Special Issue "Geriatric Care Models"

A special issue of Geriatrics (ISSN 2308-3417). This special issue belongs to the section "Healthy Aging".

Deadline for manuscript submissions: closed (30 June 2018)

Special Issue Editor

Guest Editor
Prof. Dr. James S. Powers

1. Professor of Medicine, Vanderbilt University School of Medicine, 7159 Vanderbilt Medical Center East,Nashville, TN 37232, USA
2. Clinical Associate Director, Tennessee Valley Geriatric Research, Education, and Clinical Center, Nashville TN, USA
Website | E-Mail
Interests: geriatrics education; long-term care; geriatric nutrition; frail elderly; quality improvement; geriatric care models

Special Issue Information

The Importance of Geriatric Care Models

Healthcare is undergoing a value-based transformation. Value-driven healthcare strives to improve access to healthcare, to improve the patient’s experience and quality of care, and to moderate healthcare costs. Value-based purchasing drives quality metrics and can serve as an important lever for changes in healthcare delivery. 

Geriatric patients consume a disproportionate share of healthcare resources. Estimates from the US suggest that 50% of healthcare costs are attributed to 5% of the population characterized as hi-risk, hi-need patients. The high-need population is characterized by heavy healthcare utilization and having functional self-care limitations. In addition to clinical needs, the high-need population also has behavioral, functional, and social needs.

Program targeting for added services for high-risk populations, and focusing service resources to needs makes enormous sense. We are in the early stages of understanding how to identify appropriate patients and provide them the right intensity and mix of services. Innovative geriatric care models which demonstrate improved outcomes in health and well-being, care utilization, and cost moderation can be scaled to enhance care generally. Successful care models can involve the service setting, care delivery, and organizational culture. Focused management of high-need and frequent utilizers is critical, and may include enhanced primary care, transitional and integrated care across settings, new techniques for patient monitoring, inter-professional teamfunction, and continuous outcome assessment utilizing multiple data sources. The delivery transformation stimulated by value-based purchasing is forcing healthcare systems to evaluate the effects of different components of service along the continuum of care.

Potential contributors to this special edition of Geriatrics may include investigators and participants in innovative models of care such as accountable care organizations, advanced alternative payment models, transitions of care models, telehealth programs, patient-centered medical homes, acute care for elderly units, early mobility and healthy aging programs, medication reconciliation, and quality assessment and performance improvement (QAPI) programs. Submissions with data and analyses are particularly welcome. Additionally, thoughtful descriptive proposals of data analytics and continuous feedback to clinicians, identification of hi-need patients, improving the cultural environment and attitudes regarding aging and society, health policy concerns, and successful team-based and collaborative care models are welcome.

Dear Colleagues,

I am serving as Guest Editor for a Special Issue of the journal Geriatrics (https://www.mdpi.com/journal/geriatrics, ISSN 2308-3417) on the subject of "Geriatric Care Models". Innovative geriatric care models which demonstrate improved outcomes in health and well-being, care utilization, and cost moderation can be scaled to enhance care generally. Successful care models can involve the service setting, care delivery, and organizational culture. It is my pleasure to invite you to submit an invited feature article on the topic of Geriatric Care Models. The manuscript may be either a full paper or a communication based on your own research in this area, or may be a focused review article on some aspect of the subject. Please note that for your contribution, all article processing charges will be *waived*.

Geriatrics is fully open access. Open access (unlimited and free access by readers) increases publicity and promotes more frequent citations, as indicated by several studies. Open access is supported by the authors and their institutes.

The submission deadline is *30 June 2018*. You may send your manuscript now or up until the deadline. If you require an extension, just advise us of a more realistic deadline. Submitted papers should not be under consideration for publication elsewhere. We also encourage authors to send a short abstract or tentative title to the Editorial Office in advance ([email protected]).

For further details on the submission process, please see the instructions for authors at the journal website.

Thanking you in anticipation.

With best wishes

Prof. James S. Powers MD
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All papers will be peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Geriatrics is an international peer-reviewed open access quarterly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 350 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • Geriatric Models of Care
  • Valuebased Healthcare
  • Healthcare Outcomes
  • Transitions of Care
  • Identification of Highrisk, Highneed Patients
  • Aging and Society
  • Healthcare Policy
  • Data Analytics

Published Papers (17 papers)

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Editorial

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Open AccessEditorial
The Importance of Geriatric Care Models
Received: 21 December 2018 / Accepted: 25 December 2018 / Published: 27 December 2018
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Abstract
I am delighted to edit this Special Issue of Geriatrics focusing on Geriatric Care Models. [...] Full article
(This article belongs to the Special Issue Geriatric Care Models)
Open AccessFeature PaperEditorial
Strategies to Promote Broad-Based Implementation of Acute Care for Elders (ACE) Units
Received: 4 September 2018 / Revised: 4 September 2018 / Accepted: 4 September 2018 / Published: 6 September 2018
Cited by 1 | PDF Full-text (144 KB) | HTML Full-text | XML Full-text
(This article belongs to the Special Issue Geriatric Care Models)

Research

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Open AccessArticle
Improving Care Transitions for Hospitalized Veterans Discharged to Skilled Nursing Facilities: A Focus on Polypharmacy and Geriatric Syndromes
Received: 30 December 2018 / Revised: 31 January 2019 / Accepted: 5 February 2019 / Published: 9 February 2019
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Abstract
Geriatric syndromes and polypharmacy are common in older patients discharged to skilled nursing facilities (SNFs) and increase 30-day readmission risk. In a U.S.A. Department of Veterans Affairs (VA)-funded Quality Improvement study to improve care transitions from the VA hospital to area SNFs, Veterans [...] Read more.
Geriatric syndromes and polypharmacy are common in older patients discharged to skilled nursing facilities (SNFs) and increase 30-day readmission risk. In a U.S.A. Department of Veterans Affairs (VA)-funded Quality Improvement study to improve care transitions from the VA hospital to area SNFs, Veterans (N = 134) were assessed for geriatric syndromes using standardized instruments as well as polypharmacy, defined as five or more medications. Warm handoffs were used to facilitate the transfer of this information. This paper describes the prevalence of geriatric syndromes, polypharmacy, and readmission rates. Veterans were prescribed an average of 14.7 medications at hospital discharge. Moreover, 75% of Veterans had more than two geriatric syndromes, some of which began during hospitalization. While this effort did not reduce 30-day readmissions, the high prevalence of geriatric syndromes and polypharmacy suggests that future efforts targeting these issues may be necessary to reduce readmissions among Veterans discharged to SNF. Full article
(This article belongs to the Special Issue Geriatric Care Models)
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Open AccessArticle
Geriatrics Evaluation and Management in the Veterans Administration—An Historical Perspective
Received: 24 August 2018 / Revised: 18 November 2018 / Accepted: 21 November 2018 / Published: 25 November 2018
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Abstract
Comprehensive geriatric assessment, defined as an interdisciplinary assessment and development of an overall plan of treatment and follow-up, has become a fundamental part of clinical geriatric care. Since the 1970s, the US Department of Veterans Affairs (VA) has encouraged the development of geriatric [...] Read more.
Comprehensive geriatric assessment, defined as an interdisciplinary assessment and development of an overall plan of treatment and follow-up, has become a fundamental part of clinical geriatric care. Since the 1970s, the US Department of Veterans Affairs (VA) has encouraged the development of geriatric evaluation and management programs. Evolution of geriatric evaluation and management has occurred over time and many VA medical centers have transferred inpatient geriatric evaluation programs to long-term care Community Living Centers, home, and outpatient settings. Availability of geriatric resources and trained personnel across the continuum of care as well as administrative collaboration between care components are critical to the successful implementation of geriatric services. Facilities may need to prioritize their resources and utilize the most effective and relevant elements of geriatric evaluation and management according to patient population needs, available space, resources, and institutional priorities. New risk assessment tools derived from the VA’s experience in geriatric evaluation may be useful for targeting services for other high-risk populations. Full article
(This article belongs to the Special Issue Geriatric Care Models)
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Open AccessArticle
Early Mobility in the Hospital: Lessons Learned from the STRIDE Program
Received: 25 July 2018 / Revised: 17 September 2018 / Accepted: 21 September 2018 / Published: 26 September 2018
Cited by 1 | PDF Full-text (196 KB) | HTML Full-text | XML Full-text
Abstract
Immobility during hospitalization is widely recognized as a contributor to deconditioning, functional loss, and increased need for institutional post-acute care. Several studies have demonstrated that inpatient walking programs can mitigate some of these negative outcomes, yet hospital mobility programs are not widely available [...] Read more.
Immobility during hospitalization is widely recognized as a contributor to deconditioning, functional loss, and increased need for institutional post-acute care. Several studies have demonstrated that inpatient walking programs can mitigate some of these negative outcomes, yet hospital mobility programs are not widely available in U.S. hospitals. STRIDE (assiSTed eaRly mobIlity for hospitalizeD older vEterans) is a supervised walking program for hospitalized older adults that fills this important gap in clinical care. This paper describes how STRIDE works and how it is being disseminated to other hospitals using the Replicating Effective Programs (REP) framework. Guided by REP, we define core components of the program and areas where the program can be tailored to better fit the needs and local conditions of its new context (hospital). We describe key adaptations made by four hospitals who have implemented the STRIDE program and discuss lessons learned for successful implementation of hospital mobility programs. Full article
(This article belongs to the Special Issue Geriatric Care Models)
Open AccessFeature PaperCommunication
A Healthcare Pathway to Nirvana? The SNF Transition to Home
Received: 16 July 2018 / Revised: 15 August 2018 / Accepted: 22 August 2018 / Published: 24 August 2018
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Abstract
While the majority of attention and the literature has focused on transitional models out of the acute care setting, transitions from the post-acute setting—especially from the skilled nursing facility (SNF)—are not well understood. What are the ‘best practices’, or thoughtful considerations, for a [...] Read more.
While the majority of attention and the literature has focused on transitional models out of the acute care setting, transitions from the post-acute setting—especially from the skilled nursing facility (SNF)—are not well understood. What are the ‘best practices’, or thoughtful considerations, for a successful transition back to home and the community? Facilitation of a smooth and seamless transition relies on the abilities of the SNF and primary care teams, as well as community agencies, to coordinate care in a patient-centered manner together. This article will focus on this specific transition within the healthcare continuum. Full article
(This article belongs to the Special Issue Geriatric Care Models)
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Open AccessArticle
Geriatric Patient-Aligned Care Teams in Department of Veterans Affairs: How Are They Structured?
Received: 18 June 2018 / Revised: 27 July 2018 / Accepted: 30 July 2018 / Published: 1 August 2018
Cited by 1 | PDF Full-text (215 KB) | HTML Full-text | XML Full-text | Supplementary Files
Abstract
Geriatric Patient-Aligned Care Teams (GeriPACT) were implemented in the Department of Veterans Affairs (VA) (i.e., Patient-Centered Medical Homes for older adults) to provide high quality coordinated care to older adults with more risk of negative health and psychosocial outcomes. The objectives of this [...] Read more.
Geriatric Patient-Aligned Care Teams (GeriPACT) were implemented in the Department of Veterans Affairs (VA) (i.e., Patient-Centered Medical Homes for older adults) to provide high quality coordinated care to older adults with more risk of negative health and psychosocial outcomes. The objectives of this paper are: (1) to present data on GeriPACT structural characteristics; and (2) to examine a composite measure of GeriPACT model consistency. We utilized a web survey targeting 71 physician leads resulting in a 62% response rate. We found GeriPACTs employed a range of staffing, empanelment, clinic space, and patient assignment practices. The mean value of the GeriPACT consistency measure was 2.03 (range: 1–4) and 6.3% of facilities were considered consistent to the GeriPACT model. We observed large variation in GeriPACT structure and in model consistency. More research is needed to understand how these variations are related to processes and outcomes of care. Full article
(This article belongs to the Special Issue Geriatric Care Models)
Open AccessArticle
Use of Clinical Video Telehealth as a Tool for Optimizing Medications for Rural Older Veterans with Dementia
Received: 1 July 2018 / Revised: 20 July 2018 / Accepted: 21 July 2018 / Published: 30 July 2018
Cited by 1 | PDF Full-text (410 KB) | HTML Full-text | XML Full-text | Supplementary Files
Abstract
Community-Based Outpatient Clinics (CBOCs) allow delivery of primary care to rural veterans who are far from a main Veterans Affairs (VA) campus. However, CBOCs often do not have physicians with geriatric training. We used a clinical video telehealth (CVT) dementia service (Teledementia clinic) [...] Read more.
Community-Based Outpatient Clinics (CBOCs) allow delivery of primary care to rural veterans who are far from a main Veterans Affairs (VA) campus. However, CBOCs often do not have physicians with geriatric training. We used a clinical video telehealth (CVT) dementia service (Teledementia clinic) based in the Pittsburgh VA Healthcare System to optimize dementia patients’ medications and potentially inappropriate medications (PIMs). We analyzed 199 CVT patient encounters from 1 January 2016 to 31 December 2016 and compared different medication changes per encounter between the initial CVT consults and the follow-up visits for all medications and PIMs as listed in the 2015 Beers Criteria, to see if there was a decrease of each kind of change, which is being used as a surrogate for optimization. We found that initial CVT consults, compared to follow-up visits, had greater medications added (0.731 vs. 0.434, p = 0.0092), total overall medications changes (1.769 vs. 1.130, p = 0.0078), and the stopping of 2015 Beers Criteria PIMs (0.208 vs. 0.072, p = 0.0255) per encounter. The fewer PIMs discontinued and fewer medication additions in follow-ups implies that our patients’ medications tend to stay optimized between visits. The teledementia service represents a novel way to provide geriatric assistance to CBOC VA primary care physicians for rural veterans with dementia. Full article
(This article belongs to the Special Issue Geriatric Care Models)
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Open AccessArticle
Frailty Screening and Case-Finding for Complex Chronic Conditions in Older Adults in Primary Care
Received: 9 June 2018 / Revised: 3 July 2018 / Accepted: 6 July 2018 / Published: 7 July 2018
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Abstract
With the aging population, escalating demand for seniors’ care and limited specialist resources, new care delivery models are needed to improve capacity for primary health care for older adults. This paper describes the “C5-75” (Case-finding for Complex Chronic Conditions in Seniors 75+) program, [...] Read more.
With the aging population, escalating demand for seniors’ care and limited specialist resources, new care delivery models are needed to improve capacity for primary health care for older adults. This paper describes the “C5-75” (Case-finding for Complex Chronic Conditions in Seniors 75+) program, an innovative care model aimed at identifying frailty and commonly associated geriatric conditions among older adults within a Canadian family practice setting and targeting interventions for identified conditions using a feasible, systematic, evidence-informed multi-disciplinary approach. We screen annually for frailty using gait speed and handgrip strength, screen for previously undiagnosed comorbid conditions, and offer frail older adults multi-faceted interventions that identify and address unrecognized medical and psychosocial needs. To date, we have assessed 965 older adults through this program; 14% were identified as frail based on gait speed alone, and 5% identified as frail based on gait speed with grip strength. The C5-75 program aims to re-conceptualize care from reactive interventions post-diagnosis for single disease states to a more proactive approach aimed at identifying older adults who are at highest risk of poor health outcomes, case-finding for unrecognized co-existing conditions, and targeting interventions to maintain health and well-being and potentially reduce vulnerability and health destabilization. Full article
(This article belongs to the Special Issue Geriatric Care Models)
Open AccessArticle
Reaching Out to Rural Caregivers and Veterans with Dementia Utilizing Clinical Video-Telehealth
Received: 12 April 2018 / Revised: 4 June 2018 / Accepted: 7 June 2018 / Published: 9 June 2018
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Abstract
Context: A clinical video telehealth (CVT) program was implemented to improve access and quality of dementia care to patients and their caregivers in rural areas. The program was offered as part of an established dementia clinic/geriatric primary care clinic in collaboration with five [...] Read more.
Context: A clinical video telehealth (CVT) program was implemented to improve access and quality of dementia care to patients and their caregivers in rural areas. The program was offered as part of an established dementia clinic/geriatric primary care clinic in collaboration with five community-based outpatient clinics (CBOC’s) affiliated with the Tennessee Valley Healthcare System (TVHS) in middle Tennessee. Telehealth support was provided by a physician–social worker team visit. Methods: Telehealth training and equipment were provided to clinic personnel, functioning part-time with other collateral clinical duties. Patients and caregivers were referred by primary care providers and had an average of one to two CVT encounters originating at their local CBOC lasting 20 to 30 min. Clinical characteristics and outcomes of patients and caregivers receiving CVT support were collected by retrospective electronic medical record (EMR) review. Results: Over a 3-year period 45 CVT encounters were performed on patient–caregiver dyads, followed for a mean of 15 (1–36) months. Some 80% patients had dementia confirmed and 89% of these had serious medical comorbidities, took an average of eight medications, and resided at a distance of 103 (76–148) miles from the medical center. Dementia patients included 33% with late stage dementia, 25% received additional care from a mental health provider, 23% took antipsychotic medications, 19% transitioned to a higher level of care, and 19% expired an average of 10.2 months following consultation. Significant caregiver distress was present in 47% of family members. Consult recommendations included 64% community-based long-term care services and supports (LTSS), 36% medications, and 22% further diagnostic testing. Acceptance of the CVT encounter was 98%, with 8770 travel miles saved. Conclusions: CVT is well received and may be helpful in providing dementia care and supporting dementia caregivers to obtain LTSS for high-need older adults in rural areas. Full article
(This article belongs to the Special Issue Geriatric Care Models)
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Open AccessArticle
A Statewide Model for Assisting Nursing Home Residents to Transition Successfully to the Community
Received: 9 March 2018 / Revised: 3 April 2018 / Accepted: 5 April 2018 / Published: 10 April 2018
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Abstract
Minnesota’s Return to Community Initiative (RTCI) is a novel, statewide initiative to assist private paying nursing home residents to return to the community and to remain in that setting without converting to Medicaid. The objective of this manuscript is to describe in detail [...] Read more.
Minnesota’s Return to Community Initiative (RTCI) is a novel, statewide initiative to assist private paying nursing home residents to return to the community and to remain in that setting without converting to Medicaid. The objective of this manuscript is to describe in detail RTCI’s development and design, its key operational components, and characteristics of its clients and their care outcomes. Data on client characteristics and outcomes come from the Minimum Data Set, staff assessments of clients and caregivers, and Medicaid eligibility files. Most clients transitioned by the RTCI had entered the nursing facility from a hospital. Clients overwhelmingly wanted to return to the community and fit a health and functional profile making them good candidates for community discharge. Most clients went to a private residence, living alone or with a spouse; yet, adult children were the most frequent caregivers. At one year of follow-up 76% of individuals were alive and living in the community and only a small percentage (8.2%) had converted to Medicaid. The RTCI holds promise as a successful model for states to adopt in assisting individuals who are at risk to become long stay nursing home residents instead to return to the community. Full article
(This article belongs to the Special Issue Geriatric Care Models)

Review

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Open AccessReview
Orthogeriatrics and Hip Fracture Care in the UK: Factors Driving Change to More Integrated Models of Care
Received: 23 July 2018 / Revised: 24 August 2018 / Accepted: 24 August 2018 / Published: 28 August 2018
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Abstract
In the United Kingdom (UK), approximately 80,000 hip fractures each year result in an estimated annual cost of two billion pounds in direct healthcare costs alone. Various models of care exist for collaboration between orthopaedic surgeons and geriatricians in response to the complex [...] Read more.
In the United Kingdom (UK), approximately 80,000 hip fractures each year result in an estimated annual cost of two billion pounds in direct healthcare costs alone. Various models of care exist for collaboration between orthopaedic surgeons and geriatricians in response to the complex medical, rehabilitation, and social needs of this patient group. Mounting evidence suggests that more integrated models of orthogeriatric care result in superior quality of care indicators and clinical outcomes. Clinical governance through national guidelines, audit through the National Hip Fracture Database (NHFD), and financial incentives through the Best Practice Tariff (providing a £1335 bonus for each patient) have driven hip fracture care in the UK forward. The demanded improvement in quality indicators has increased the popularity of collaborative care models and particularly integrated orthogeriatric services. A significant fall in 30-day mortality has resulted nationally. Ongoing data collection by the NHFD will lead to greater understanding of the impact of all elements of hip fracture care including models of orthogeriatrics. Full article
(This article belongs to the Special Issue Geriatric Care Models)
Open AccessReview
Acute Care for Elders (ACE) Team Model of Care: A Clinical Overview
Received: 2 July 2018 / Revised: 1 August 2018 / Accepted: 2 August 2018 / Published: 6 August 2018
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Abstract
The Institute of Medicine (IOM) Reports of To Err is Human and Crossing the Quality Chasm have called for more interprofessional and coordinated hospital care. For over 20 years, Acute Care for Elders (ACE) Units and models of care that disseminate ACE principles [...] Read more.
The Institute of Medicine (IOM) Reports of To Err is Human and Crossing the Quality Chasm have called for more interprofessional and coordinated hospital care. For over 20 years, Acute Care for Elders (ACE) Units and models of care that disseminate ACE principles have demonstrated outcomes in-line with the IOM goals. The objective of this overview is to provide a concise summary of studies that describe outcomes of ACE models of care published in 1995 or later. Twenty-two studies met the inclusion. Of these, 19 studies were from ACE Units and three were evaluations of ACE Services, or teams that cared for patients on more than one hospital unit. Outcomes from these studies included increased adherence to evidence-based geriatric care processes, improved patient functional status at time of hospital discharge, and reductions in length of stay and costs in patients admitted to ACE models compared to usual care. These outcomes represent value-based care. As interprofessional team models are adopted, training in successful team functioning will also be needed. Full article
(This article belongs to the Special Issue Geriatric Care Models)
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Open AccessReview
The Resurgence of Home-Based Primary Care Models in the United States
Received: 24 June 2018 / Revised: 13 July 2018 / Accepted: 14 July 2018 / Published: 16 July 2018
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Abstract
This article describes the forces behind the resurgence of home-based primary care (HBPC) in the United States and then details different HBPC models. Factors leading to the resurgence include an aging society, improved technology, an increased emphasis on home and community services, higher [...] Read more.
This article describes the forces behind the resurgence of home-based primary care (HBPC) in the United States and then details different HBPC models. Factors leading to the resurgence include an aging society, improved technology, an increased emphasis on home and community services, higher fee-for-service payments, and health care reform that rewards value over volume. The cost savings come principally from reduced institutional care in hospitals and skilled nursing facilities. HBPC targets the most complex and costliest patients in society. An interdisciplinary team best serves this high-need population. This remarkable care model provides immense provider satisfaction. HBPC models differ based on their mission, target population, geography, and revenue structure. Different missions include improved care, reduced costs, reduced readmissions, and teaching. Various payment structures include fee-for-service and value-based contracts such as Medicare Shared Savings Programs, Medicare capitation programs, or at-risk contracts. Future directions include home-based services such as hospital at home and the expansion of the home-based workforce. HBPC is an area that will continue to expand. In conclusion, HBPC has been shown to improve the quality of life of home-limited patients and their caregivers while reducing health care costs. Full article
(This article belongs to the Special Issue Geriatric Care Models)

Other

Open AccessConcept Paper
ACE Model for Older Adults in ED
Received: 31 December 2018 / Revised: 1 February 2019 / Accepted: 13 February 2019 / Published: 21 February 2019
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Abstract
The emergency department (ED) is uniquely positioned to improve care for older adults and affect patient outcome trajectories. The Mount Sinai Hospital ED cares for 15,000+ patients >65 years old annually. From 2012 to 2015, emergency care in a dedicated Geriatric Emergency Department [...] Read more.
The emergency department (ED) is uniquely positioned to improve care for older adults and affect patient outcome trajectories. The Mount Sinai Hospital ED cares for 15,000+ patients >65 years old annually. From 2012 to 2015, emergency care in a dedicated Geriatric Emergency Department (GED) replicated an Acute Care for Elderly (ACE) model, with focused assessments on common geriatric syndromes and daily comprehensive interdisciplinary team (IDT) meetings for high-risk patients. The IDT, comprised of an emergency physician, geriatrician, transitional care nurse (TCN) or geriatric nurse practitioner (NP), ED nurse, social worker (SW), pharmacist (RX), and physical therapist (PT), developed comprehensive care plans for vulnerable older adults at high risk for morbidity, ED revisit, functional decline, or potentially avoidable hospital admission. Patients were identified using the Identification of Seniors at Risk (ISAR) screen, followed by geriatric assessments to assist in the evaluation of elders in the ED. On average, 38 patients per day were evaluated by the IDT with approximately 30% of these patients formally discussed during IDT rounds. Input from the IDT about functional and cognitive, psychosocial, home safety, and pharmacological assessments influenced decisions on hospital admission, care transitions, access to community based resources, and medication management. This paper describes the role of a Geriatric Emergency Medicine interdisciplinary team as an innovative ACE model of care for older adults who present to the ED. Full article
(This article belongs to the Special Issue Geriatric Care Models)
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Open AccessFeature PaperCommentary
The Acute Care for Elders Unit Model of Care
Received: 16 August 2018 / Revised: 6 September 2018 / Accepted: 8 September 2018 / Published: 11 September 2018
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Abstract
Older patients are at risk for loss of self-care abilities during the course of an acute medical illness that results in hospitalization. The Acute Care for Elders (ACE) Unit is a continuous quality improvement model of care designed to prevent the patient’s loss [...] Read more.
Older patients are at risk for loss of self-care abilities during the course of an acute medical illness that results in hospitalization. The Acute Care for Elders (ACE) Unit is a continuous quality improvement model of care designed to prevent the patient’s loss of independence from admission to discharge in the performance of activities of daily living (hospital-associated disability). The ACE unit intervention includes principles of a prepared environment that encourages safe patient self-care, a set of clinical guidelines for bedside care by nurses and other health professionals to prevent patient disability and restore self-care lost by the acute illness, and planning for transitions of care and medical care. By applying a structured process, an interdisciplinary team completes a geriatric assessment, follows clinical guidelines, and initiates plans for care transitions in concert with the patient and family. Three randomized clinical trials and systematic reviews of ACE or related interventions demonstrate reduced functional disability among patients, reduced risk of nursing home admission, and lower costs of hospitalization. ACE principles could improve elderly care in any acute setting. The aim of this commentary is to describe the ACE model and the basis of its effectiveness. Full article
(This article belongs to the Special Issue Geriatric Care Models)
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Open AccessFeature PaperCase Report
Vet Connect: A Quality Improvement Program to Provide Telehealth Subspecialty Care for Veterans Residing in VA-Contracted Community Nursing Homes
Received: 29 June 2018 / Revised: 21 August 2018 / Accepted: 31 August 2018 / Published: 5 September 2018
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Abstract
Veterans residing in Veterans Health Administration (VA) contracted Community Nursing Homes (CNHs) receive primary care from the CNH they reside in, but often travel to Veterans Affairs Medical Centers (VAMCs) for specialty care services. The Vet Connect project is a quality improvement project [...] Read more.
Veterans residing in Veterans Health Administration (VA) contracted Community Nursing Homes (CNHs) receive primary care from the CNH they reside in, but often travel to Veterans Affairs Medical Centers (VAMCs) for specialty care services. The Vet Connect project is a quality improvement project aiming to implement video technology to support access to specialty care. Methods: Eight Denver VAMC specialty care providers and three project nurses underwent telehealth training and obtained appropriate equipment. To identify in-person visits eligible for substitution of video visits, project nurses review charts of CNH Veterans, consult directly with Veterans, and obtain recommendations from staff. Project nurses serve as tele-presenters within the CNHs, while VA specialists provide care from the VAMC. After each visit, team nurses coordinate care with and deliver specialty care recommendations to CNH staff. Results: We assessed clinical, business, and technical domains of the Vet Connect project, and utilized process mapping to identify barriers and facilitators to implementation. Clinically, starting on 26 June 2017 through 1 June 2018, N = 203 video visits have been conducted with 11 different CNHs in three subspecialties: geriatrics, palliative care, and mental health. These visits generated 49 referrals for 37 Veterans. Fiscally, cost analyses indicate that per visit, the health care system saves an estimated $310. Technologically, the success rate was 83%. Process mapping helped identify facilitators and barriers to implementation of the telehealth program, including cultivating buy-in from key stakeholders (i.e., medical and mental health providers, telehealth staff, and CNH staff), communication allowing for ongoing program adaptation, and building relationships. Conclusion: Subspecialty care delivery to nursing homes using video visit technology in the Vet Connect program is feasible using centralized organization to coordinate complex clinical, business and technical processes. Vet Connect has proved sustainable and has potential to expand within and outside of the VA. Full article
(This article belongs to the Special Issue Geriatric Care Models)
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