The Geriatrics in Primary Care Demonstration: Integrating Comprehensive Geriatric Care into the Medical Home: Preliminary Data.

Three thousand nine hundred thirty-one veterans aged 75 and older receive primary care (PC) in two large practices of the Department of Veterans Affairs (VA) Boston Healthcare System. Cognitive and functional disabilities are endemic in this group, creating needs that predictably exceed available or appropriate resources. To address this problem, Geriatrics in Primary Care (GPC) embeds geriatric services directly into primary care. An on-site consulting geriatrician and geriatric nurse care manager work directly with PC colleagues in medicine, nursing, social work, pharmacy, and mental health within the VA medical home. This design delivers interdisciplinary geriatric care within PC that emphasizes comprehensive evaluations, care management, planned transitions, informed resource use, and a shift in care focus from multiple subspecialties to PC. Four hundred thirty-five veterans enrolled during the project's 4-year course. Complex, fragmented care was evident in a series of 50 individuals (aged 82 ± 7) enrolled during Months 1 to 6. The year before, these individuals made 372 medical or surgical subspecialty clinic visits (7.4 ± 9.8); 34% attended five or more subspecialty clinics, 48% had dementia, and 18% lacked family caregivers. During the first year after enrollment the mean number of subspecialty clinic visits declined significantly (4.7 ± 5.0, P = .01), whereas the number of PC-based visits remained stable (3.1 ± 1.5 and 3.3 ± 1.5, respectively, P = .50). Telephone contact by GPC (2.3 ± 2.0) and collaboration with PC clinicians replaced routine follow-up geriatric care. GPC facilitated planned transitions to rehabilitation centers (n = 5), home hospice (n = 2), dementia units (n = 3), and home care (n = 37). GPC provides efficient, comprehensive geriatric care and case management while preserving established relationships between patients and the PC team. Preliminary results suggest "care defragmentation," as reflected by a significant reduction in subspecialty clinic use. Model simplicity and flexibility facilitated ready implementation.

Barriers to patient portal access among veterans receiving home-based primary care: a qualitative study.

BACKGROUND: Electronic, or web-based, patient portals can improve patient satisfaction, engagement and health outcomes and are becoming more prevalent with the advent of meaningful use incentives. However, adoption rates are low, particularly among vulnerable patient populations, such as those patients who are home-bound with multiple comorbidities. Little is known about how these patients view patient portals or their barriers to using them. OBJECTIVE: To identify barriers to and facilitators of using My HealtheVet (MHV), the United States Department of Veterans Affairs (VA) patient portal, among Veterans using home-based primary care services. DESIGN: Qualitative study using in-depth semi-structured interviews. We conducted a content analysis informed by grounded theory. PARTICIPANTS: Fourteen Veterans receiving home-based primary care, surrogates of two of these Veterans, and three home-based primary care (HBPC) staff members. KEY RESULTS: We identified five themes related to the use of MHV: limited knowledge; satisfaction with current HBPC care; limited computer and Internet access; desire to learn more about MHV and its potential use; and value of surrogates acting as intermediaries between Veterans and MHV. CONCLUSIONS: Despite their limited knowledge of MHV and computer access, home-bound Veterans are interested in accessing MHV and using it as an additional point of care. Surrogates are also potential users of MHV on behalf of these Veterans and may have different barriers to and benefits from use.

A qualitative study: barriers and facilitators to health care access for individuals with psychiatric disabilities.

OBJECTIVE: This qualitative study was conducted as part of a larger randomized trial to examine barriers and facilitators to accessing and providing comprehensive primary health care for individuals with serious mental illnesses. We examined the perspectives of administrators and providers in a behavioral health organization surrounding the use of a nurse practitioner model of delivering primary healthcare. METHODS: Ten key informant interviews were conducted and analyzed using qualitative data analysis software. Concepts and themes regarding access to and delivery of primary healthcare were inductively derived from the data. RESULTS: Results confirmed significant issues related to chronic physical health problems among individuals with psychiatric disabilities and detailed a host of barriers to receiving health care as well as the perceived benefits of the nurse practitioner intervention. Financial challenges played a significant role in the organization's ability to make primary and mental health care integration a sustainable endeavor. In addition, staff faced increased burdens on their time due to adding a focus on physical health to their existing job duties. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: A nurse practitioner stationed in a behavioral healthcare setting is viewed by administrators and providers as extremely beneficial in addressing issues of access to comprehensive and integrated primary healthcare for individuals with severe psychiatric disabilities but sustaining such a model of care is not without organizational challenges.