University of California, San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA.
Gary and Mary West Health Institute, 10350 N. Torrey Pines Road, La Jolla, CA, 92037, USA.
BMC Geriatr. 2020 Jun 5;20(1):193. doi: 10.1186/s12877-020-1502-7.
Many health and social needs can be assessed and met in community settings, where lower-cost, person-centered, preventative and proactive services predominate. This study reports on the development and implementation of a person-centered care model integrating dental, social, and health services for low-income older adults at a community dental clinic co-located within a senior wellness center.
A digital comprehensive geriatric assessment (CGA) and referral system linking medical, dental, and psychosocial needs by real-time CGA-derived metrics for 996 older adults (age ≥ 60) was implemented in 2016-2018 as part of a continuous quality improvement project. This study aims to describe: 1) the development and content of a new CGA; 2) CGA implementation, workflows, triage, referrals; 3) correlations between CGA domains, and adjusted regression models, assessing associations with self-reported recent hospitalizations, emergency department (ED) visits, and clinically-assessed dental urgency.
The multidisciplinary team from the senior wellness and dental centers planned and implemented a CGA that included standard medical history along with validated instruments for functional status, mental health and social determinants, and added oral health. Care navigators employed the CGA with 996 older adults, and made 1139 referrals (dental = 797, care coordination = 163, social work = 90, mental health = 32). CGA dimensions correlated between oral health, medical status, depressive symptoms, isolation, and reduced quality of life (QoL). Pain, medical symptoms, isolation and depressive symptoms were associated with poorer self-reported health, while general health was most strongly correlated with lower depressive symptoms, and higher functional status and QoL. Isolation was the strongest correlate of lower QoL. Adjusted odds ratios identified social and medical factors associated with recent hospitalization and ED visits. General and oral health were associated with dental urgency. Dental urgency was most strongly associated with general health (AOR = 1.78,95%CI [1.31, 2.43]), dental symptoms (AOR = 2.39,95%CI [1.78, 3.20]), dental pain (AOR = 2.06,95%CI [1.55-2.74]), and difficulty chewing (AOR = 2.80, 95%CI [2.09-3.76]). Dental symptoms were associated with recent ED visits (AOR = 1.61, 95%CI [1.12-2.30]) or hospitalizations (AOR = 1.47, 95%CI [1.04-2.10]).
Community-based inter-professional care is feasible with CGAs that include medical, dental, and social factors. A person-centered care model requires coordination supported by new workflows. Real-time metrics-based triage process provided efficient means for client review and a robust process to surface needs in complex cases.
许多健康和社会需求都可以在社区环境中得到评估和满足，社区环境中以低成本、以人为本、预防和主动服务为主。本研究报告了在一个社区牙科诊所中整合牙科、社会和健康服务的以人为中心的护理模式的发展和实施情况，该诊所与老年人健康中心位于同一地点。
2016-2018 年，作为持续质量改进项目的一部分，实施了一项针对 996 名（年龄≥60 岁）老年人的数字化综合老年评估（CGA）和实时 CGA 衍生指标链接医疗、牙科和心理社会需求的转诊系统。本研究旨在描述：1）新 CGA 的开发和内容；2）CGA 的实施、工作流程、分诊、转诊；3）CGA 各领域之间的相关性以及评估与自我报告的近期住院、急诊就诊和临床评估的牙科紧急情况相关的调整回归模型。
老年健康和牙科中心的多学科团队规划并实施了一项 CGA，其中包括标准病史以及用于功能状态、心理健康和社会决定因素的经过验证的工具，并增加了口腔健康。护理导航员使用 CGA 对 996 名老年人进行了评估，并进行了 1139 次转诊（牙科=797，护理协调=163，社会工作=90，心理健康=32）。CGA 维度与口腔健康、医疗状况、抑郁症状、孤立和生活质量（QoL）之间存在相关性。疼痛、医疗症状、孤立和抑郁症状与较差的自我报告健康状况相关，而一般健康状况与较低的抑郁症状以及更高的功能状态和 QoL 相关性最强。孤立是与较低 QoL 相关性最强的因素。调整后的优势比确定了与近期住院和急诊就诊相关的社会和医疗因素。一般健康和口腔健康与牙科紧急情况相关。牙科紧急情况与一般健康状况（AOR=1.78，95%CI [1.31, 2.43]）、牙科症状（AOR=2.39，95%CI [1.78, 3.20]）、牙科疼痛（AOR=2.06，95%CI [1.55-2.74]）和咀嚼困难（AOR=2.80，95%CI [2.09-3.76]）最相关。牙科症状与近期急诊就诊（AOR=1.61，95%CI [1.12-2.30]）或住院（AOR=1.47，95%CI [1.04-2.10]）相关。
基于社区的跨专业护理是可行的，包括医疗、牙科和社会因素的 CGA 是可行的。以人为本的护理模式需要新工作流程支持的协调。基于实时指标的分诊流程为客户审查提供了高效的手段，并为复杂病例中发现需求提供了强大的流程。
