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Chapter 61 - Practice Transformation for Better Care of Older Adults

from Section IV - Principles of Care for the Elderly

Published online by Cambridge University Press:  30 June 2022

Jan Busby-Whitehead
University of North Carolina, Chapel Hill
Samuel C. Durso
The Johns Hopkins University, Maryland
Christine Arenson
Thomas Jefferson University, Philadelphia
Rebecca Elon
The Johns Hopkins University School of Medicine
Mary H. Palmer
University of North Carolina, Chapel Hill
William Reichel
Georgetown University Medical Center
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Transformation of our health-care systems is required to better meet the complex needs of our aging population as we confront the rise of health-care costs around the world. Older adults with multiple chronic health conditions can receive care that is fragmented, incomplete, inefficient, and ineffective. Care delivery and coordination of the complicated needs of older adults resides primarily in outpatient practice, both sub-specialty and primary care. However, the overall coordination is dependent on primary care practices, which through transformation into highly effective interprofessional teams can be designed and equipped to guide comprehensive care for all patients. The term “practice transformation” refers to a process of change in the organization and delivery of care to advance quality improvement and patient-centered care. Practice transformation is a continuous process that involves leadership, goal-setting, workflow changes, quality improvement, and reporting of outcomes. It requires adapting organizational tools and processes to support advances in models of team-based care.

Reichel's Care of the Elderly
Clinical Aspects of Aging
, pp. 736 - 749
Publisher: Cambridge University Press
Print publication year: 2022

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Institute for Healthcare Improvement. An Overview of the IHI Triple Aim. Accessed on 09/02/2020.Google Scholar
European Commission: Report of the Expert Group on Health Systems Performance Assessment, A New Drive for Primary Care in Europe: Rethinking the Assessment Tools and Methodologies. Accessed on 09/02/2020.Google Scholar
Metusela, C, Usherwood, T, Lawson, K, Angus, L, Kmet, W, Ferdousi, S, Reath, J. Patient Centred Medical Home (PCMH) transitions in Western Sydney, Australia: A qualitative study. BMC Health Services Research. 2020; 20:285.Google ScholarPubMed
Moureaux, C, Perelman, J, Mendes da Costa, E, Roch, I, Annemans, L, Heymans, I, Closon M-C. Impact of the medical home model on the quality of primary care: The Belgian experience. Medical Care. 2015; 53:396400.CrossRefGoogle ScholarPubMed
Alcusky, M, Singer, L, Keith, SW, Hegarty, SE, Lombardi, M, Saccenti, E, Maio, V. Evaluation of care processes and health care utilization in newly implemented medical homes in Italy: A population-based cross-sectional study. American Journal of Medical Quality. 2020; 35(3):265273.CrossRefGoogle ScholarPubMed
Scottenfeld, L, Petersen, D, Peikes, D, Ricciardi, R, Burak, H, McNellis, R, Genevro, J. White Paper: Creating patient-centered team-based primary care. March 2016 AHRQ Pub. No. 16–0002-EF. Accessed on 09/02/2020.Google Scholar
Naylor, MD, Coburn, KD, Kurtzman, ET, et al. Inter-professional team-based primary care for chronically ill adults: State of the science. Unpublished White Paper presented at the ABIM Foundation meeting to Advance Team-Based Care for the Chronically Ill in Ambulatory Settings. 2010, March 24–25; Philadelphia, PA. Cited in Hupke, C. Team-based care: Optimizing primary care for patients and provider. Institute for Healthcare Improvement Blog, May 16, 2014. Accessed on 09/02/2020.Google Scholar
Porter, ME, Pabo, EA, Lee, TH. Redesigning primary care: A strategic vision to improve value by organizing around patients’ needs. Health Affairs. 2003; 32(3):516525.CrossRefGoogle Scholar
The Dartmouth Atlas of Health Care; Center for the Evaluative Clinical Sciences Dartmouth Medical School. Chicago, IL: Americana Hospital Publishing, Inc., 1996. Accessed on 09/02/2020.Google Scholar
Starfield, B, Shi, L, Macinko, J. Contribution of primary care to health systems and health. Milbank Quarterly. 2005; 83(3):457502.Google ScholarPubMed
Willard-Grace, R, Hessle, D, Rogers, E, Dube, K, Bodenheimer, T, Grumbach, K. Team structure and culture are associated with lower burnout in primary care. Journal of the American Board of Family Medicine. 2014; 27(2):229238.CrossRefGoogle ScholarPubMed
Faber, M, Voerman, G, Erler, A, Eriksson, T, Baker, R, de Lepeleire, J, Grol, R, Burgers, J. Survey of 5 European countries suggests that more elements of patient-centered medical homes could improve primary care. Health Affairs. 2013; 32(4):797806.CrossRefGoogle ScholarPubMed
Salzberg, C, Bitton, A, Lipsitz, S, et al. The impact of alternative payment in chronically ill and older patients in the patient-centered medical home. Medical Care. 2017; 55(5):483492(10).CrossRefGoogle Scholar
NCQA. Latest evidence: Benefits of the patient-centered medical home. Accessed on 09/02/2020.Google Scholar
NEJM Catalyst. 2017 value-based care definition. Accessed on 2 September 2020.Google Scholar
American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatric Society. 2019; 67(4):121.Google Scholar The Affordable Care Act. Accessed on 09/02/2020.Google Scholar
CMS Comprehensive Overview of A-APMs. Accessed on 09/02/2020.Google Scholar
AAFP: CMS Primary Cares Initiative: New Alternative Payment Models for Primary Care Physicians. Is this right for my practice? Accessed on 09/02/2020.Google Scholar
Avalere: Medicare advantage achieves cost-effective care and better outcomes for beneficiaries with chronic conditions relative to fee-for-service Medicare. July 11, 2018. Accessed on 09/02/2020.Google Scholar
Lieberthal, RD, Payton, C, Sarfaty, M, Valko, G. Measuring the cost of the patient-centered medical home: A cost-accounting approach. Journal of Ambulatory Care Management. 2017; 40(4):327338.CrossRefGoogle ScholarPubMed
Magill, MK, Ehrenberger, D, Scammon, DL, Day, J, Allen, T, Reall, AJ, Sides, RW, Kim, J. The cost of sustaining a patient-centered medical home: Experience from 2 states. Annals of Family Medicine. 2015; 13:429435.CrossRefGoogle ScholarPubMed
Higgins, TC, Crosson, J, Peikes, D, et al. Health information technology to support quality improvement in primary care. March 2015 AHRQ Publication No. 15–0031-EF; Accessed on 09/02/2020.Google Scholar
Jones SS, Koppel R, Ridgely MS, Palen TE, Wu S, Harrison MI. Guide to reducing unintended consequences of electronic health records. Accessed on 09/02/2020.Google Scholar
Institute for Healthcare Improvement Blog. Solberg, L. The keys to effective telemedicine for older adults. Accessed on 09/02/2020.Google Scholar
Gardner, R, Cooper, E. Physician stress and burnout: The impact of health information technology. Journal of the American Medical Informatics Association. 2019; 26(2):106114.Google ScholarPubMed
Cohen, J. Physician practices pay $14,000+ in IT operating expenses per physician. Becker’s Health IT. Accessed on 09/02/2020.Google Scholar
Kotter, J. The key to changing organizational culture. Forbes, September 27, 2012. Accessed on 09/02/2020.Google Scholar
Smith, CD, Balatbat, C, Corbridge, S, Dopp, AL, Fried, J, Harter, R, Landefeld, S, Martin, C, Opelka, F, Sandy, L, Sato, L, Sinsky, C. Implementing optimal team-based care to reduce clinician burnout. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC, 2018. Accessed on 09/02/2020.Google Scholar
Hess, DW, Reed, VA, Turco, MG, et al. Enhancing provider engagement in practice improvement: A conceptual framework. Journal of Continuing Education for Health Professions. 2015; 35(1):7179.CrossRefGoogle ScholarPubMed
AARP Fox-Grade W. April 18, 2016. The growing racial and ethnic diversity of older adults. Accessed on 09/02/2020.Google Scholar
Chesser, AK, Woods, NK, Smothers, K, Rogers, N. Health literacy and older adults: A systematic review. Gerontology and Geriatric Medicine. 2016; 2:2333721416630492.Google Scholar
Yen, P, Leasure, A. Use and effectiveness of the teach-back method in patient education and health outcomes. Federal Practitioner. 2019 (Jun.):285289.–06-284.pdf; Accessed on 09/02/2020.Google Scholar
Rockwood, K, Song, X, MacKnight, C, et al. A global clinical measure of fitness and frailty in elderly people. Canadian Medical Association Journal. 2005; 173(5):489495; doi: 10.1503/cmaj.050051.CrossRefGoogle ScholarPubMed
Chu, C, White, N, Stone, P. Prognostication in palliative care. Clinical Medicine. 2019; 19(4):306310.CrossRefGoogle ScholarPubMed
World Health Organization. Mental Health of Older Adults. December 12, 2017. Accessed on 09/02/2020.Google Scholar
Institute for Healthcare Improvement Cambridge, Massachusetts, USA. Plan-Do-Study-Act (PDSA) Worksheet. Accessed on 09/02/2020.Google Scholar
Rose, KD, Ross, JS, Horwitz, LI. Advanced access scheduling outcomes: A systematic review. Arch Intern Med. 2011; 171(13):11501159.CrossRefGoogle ScholarPubMed

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