Department of Health Service Research & Administration, University of Nebraska Medical Center, 984350 Nebraska Medical Center, Omaha, NE 68198, USA.
Nebraska Medicine Nebraska Medical Center, Omaha, NE 68198, USA.
Int J Environ Res Public Health. 2021 Oct 23;18(21):11135. doi: 10.3390/ijerph182111135.
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.
评估和解决健康的社会决定因素可以改善老年人的健康结果。内布拉斯加老年人才队伍增强计划实施了初级保健联络（PCL）护理模式，包括培训初级保健人员评估和解决未满足的社会需求、对患者进行咨询以确定未满足的需求，以及通过跨部门伙伴关系规划转介服务。一名 PCL 与三个作为大型综合健康系统一部分的以患者为中心的医疗之家（PCMH）合作。采用培训后调查和患者跟踪工具的混合方法，了解 PCL 模型的覆盖范围、采用情况和实施情况。2020 年 6 月至 2021 年 5 月，PCL 培训了 61 名初级保健人员，以评估和解决老年患者未满足的社会需求。共有 327 名年龄在 65 岁及以上、在急性护理出院后 3-5 天的患者接受了 PCL 的咨询。对于有未满足需求的患者，通过社区机构安排支持服务：交通（37%）、家庭护理（33%）、食品（16%）、护理人员支持（2%）、法律（16%）和其他（16%）。我们的初步结果表明，PCL 模型在 PCMH 环境中是可行和可实施的，可用于解决老年患者的未满足社会需求，以改善他们的健康结果。
