division of Geriatrics, Gerontology and Palliative Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA.
BT - International journal of environmental research and public health
C5 - Education & Workforce; Healthcare Disparities; Medical Home
CP - 21
DO - 10.3390/ijerph182111135
IS - 21
JF - International journal of environmental research and public health
LA - eng
M1 - Journal Article
N2 - Assessing and addressing social determinants of health can improve health outcomes of older adults. The Nebraska Geriatrics Workforce Enhancement Program implemented a primary care liaison (PCL) model of care, including training primary care staff to assess and address unmet social needs, patient counseling to identify unmet needs, and mapping referral services through cross-sectoral partnerships. A PCL worked with three patient-centered medical homes (PCMHs) that are part of a large integrative health system. A mixed-methods approach using a post-training survey and a patient tracking tool, was used to understand the reach, adoption, and implementation of the PCL model. From June 2020 to May 2021, the PCL trained 61 primary care staff to assess and address unmet social needs of older patients. A total of 327 patients, aged 65 years and older and within 3-5 days of acute-care hospital discharges, were counseled by the PCL. For patients with unmet needs, support services were arranged through community agencies: transportation (37%), in-home care (33%), food (16%), caregiver support (2%), legal (16%), and other (16%). Our preliminary results suggest that the PCL model is feasible and implementable within PCMH settings to address unmet social needs of older patients to improve their health outcomes.
PY - 2021
SN - 1660-4601; 1661-7827; 1660-4601
SP - 11135
T1 - System Redesign: The Value of a Primary Care Liaison Model to Address Unmet Social Needs among Older Primary Care Patients
T2 - International journal of environmental research and public health
TI - System Redesign: The Value of a Primary Care Liaison Model to Address Unmet Social Needs among Older Primary Care Patients
U1 - Education & Workforce; Healthcare Disparities; Medical Home
U2 - 34769655
U3 - 10.3390/ijerph182111135
VL - 18
VO - 1660-4601; 1661-7827; 1660-4601
Y1 - 2021
Y2 - Oct 23
ER -