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

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 co...

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Autores principales:	Jungyoon Kim, Valerie Pacino, Hongmei Wang, April Recher, Isha Jain, Vaibhavi Mone, Jihyun Ma, Mary Jo Spurgin, Daniel Jeffrey, Stephen Mohring, Jane Potter
Formato:	article
Lenguaje:	EN
Publicado:	MDPI AG 2021
Materias:	older adult health promotion what matters primary care liaison social determinants of health Medicine R
Acceso en línea:	https://doaj.org/article/6ac2d645aea3484d867d0a4c498d1534
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id	oai:doaj.org-article:6ac2d645aea3484d867d0a4c498d1534
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spelling	oai:doaj.org-article:6ac2d645aea3484d867d0a4c498d15342021-11-11T16:17:32ZSystem Redesign: The Value of a Primary Care Liaison Model to Address Unmet Social Needs among Older Primary Care Patients10.3390/ijerph1821111351660-46011661-7827https://doaj.org/article/6ac2d645aea3484d867d0a4c498d15342021-10-01T00:00:00Zhttps://www.mdpi.com/1660-4601/18/21/11135https://doaj.org/toc/1661-7827https://doaj.org/toc/1660-4601Assessing 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.Jungyoon KimValerie PacinoHongmei WangApril RecherIsha JainVaibhavi MoneJihyun MaMary Jo SpurginDaniel JeffreyStephen MohringJane PotterMDPI AGarticleolder adulthealth promotionwhat mattersprimary care liaisonsocial determinants of healthMedicineRENInternational Journal of Environmental Research and Public Health, Vol 18, Iss 11135, p 11135 (2021)
institution	DOAJ
collection	DOAJ
language	EN
topic	older adult health promotion what matters primary care liaison social determinants of health Medicine R
spellingShingle	older adult health promotion what matters primary care liaison social determinants of health Medicine R Jungyoon Kim Valerie Pacino Hongmei Wang April Recher Isha Jain Vaibhavi Mone Jihyun Ma Mary Jo Spurgin Daniel Jeffrey Stephen Mohring Jane Potter System Redesign: The Value of a Primary Care Liaison Model to Address Unmet Social Needs among Older Primary Care Patients
description	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.
format	article
author	Jungyoon Kim Valerie Pacino Hongmei Wang April Recher Isha Jain Vaibhavi Mone Jihyun Ma Mary Jo Spurgin Daniel Jeffrey Stephen Mohring Jane Potter
author_facet	Jungyoon Kim Valerie Pacino Hongmei Wang April Recher Isha Jain Vaibhavi Mone Jihyun Ma Mary Jo Spurgin Daniel Jeffrey Stephen Mohring Jane Potter
author_sort	Jungyoon Kim
title	System Redesign: The Value of a Primary Care Liaison Model to Address Unmet Social Needs among Older Primary Care Patients
title_short	System Redesign: The Value of a Primary Care Liaison Model to Address Unmet Social Needs among Older Primary Care Patients
title_full	System Redesign: The Value of a Primary Care Liaison Model to Address Unmet Social Needs among Older Primary Care Patients
title_fullStr	System Redesign: The Value of a Primary Care Liaison Model to Address Unmet Social Needs among Older Primary Care Patients
title_full_unstemmed	System Redesign: The Value of a Primary Care Liaison Model to Address Unmet Social Needs among Older Primary Care Patients
title_sort	system redesign: the value of a primary care liaison model to address unmet social needs among older primary care patients
publisher	MDPI AG
publishDate	2021
url	https://doaj.org/article/6ac2d645aea3484d867d0a4c498d1534
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System Redesign: The Value of a Primary Care Liaison Model to Address Unmet Social Needs among Older Primary Care Patients

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