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.