scholarly journals Disconnected relationships between primary care and community-based health and social services and system navigation for older adults: a qualitative descriptive study

2020 ◽  
Vol 21 (1) ◽  
Author(s):  
Ruta Valaitis ◽  
Laura Cleghorn ◽  
Jenny Ploeg ◽  
Cathy Risdon ◽  
Derelie Mangin ◽  
...  
Keyword(s):  
Older Adults ◽  
Primary Care ◽  
Social Services ◽  
Descriptive Study ◽  
Community Based ◽  
Health And Social Services ◽  
Qualitative Descriptive

scholarly journals A Usability and Feasibility Study: GENIE - An App Supporting Self-Management among Older Adults who are High Users of the Health Care System (Preprint)

2020 ◽  
Author(s):  
Ruta Valaitis ◽  
Laura Cleghorn ◽  
Ivaylo Vassilev ◽  
Anne Rogers ◽  
Jenny Ploeg ◽  
...  
Keyword(s):  
Older Adults ◽  
Primary Care ◽  
Health Care ◽  
Social Networks ◽  
Social Services ◽  
Health Care System ◽  
Self Management ◽  
Health And Social Services ◽  
Primary Care Clinicians ◽  
Care System

BACKGROUND Primary care providers have been tasked with fostering self-management through managing referrals and linking patients to community-based health and social services. This study evaluated a web-based tool –GENIE (Generating Engagement in Network InvolvEment)– as a component of the Health TAPESTRY program to support self-management of older adults who are high health care system users. GENIE aims to empower patients to leverage their personal social networks to access community services towards reaching their health goals. GENIE maps client’s personal networks, elicits preferences, and filters local health and social resources from a community service directory based on results of a questionnaire that explores client’s interests. In the Health TAPESTRY program, volunteers conducted home visits to gather health information on tablets and implemented the GENIE tool. A report was generated for the primary care team for follow up. OBJECTIVE This study examined the usability, feasibility, and perceived outcomes of the implementation of GENIE with older adults who were enrolled in Ontario’s Health Links Program, which coordinates care for the highest users of the health care system. METHODS This study involved two primary care clinician focus groups, one clinician interview, a volunteer focus group, client telephone interviews, field observations, and GENIE utilization statistics. RESULTS Eight patients, three volunteers, and 16 primary care clinicians participated. Patients were most interested in services that were health-related (exercise and socialization). Overall, participants perceived GENIE to be useful and easy to use, despite challenges related to email set up, disease terminology, instructions for personal network mapping, and clarity of questionnaire items. Volunteer facilitation was critical to support implementation of Genie. Tool completion averaged 39 minutes. Almost all patients identified a community program or activity of interest using GENIE. Half followed up on health and social services and added new members to their network over 6 months, while one participant lost a member. Clinicians had concerns about accuracy, suitability, and quantity of suggested programs and services generated from the tool and believed that they could better tailor choices for their patients highlighting the inherent tension between user-centred preferences focused on capabilities and bio-medical definitions of need shaping professional judgement. However, clinicians did note that GENIE strengthened their understanding of patients’ personal social networks. CONCLUSIONS This study demonstrated GENIE’s potential, facilitated by volunteers, to expand patients’ social networks and link them to relevant health and social services to support self-management. Volunteers require training to effectively implement GENIE for self-management support and can help overcome time limitations that primary care clinicians face. Refining the filtering capability of GENIE to allow for better tailoring of results to address the complex needs of those who are high system users may help to improve primary care provider’s confidence in such tools. CLINICALTRIAL Not applicable

scholarly journals Customizing a Program for Older Adults Living with Frailty in Primary Care

2021 ◽  
Vol 12 ◽  
pp. 215013272110348
Author(s):  
Jananee Rasiah ◽  
Tammy O’Rourke ◽  
Brian Dompé ◽  
Darryl Rolfson ◽  
Beth Mansell ◽  
...  
Keyword(s):  
Older Adults ◽  
Primary Care ◽  
Social Services ◽  
Nurse Practitioner ◽  
Care Delivery ◽  
Social Needs ◽  
Health And Social Services ◽  
Frailty Assessment ◽  
Healthcare Improvement

Coordination of primary care is essential to improving care delivery within health systems, especially for older adults with increased health/social needs. A program jointly funded by the Canadian Foundation for Healthcare Improvement and Canadian Frailty Network, was implemented in a nurse practitioner-led clinic to address the gap in frailty care for older adults. The clinic was situated within a health and social services organization with a mandate to enhance the quality of life of older adults living in the community. Through this program, a frailty assessment pathway and social/clinical prescriptions were implemented with necessary adaptations as a result of COVID-19.

scholarly journals Palliative care physicians’ motivations for models of practicing in the community: A qualitative descriptive study

2021 ◽  
pp. 026921632110550
Author(s):  
Abby Maybee ◽  
Samantha Winemaker ◽  
Michelle Howard ◽  
Hsien Seow ◽  
Alexandra Farag ◽  
...  
Keyword(s):  
Primary Care ◽  
Palliative Care ◽  
Family Physician ◽  
Descriptive Study ◽  
Care Providers ◽  
Community Based ◽  
The Family ◽  
Consultation Model ◽  
Care Models ◽  
Qualitative Descriptive

Background: Internationally, both primary care providers and palliative care specialists are required to address palliative care needs of our communities. Clarity on the roles of primary and specialist-level palliative care providers is needed in order to improve access to care. This study examines how community-based palliative care physicians apply their roles as palliative care specialists, what motivates them, and the impact that has on how they practice. Design: A qualitative descriptive study using semi-structured virtual interviews of community-based palliative care specialists. We asked participants to describe their care processes and the factors that influence how they work. Setting/participants: A qualitative descriptive study using semi-structured virtual interviews of community-based palliative care physicians in Ontario, Canada was undertaken between March and June 2020. At interview end, participants indicated whether their practice approaches aligned with one or more models depicted in a conceptual framework that includes consultation (specialist provides recommendations to the family physician) and takeover (palliative care physician takes over all care responsibility from the family physician) models. Results: Of the 14 participants, 4 worked in a consultation model, 8 in a takeover model, and 2 were transitioning to a consultation model. Different motivators were found for the two practice models. In the takeover model, palliative care physicians were primarily motivated by their relationships with patients. In the consultation model, palliative care physicians were primarily motivated by their relationships with primary care. These differing motivations corresponded to differences in the day-to-day processes and outcomes of care. Conclusions: The physician’s personal or internal motivators were drivers in their practice style of takeover versus consultative palliative care models. Awareness of these motivations can aid our understanding of current models of care and help inform strategies to enhance consultative palliative care models.

scholarly journals Evidence for the Effectiveness of Health and Social Services Partnerships

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 225-226
Author(s):  
Traci Wilson ◽  
Suzanne Kunkel ◽  
Amanda Brewster ◽  
Jane Straker ◽  
Elizabeth Blair ◽  
...  
Keyword(s):  
Older Adults ◽  
Health Care ◽  
Health Outcomes ◽  
Social Services ◽  
Independent Living ◽  
Social Needs ◽  
Care Utilization ◽  
Community Based ◽  
Health And Social Services ◽  
Community Based Organizations

Abstract Integration of health and social services is touted as a key method to address social needs and improve population health. We will share the latest evidence on how Area Agency on Aging (AAA) partnerships with health care entities and other organizations improve health outcomes for older adults, while reducing health care costs. AAAs are community leaders in cross-sectoral partnerships that effectively address social determinants of health for older adults, who account for a substantial share of overall health care spending. Results of a longitudinal study (2008 – 2016) which links data from four waves of the National Surveys of AAAs to data on county-level health outcomes show that AAA–health care partnerships and programs reduced health care utilization and costs. AAA partnerships with hospitals reduced Medicare spending by $136 per beneficiary. AAA involvement in evidence-based health promotion programs decreased potentially avoidable nursing home use by nearly one percentage point (representing a change of 6.5%). Finally, we will describe the prevalence and nature of contracting relationships between community-based organizations and health care entities, based on data from the 2020 CBOs and Health Care Contracting Request for Information, the third national RFI of AAAs, Centers for Independent Living, and other aging and disability community-based organizations.

scholarly journals Innovative Partnership Between Primary Care, AAA, and Academia Connects 4Ms and Social Determinants of Health

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 107-107
Author(s):  
Suzanne Leahy ◽  
Katie Ehlman ◽  
Lisa Maish ◽  
Brad Conrad ◽  
Jillian Hall ◽  
...  
Keyword(s):  
Older Adults ◽  
Primary Care ◽  
Health System ◽  
Preliminary Evaluation ◽  
Language And Literacy ◽  
Community Based ◽  
Primary Care Clinics ◽  
College Of Nursing ◽  
Value Based Care ◽  
The University

Abstract Nationally, there is a growing focus on addressing geriatric care in primary care settings. HRSA’s Geriatric Workforce Enhancement Program (GWEP) has called for academic and health system partners to develop a reciprocal, innovative, cross-sector partnership that includes primary care sites and community-based agencies serving older adults. Through the University of Southern Indiana’s GWEP, the College of Nursing and Health Professions, the Deaconess Health System, three primary care clinics, and two Area Agencies on Aging (AAA) have joined to transform the healthcare of older adults regionally, including rural residents in the 12-county area. Core to the project is a value-based care model that “embeds” AAA care managers in primary care clinics. Preliminary evaluation indicates early success in improving the healthcare of older adults at one primary clinic, where clinical teams have referred 64 older adult patients to the AAA care manager. Among these 64 patients, 80% were connected to supplemental, community-based health services; 22% to programs addressing housing and transportation; and, nearly 10% to a range of other services (e.g., job training; language and literacy; and technology). In addition to presenting limited data on referred patients and referral outcomes, the presentation will share copies of the AAA referral log, to illustrate how resources were categorized by SDOH and added to support integration of the 4Ms.

scholarly journals BUILDING DISASTER RESILIENCE FOR OLDER ADULTS AGING IN PLACE: THE ROLE OF COMMUNITY-BASED ORGANIZATIONS

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S340-S341
Author(s):  
Claire Pendergrast ◽  
Basia Belza ◽  
Ann Bostrom ◽  
Nicole Errett
Keyword(s):  
Older Adults ◽  
Social Services ◽  
Aging In Place ◽  
Well Being ◽  
Local Context ◽  
Disaster Resilience ◽  
Community Based ◽  
Senior Centers ◽  
Community Based Organizations

Abstract Older adults are more susceptible to adverse health outcomes during and after a disaster compared with their younger counterparts. Developing community resilience, or strengthening communities to reduce the negative impacts of disasters, has the potential support older adults’ health and well-being. Community-based organizations (CBOs), such as senior centers and Villages, provide social services and programming that support aging in place and may support older adults’ resilience to disasters. This study examines CBO leadership perspectives on the role of CBOs in building disaster resilience for older adults aging in place, as well as perceived barriers and facilitators to incorporating disaster resilience activities into organizational programming. In-depth interviews were conducted with a purposive sample of staff-members of CBOs serving older adults aging in place in King County, Washington. Participants included representatives from 14 organizations that varied in size, geographic setting, organizational structure, and ethnic, linguistic, and socio-economic backgrounds of organizational members. The sample included five government-run senior centers, seven non-profit senior centers, and two Villages. Interviews were audio-recorded and transcribed verbatim. We used a combined inductive and deductive approach to code and thematically analyze the data. Results indicate that local context, leadership risk perception, collaborations, and existing services and programming influence CBOs’ willingness to engage in activities supporting disaster resilience for older adults aging in place. Findings suggest that CBOs supporting aging in place may support disaster resilience for older adults by serving as a trusted source of disaster preparedness information and tailoring disaster-related messages for an older adult audience.

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