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Article

System Redesign: The Value of a Primary Care Liaison Model to Address Unmet Social Needs among Older Primary Care Patients

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Department of Health Service Research & Administration, University of Nebraska Medical Center, 984350 Nebraska Medical Center, Omaha, NE 68198, USA
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Nebraska Medicine Nebraska Medical Center, Omaha, NE 68198, USA
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Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE 68198, USA
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Department of Internal Medicine, Division of Geriatrics, Gerontology and Palliative Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
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Department of Internal Medicine, Division of General Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
*
Author to whom correspondence should be addressed.
Academic Editor: Kevin M. Kelly
Int. J. Environ. Res. Public Health 2021, 18(21), 11135; https://doi.org/10.3390/ijerph182111135
Received: 1 September 2021 / Revised: 8 October 2021 / Accepted: 21 October 2021 / Published: 23 October 2021
(This article belongs to the Special Issue Wellness and Health Promotion for the Older Adults)
Assessing and addressing social determinants of health can improve health outcomes of older adults. The Nebraska Geriatrics Workforce Enhancement Program implemented a primary care liaison (PCL) model of care, including training primary care staff to assess and address unmet social needs, patient counseling to identify unmet needs, and mapping referral services through cross-sectoral partnerships. A PCL worked with three patient-centered medical homes (PCMHs) that are part of a large integrative health system. A mixed-methods approach using a post-training survey and a patient tracking tool, was used to understand the reach, adoption, and implementation of the PCL model. From June 2020 to May 2021, the PCL trained 61 primary care staff to assess and address unmet social needs of older patients. A total of 327 patients, aged 65 years and older and within 3–5 days of acute-care hospital discharges, were counseled by the PCL. For patients with unmet needs, support services were arranged through community agencies: transportation (37%), in-home care (33%), food (16%), caregiver support (2%), legal (16%), and other (16%). Our preliminary results suggest that the PCL model is feasible and implementable within PCMH settings to address unmet social needs of older patients to improve their health outcomes. View Full-Text
Keywords: older adult; health promotion; what matters; primary care liaison; social determinants of health older adult; health promotion; what matters; primary care liaison; social determinants of health
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MDPI and ACS Style

Kim, J.; Pacino, V.; Wang, H.; Recher, A.; Jain, I.; Mone, V.; Ma, J.; Spurgin, M.J.; Jeffrey, D.; Mohring, S.; Potter, J. System Redesign: The Value of a Primary Care Liaison Model to Address Unmet Social Needs among Older Primary Care Patients. Int. J. Environ. Res. Public Health 2021, 18, 11135. https://doi.org/10.3390/ijerph182111135

AMA Style

Kim J, Pacino V, Wang H, Recher A, Jain I, Mone V, Ma J, Spurgin MJ, Jeffrey D, Mohring S, Potter J. System Redesign: The Value of a Primary Care Liaison Model to Address Unmet Social Needs among Older Primary Care Patients. International Journal of Environmental Research and Public Health. 2021; 18(21):11135. https://doi.org/10.3390/ijerph182111135

Chicago/Turabian Style

Kim, Jungyoon, Valerie Pacino, Hongmei Wang, April Recher, Isha Jain, Vaibhavi Mone, Jihyun Ma, Mary J. Spurgin, Daniel Jeffrey, Stephen Mohring, and Jane Potter. 2021. "System Redesign: The Value of a Primary Care Liaison Model to Address Unmet Social Needs among Older Primary Care Patients" International Journal of Environmental Research and Public Health 18, no. 21: 11135. https://doi.org/10.3390/ijerph182111135

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