Buhr Gwendolen, Dixon Carrissa, Dillard Jan, Nickolopoulos Elissa, Bowlby Lynn, Canupp Holly, Matters Loretta, Konrad Thomas, Previll Laura, Heflin Mitchell, McConnell Eleanor
Duke Center for the Study of Aging and Human Development, Durham, NC 27710, USA.
Duke Office of Clinical Research, Durham, NC 27710, USA.
Geriatrics (Basel). 2019 Oct 21;4(4):59. doi: 10.3390/geriatrics4040059.
Primary care practices lack the time, expertise, and resources to perform traditional comprehensive geriatric assessment. In particular, they need methods to improve their capacity to identify and care for older adults with complex care needs, such as cognitive impairment. As the US population ages, discovering strategies to address these complex care needs within primary care are urgently needed. This article describes the development of an innovative, team-based model to improve the diagnosis and care of older adults with cognitive impairment in primary care practices. This model was developed through a mentoring process from a team with expertise in geriatrics and quality improvement. Refinement of the existing assessment process performed during routine care allowed patients with cognitive impairment to be identified. The practice team then used a collaborative workflow to connect patients with appropriate community resources. Utilization of these processes led to reduced referrals to the geriatrics specialty clinic, fewer patients presenting in a crisis to the social worker, and greater collaboration and self-efficacy for care of those with cognitive impairment within the practice. Although the model was initially developed to address cognitive impairment, the impact has been applied more broadly to improve the care of older adults with multimorbidity.
基层医疗诊所缺乏时间、专业知识和资源来进行传统的全面老年评估。特别是，他们需要方法来提高识别和照顾有复杂护理需求的老年人的能力，比如认知障碍患者。随着美国人口老龄化，迫切需要找到在基层医疗中满足这些复杂护理需求的策略。本文描述了一种创新的、基于团队的模式的发展，以改善基层医疗诊所中对认知障碍老年人的诊断和护理。该模式是在一个拥有老年医学和质量改进专业知识的团队的指导过程中开发的。对常规护理期间进行的现有评估过程进行完善，从而能够识别出认知障碍患者。然后，实践团队使用协作工作流程将患者与适当的社区资源联系起来。这些流程的运用减少了转介到老年医学专科诊所的情况，减少了患者向社会工作者寻求危机救助的情况，并增强了诊所内对认知障碍患者护理的协作和自我效能感。尽管该模式最初是为解决认知障碍问题而开发的，但其影响已更广泛地应用于改善患有多种疾病的老年人的护理。
