Bridging the gap between primary care and community-based organizations to address complex care needs of older adults.

Supporting older adults in their desire to remain in an independent living environment requires a collaborative, interprofessional approach in which the individual's medical and social needs are coordinated. This approach requires recognizing the difference in the culture of care between primary care and community-based organizations. Identifying how the two cultures differ may be the first step to learning how to work collaboratively and effectively to meet the social and medical needs of older adults. In this paper, we describe the rationale and process for integrated primary and community-based care in a comprehensive restructuring of care for older adults as well as recommendations for implementation.

Geriatric Interprofessional Team Transformation for Primary Care overview.

BACKGROUND: The Geriatric Interprofessional Team Transformation for Primary Care (GITT-PC) is a model developed to deliver optimal care to older adults in primary care. GITT-PC is an expansion of the John A. Hartford Foundation Geriatric Interdisciplinary Team Training (GITT) program developed at New York University and funded from 1995 to 2002 (Fulmer et al., 2004). GITT was designed to create training models that reflect the needs of the changing health care system and the challenge of caring for older adults with complex conditions (Fulmer et al., 2005). The GITT-PC model builds on the lessons learned from GITT and the development of curricula and training materials based on best practices. METHODS: Implementation of GITT-PC is accomplished through systems and practices that meet the needs and preferences of patients and their families and that are implemented by teams of health professionals and community service providers. GITT-PC is focused on four core components of high-quality geriatric care: (1) health promotion and prevention, (2) chronic disease management, (3) advanced care planning, and (4) transitional care management, each component corresponding to a Medicare-reimbursable visit. RESULTS: Implementation of these reimbursable services enables practices to provide evidence-based geriatric care while realizing a potential significant return on investment. CONCLUSIONS: The GITT-PC model has evolved from an academic training program to a financially sustainable model that serves to improve the care of older adults through a systematic team transformation process that makes a clear business case for primary care (Tabbush et al., 2021). The GITT-PC training program can be implemented in primary care practices with a focus on improving or expanding delivery of annual wellness visits (AWVs) and, potentially, registered RN-led AWVs.

Age-friendly health care and the 4Ms in RN-led annual wellness visits.

BACKGROUND: Medicare annual wellness visits (AWVs) are prevention-focused healthcare visits free to Medicare recipients. These visits focus on health maintenance, health risk assessment, prevention of illness, and maintaining independence, all of which are within the scope of registered nurse (RN) practice as well as aligned with what matters, medication, mentation, and mobility - the 4Ms - of age-friendly health care. The objective of this pilot study was to evaluate the implementation of the 4Ms in the context of RN-led Medicare AWVs in a primary care practice. METHODS: In a primary care practice with approximately 2500 patients, including approximately 571 of whom were enrolled in Medicare, RN-led Medicare AWVs were implemented, incorporating the 4Ms framework. During this time, data were collected on the effect of the AWV on access to care-conceptualized here as the number of visits available as well as the type of clinician open to staff these visits. Data collection also included patient responses to the 4Ms question "what matters most?" RESULTS: Overall, the RN-led visits were successful and beneficial to the practice. Each RN-led visit allowed for 2 additional acute or monitoring visits per provider (nurse practitioner, MD) per day, increasing patient access to their primary care providers. Inclusion of the 4Ms questions facilitated discussion around overall mental and emotional well-being, life stressors, quality of life, and goals of care. CONCLUSION: RN-led Medicare AWVs incorporating the 4Ms framework enhances the role of RNs in primary care by focusing on a health promotion role, utilizing RNs to their full scope of practice. RN-led AWVs increase provider availability for acute and chronic care appointments, as well as foster conversations around quality of life, as well as mental and emotional well-being.

Expanding the use of brief cognitive assessments to detect suspected early-stage cognitive impairment in primary care.

INTRODUCTION: Mild cognitive impairment remains substantially underdiagnosed, especially in disadvantaged populations. Failure to diagnose deprives patients and families of the opportunity to treat reversible causes, make necessary life and lifestyle changes and receive disease-modifying treatments if caused by Alzheimer's disease. Primary care, as the entry point for most, plays a critical role in improving detection rates. METHODS: We convened a Work Group of national experts to develop consensus recommendations for policymakers and third-party payers on ways to increase the use of brief cognitive assessments (BCAs) in primary care. RESULTS: The group recommended three strategies to promote routine use of BCAs: providing primary care clinicians with suitable assessment tools; integrating BCAs into routine workflows; and crafting payment policies to encourage adoption of BCAs. DISSCUSSION: Sweeping changes and actions of multiple stakeholders are necessary to improve detection rates of mild cognitive impairment so that patients and families may benefit from timely interventions.

Medicare's annual wellness visit: 10 years of opportunities gained and lost.

Medicare annual wellness visits (AWV) were initiated 10 years ago. Though AWVs emphasize on disease prevention and health promotion for older adults was a huge step forward, the current "one size fits all" approach does not adequately meet the wellness needs of a diverse population of older adults. Current AWVs do not sufficiently take into consideration the medical, psychological, functional, racial, cultural and socio-economic diversity of older adults. Updated AWVs should be tailored to meet the needs and priorities of older adults receiving them. Several geriatrics approaches to care, including geriatrics Glidepaths and the 4Ms of an Age-Friendly Health System, could help develop and guide a more patient-specific geriatrics focused approach to AWVs. Medicare's IPPE is an ideal time to advise new Medicare beneficiaries regarding what they should and should not do to maximize their ability to be healthy and functionally independent into their 80s, 90s, and 100s.

Reducing Avoidable Facility Transfers (RAFT): Outcomes of a Team Model to Minimize Unwarranted Emergency Care at Skilled Nursing Facilities.

BACKGROUND: Acute health care interventions for residents of skilled nursing facilities (SNFs) are often unwarranted, unwanted, and/or harmful. We describe a provider-focused care model to reduce unwarranted or unwanted acute health care utilization. OBJECTIVE: Assess the capability of the Reducing Avoidable Facility Transfers (RAFT) model to reduce unwanted and unwarranted acute health care utilization among residents in 3 rural SNFs between January 1, 2016 and June 30, 2017. DESIGN: Prospective cohort, pre/post study. SETTING: Three rural SNFs in collaboration with a geriatric practice in a tertiary academic medical center. PARTICIPANTS: Post-acute care (PAC) and long-term care (LTC) residents of 3 rural SNFs. INTERVENTION: RAFT includes the following components: (1) a small team of providers who manage longitudinal care and after hours call; (2) elicitation of advance care plans and preferences regarding acute care; (3) standardized communication process engaging the provider at the identification of an acute care event; (4) a biweekly case review of all emergency department (ED) transfers. MEASURES: ED and hospital utilization. RESULTS: RAFT demonstrated a 35% reduction in monthly ED transfers and a 30.5% reduction in monthly hospitalizations. These reductions were greatest for LTC residents. CONCLUSIONS/IMPLICATIONS: The RAFT approach substantially reduced unwarranted ED and hospital utilization in this study. Results support replication and evaluation in a larger, more diverse setting and population.

The Geriatric Workforce Enhancement Program: Review of the Coordinating Center and Examples of the GWEP in Practice.

The Health Resources and Services Administration created the Geriatric Workforce Enhancement Program (GWEP) in 2015 to address future geriatric workforce challenges and redefine the delivery of care to older adults. The John A. Hartford Foundation subsequently funded the GWEP Coordinating Center (GWEP-CC) to offer centralized, strategic support to these 44 diverse GWEP sites. This article outlines the last 3 years of GWEP work done at the national and local levels to transform geriatric care. Dissemination of the innovative Geriatric Interprofessional Team Transformation in Primary Care program, created by the Dartmouth GWEP, demonstrates how the GWEP-CC can benefit local initiatives and inform national perspectives. The GWEP-CC is a change agent in this way, scaling and distributing information and implementation support across the country. The GWEP-CC also serves as an essential repository of data, continuously determining what is working and what could be improved. This informs activity of the GWEP-CC, funders and other stakeholders, and provides the most up-to-date resources to GWEP sites and their partners. The GWEP-CC achieves its objectives through several key pillars: networking opportunities, education and training, advocacy, and evaluation. Although many advances have been made, opportunities to continue paving the way are plenty, especially with regards to mental health. This article discusses the work accomplished to date and presents some future considerations for mental health and overall healthcare transformation.

Addressing the Community-Based Geriatric Healthcare Workforce Shortage by Leveraging the Potential of Interprofessional Teams.

As Americans live longer lives, we will see an increased demand for quality healthcare for older adults. Despite the growth in the number of older adults, there will be a decrease in the supply of a primary care physician workforce to provide adequately for their care and health needs. This article reviews the literature that explores ways to address the primary care workforce shortage in a community-based geriatric healthcare setting, with special attention to elevating the role of nurses and caregivers and shifting the way we think about delivery of care and end-of-life conversations and planning. The shift is toward a more integrated and collaborative approach to care where medical and nonmedical, social services, and community providers all play a role. Several models have demonstrated promising positive benefits and outcomes to patients, families, and providers alike. The goal is to provide high quality care that addresses the unique attributes of older adults, especially those with complex conditions, and to focus more on care goals and priorities. The many barriers to scaling and spreading models of care across varied settings include payment structures, lack of education and training among all stakeholders, and, at the top of the list, leadership resistance. We address these barriers and make recommendations for a path forward where healthcare providers, policymakers, patients, families, and everyone else involved can play a role in shaping the workforce caring for older adults. J Am Geriatr Soc 67:S400-S408, 2019.

Geriatric interdisciplinary team training program: evaluation results.

Geriatric interdisciplinary team training has long been a goal in health education with little progress. In 1997, the John A. Hartford Foundation funded eight programs nationally to create Geriatric Interdisciplinary Team Training (GITT) programs. Faculty trained 1,341 health professions students. The results of the evaluation, including presentation of new measures developed to assess interdisciplinary knowledge, are presented, and the implications of the program as a model of interdisciplinary education are discussed. Evaluation data from 537 student trainees are presented. At posttest, GITT trainees demonstrated improvement on all measures of attitudinal change, no change on the geriatric care planning measure, and a change in some of the questions on the test of team dynamics that varied by discipline. Changes were greatest for all the attitudinal measures with the self-reported Team Skills Scale indicating the most significant change--a change that is significant across medicine, nursing, and social work trainees.

Agitation and depression in frail nursing home elderly patients with dementia: treatment characteristics and service use.

OBJECTIVE: The authors describe characteristics, treatment, and acute service use associated with agitation and depression in dementia. METHODS: Authors used retrospective chart review of symptoms, physician-level prescribing, and acute service use over 3 months for 2,487 physically frail older residents, including 1,836 with dementia, (mean age: 79.8 years) in 109 long-term care facilities, describing differences between uncomplicated dementia and three mutually exclusive subgroups of complicated dementia, including dementia with agitation-only, dementia with depression-only, and dementia with mixed agitation and depression. RESULTS: Compared with the other subgroups, frail elderly patients with dementia complicated by mixed agitation and depression have the highest rate of hospitalization, the greatest number of medical diagnoses, and the greatest medical severity, and they receive the greatest number of psychiatric medications. Depression in dementia (either alone or mixed with agitation) was associated with greater prevalence of pain. CONCLUSIONS: Dementia complicated by mixed agitation and depression accounts for over one-third of complicated dementia and is associated with multiple psychiatric and medical needs, intensive pharmacological treatment, and use of high-cost services. Research should target this complex, high-risk group to develop appropriate diagnostic criteria and effective treatment interventions.