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

Author

Listed:
  • Jungyoon Kim

    (Department of Health Service Research & Administration, University of Nebraska Medical Center, 984350 Nebraska Medical Center, Omaha, NE 68198, USA)

  • Valerie Pacino

    (Department of Health Service Research & Administration, University of Nebraska Medical Center, 984350 Nebraska Medical Center, Omaha, NE 68198, USA)

  • Hongmei Wang

    (Department of Health Service Research & Administration, University of Nebraska Medical Center, 984350 Nebraska Medical Center, Omaha, NE 68198, USA)

  • April Recher

    (Nebraska Medicine Nebraska Medical Center, Omaha, NE 68198, USA)

  • Isha Jain

    (Department of Health Service Research & Administration, University of Nebraska Medical Center, 984350 Nebraska Medical Center, Omaha, NE 68198, USA)

  • Vaibhavi Mone

    (Department of Health Service Research & Administration, University of Nebraska Medical Center, 984350 Nebraska Medical Center, Omaha, NE 68198, USA)

  • Jihyun Ma

    (Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE 68198, USA)

  • Mary Jo Spurgin

    (Department of Internal Medicine, Division of Geriatrics, Gerontology and Palliative Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA)

  • Daniel Jeffrey

    (Department of Internal Medicine, Division of General Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA)

  • Stephen Mohring

    (Department of Internal Medicine, Division of General Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA)

  • Jane Potter

    (Department of Internal Medicine, Division of Geriatrics, Gerontology and Palliative Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA)

Abstract

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.

Suggested Citation

  • Jungyoon Kim & Valerie Pacino & Hongmei Wang & April Recher & Isha Jain & Vaibhavi Mone & Jihyun Ma & Mary Jo Spurgin & Daniel Jeffrey & Stephen Mohring & Jane Potter, 2021. "System Redesign: The Value of a Primary Care Liaison Model to Address Unmet Social Needs among Older Primary Care Patients," IJERPH, MDPI, vol. 18(21), pages 1-11, October.
    • Handle: RePEc:gam:jijerp:v:18:y:2021:i:21:p:11135-:d:663122
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    References listed on IDEAS

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    2. Porterfield, D.S. & Hinnant, L.W. & Kane, H. & Horne, J. & McAleer, K. & Roussel, A., 2012. "Linkages between clinical practices and community organizations for prevention: A literature review and environmental scan," American Journal of Public Health, American Public Health Association, vol. 102(S3), pages 375-382.
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    2. Nina Tumosa, 2023. "Using the Age-Friendly Health Systems Framework to Track Wellness and Health Promotion Priorities of Older Adults in the Global Community," IJERPH, MDPI, vol. 20(5), pages 1-5, March.

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