Transforming routine primary care into a comprehensive Medical Home serving an immigrant older adult population

As seniors age, they will increasingly need supportive health and social services to remain functional and maintain their independence. Older adults generally cope with multiple and more complex chronic conditions than adults. They also deal with a range of geriatric syndromes, such as memory loss. Yet, in primary care practice, older adults are usually treated in the same context, with the same protocols and workflows as adult patients. With the elderly population aging and growing, there is a need to put in place geriatric-tailored services that will meet the current needs of seniors and provide ongoing comprehensive care for them as they age.

A community health center serving a vulnerable Chinese immigrant population identified and assessed system redesigns needed in order to transform routine primary care services into a comprehensive geriatric-tailored program. The redesigns are guided by the principles of the Patient-Centered Medical Home Model.

The session will focus on how to redesign processes more appropriate for the geriatric population relating to screening, assessments, follow-up care, health education, care management and medication management. Additionally, results from piloting bilingual screening and geriatric assessment instruments will be presented.

Providers agree that older adults need intensive case management and educational support to help them navigate a complex health care system, follow up with referrals, adhere to treatment plans, and adopt lifestyle changes necessary to improve their health. The session will provide strategies for implementing a quality of care geriatric program serving vulnerable older adults in need of such services.