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Primary
outpatient care is provided to targeted patients over the
age of 65 years using a multidisciplinary team approach. The
care is comprehensive, coordinated and continuous through
any level of care within the medical center. The goal is to
provide better diagnosis of age-related diseases and geriatric
syndromes or issues, optimize drug profiles, provide psycho-social
support, and to maintain and promote functional independence.
Mission/Goals
of Program
To
provide primary care to a targeted patient population that
is coordinated, comprehensive and continuous through any level
of care in the medical center.
Essential
elements of Primary Care include:
- Initial
comprehensive exam that involves the interdisciplinary team
- Personal
involvement of the team in all decision of non-emergent
care
- Provide
appropriate preventive care- addressing geriatric issues
in particular
That
the interdisciplinary team functions as the integral unit
providing care, with the physician providing leadership and
primary responsibility, with the goal of improved clinical
care by:
- Better
diagnosis of age-related diseases and geriatric syndromes
or issues
- Optimal
and efficacious drug profiles with reduced drug-disease
interactions
- Maintenance
of patient independence in the community with optimal physical
and psychosocial function
- Reduced
inappropriate use of resources, and facilitation of access
of needed, appropriate services
Targeting:
Based on patients over the age of 65 (most over 75) with geriatric
syndromes and/or complex medical issues with a recent decline
in function or independence. "Logistically" this means that
it takes > 5-10 minutes to review medical records of what
has occurred between visits, or a patient has multiple subspecialty
consults with a high no show rate, related to physical and/or
mental frailty.
Ensure
performance of appropriate preventive health measures
Scope
of Care
Patients
are referred electronically to GRECC Senior Patriots firm
when patient care needs have exceeded the capacity of existing
care services, or when primary care has not been established
and the patient meets criteria for appropriateness. Referral
are made by other primary providers, from urgent care/ER,
and occasionally from triage or other non-primary care services
when no primary care provider has been identified. On the
initial visit, patients receive a comprehensive geriatric
assessment and are seen routinely by all team members (physician,
pharmacist, geriatric neuropsychologist, nutritionist, social
worker, and optometrist. An interdisciplinary discussion occurs
and treatment plan, aimed at patient wishes, is developed.
Patients are given information on access of services, and
the Program Assistant assists in monitoring of and the triage
of patient calls to an appropriate team member. Patients are
also directed to an appropriate staff member if they are walk
ins, even on non-clinic days. Patients on routine visits have
their med profile reviewed by the pharmacist and can see additional
team staff as needed. When problems occur outside of usual
clinic hours, this is communicated by an electronic progress
note by the person who makes a point of contact. Patients
can be admitted to the interdisciplinary inpatient GEM unit,
but this must be discussed with the ward attending and fellow,
and level of care is discussed with the Nurse Manager and
is felt appropriate for the current staffing patterns.
Types
& Ages of Patients Served
Patients
are > 65 yrs with multiple medical problems and comorbidities,
have geriatric syndromes, have had a recent decline in function
or mobility, which is likely caused by many contributing factors.
Patients should have fair to strong social support, or are
highly motivated to maintain their independence.
Scope
and Complexity of Patient Needs
Patients
must be greater than 65, and usually have complex medical
problems that often requires assessment by subspecialist,
and the Geriatric Clinic acts as an advocate and clearing
house in updating care plans. Patients with particular problems,
including falls, urinary incontinence, malnutrition or failure
to thrive, depression, elder abuse are included, as are patients
with significant underlying psychiatric problems with significant
medical care issues. Patient with primary geropsychiatric
or dementia syndromes without medical problems should be seen
in other programs.
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