Moving Primary Care Forward to Meet the Complex Care Needs of Older Adults

Moving Primary Care Forward to Meet the Complex Care Need...   13.58 MB   1 version
Uploaded - 12-01-2017
As the aging population rapidly grows, transformation of the healthcare system is imperative to meet the complex needs of older Americans. Interdisciplinary collaborative team-based care may be a solution to mitigate the complexity of geriatric care needs. With the goal of transforming primary care sites to meet the growing needs of older adults, Lehigh Valley Health Network aims to fully integrate Guided Care Nurses (GC-RNs), along with Community Health Workers and Pharmacists, into multidisciplinary healthcare teams by adapting the Guided Care model. GC-RNs target both medical and non-medical needs of elderly patients through care coordination, care planning, self-management support, facilitating transitions of care, and linkage to community resources. To date, the GC-RNs have managed the needs of more than 500 elderly patients within 6 primary care practices and performed over 600 home visits. Preliminary results of healthcare utilization demonstrate reductions in the means of emergency department visits and hospitalizations among elderly patients. Early findings of integrating GC-RNs into multidisciplinary healthcare teams show promising results for elderly primary care and better use of healthcare resources in older adults.