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

Jungyoon Kim, Valerie Pacino, Hongmei Wang, April Recher, Isha Jain, Vaibhavi Mone, Jihyun Ma, Mary Jo Spurgin, Daniel Jeffrey, Stephen Mohring and Jane Potter
Additional contact information
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

IJERPH, 2021, vol. 18, issue 21, 1-11

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.

Keywords: older adult; health promotion; what matters; primary care liaison; social determinants of health (search for similar items in EconPapers)
JEL-codes: I I1 I3 Q Q5 (search for similar items in EconPapers)
Date: 2021
References: View references in EconPapers View complete reference list from CitEc
Citations: View citations in EconPapers (2)

Downloads: (external link)
https://www.mdpi.com/1660-4601/18/21/11135/pdf (application/pdf)
https://www.mdpi.com/1660-4601/18/21/11135/ (text/html)

Related works:
This item may be available elsewhere in EconPapers: Search for items with the same title.

Export reference: BibTeX RIS (EndNote, ProCite, RefMan) HTML/Text

Persistent link: https://EconPapers.repec.org/RePEc:gam:jijerp:v:18:y:2021:i:21:p:11135-:d:663122

Access Statistics for this article

IJERPH is currently edited by Ms. Jenna Liu

More articles in IJERPH from MDPI
Bibliographic data for series maintained by MDPI Indexing Manager ().