Reducing Risks for Older Adults With an Interprofessional Community-Academic Partnership: A Case Study

Area of Science:

• Geriatric Medicine
• Public Health
• Health Services Research

Background:

• The aging US population is diversifying, increasing the need for effective risk reduction strategies for hospitalization and institutionalization.
• Vulnerable older adults require comprehensive assessments addressing medical, psychosocial, pharmacologic, and functional status.
• Culturally competent care and attention to social determinants are crucial for improving health equity in older adults.

Purpose of the Study:

• To describe a case study exemplar of an interprofessional collaborative practice program for high-risk older adults.
• To demonstrate how comprehensive assessments can identify and document risks for hospitalization and institutionalization.
• To illustrate the process of sharing recommendations with primary care providers for risk reduction.

Main Methods:

• Utilized evidence-based assessment tools for medical, psychosocial, pharmacologic, and functional status.
• Employed an interprofessional team approach for comprehensive evaluation.
• Implemented a case study exemplar of the Geriatric Outreach and Training with Care (GOT Care!) program.
• Documented identified risks and developed recommendations for primary care providers.

Main Results:

• The GOT Care! program provided a comprehensive assessment for high-risk older adults.
• Identified and documented specific risks contributing to potential hospitalization or institutionalization.
• Facilitated communication of findings and recommendations to primary care providers.

Conclusions:

• Comprehensive, interprofessional geriatric assessments are vital for identifying and mitigating risks in older adults.
• Culturally competent care and addressing social determinants are essential for improving outcomes and health equity.
• The GOT Care! model demonstrates a practical approach to risk reduction and improved care for high-risk older populations.