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

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

doi:10.3390/ijerph182111135

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.

Highlights

It is estimated that 40–90% of health outcomes are attributable to social determinants of health (SDoH), social, behavioral, and economic factors that typically fall outside the purview of traditional medical care systems [1]
The study took place in patient-centered medical homes (PCMHs) clinics as a part of a large integrative health system in a mid-Western city in the U.S Three out of the 15 PCMH clinics in the system were selected for the early phase of primary care liaison (PCL) implementation
The study findings suggest that a PCMH setting is a suitable place to start building local-level cross-sectoral collaborations to address unmet social needs of older patients through the PCL model

Summary

Introduction

It is estimated that 40–90% of health outcomes are attributable to social determinants of health (SDoH), social, behavioral, and economic factors that typically fall outside the purview of traditional medical care systems [1]. Identifying and addressing SDoH, such as access to housing, transportation, food, in-home care, and social connection, plays a significant role in improving the health of older adults and potentially reducing health care costs by preventing avoidable hospitalizations. For older adults, such SDoH significantly influence health, morbidity, mortality, and their ability to live independently and age in place. Food insecurity was reported among 16.2% of respondents, while two in five (40%) respondents were concerned that they would not be able to afford to stay in their homes or make repairs to their homes as they age

Objectives

Methods

Results

Discussion

Conclusion