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.