We assembled a cross-cutting team of experts representing primary care physicians (PCPs), home care physicians, physicians who see patients in skilled nursing facilities (SNF physicians), skilled nursing facility medical directors, human factors engineers, transitional care researchers, geriatricians, internists, family practitioners, and three major organizations: AMDA, SGIM, and AGS. This work was sponsored through a grant from the Association of Subspecialty Physicians (ASP). Members of the team mapped the process of discharging patients from a skilled nursing facility into the community and subsequent care of their outpatient PCP. Four areas of process improvement were identified, building on the prior work of the AMDA Transitions of Care Committee and the experiences of the team members. The team identified issues and developed best practices perceived as feasible for SNF physician and PCP practices to accomplish. The goal of these consensus-based recommended best practices is to provide a safe and high-quality transition for patients moving between the care of their SNF physician and PCP.

Dissemination of geriatrics research usually occurs through conference presentations or publications viewed by colleagues in the same field. Older adults and their family caregivers have limited direct access to research findings. We sought to pilot a direct-to-caregiver workshop with the intent to disseminate geriatrics research directly to family caregivers of older adults. As part of an academic national conference, an ‘Updates in Geriatrics Research’ workshop is presented as a compilation of innovative research published in the prior year. We distilled workshop content into a lay format which was presented to family caregivers at two community-based caregiver symposiums. Mixed method surveys were completed by family caregiver attendees with open-ended responses analyzed using content and constant-comparative techniques. Of the 29 survey respondents, all were female, mean age 58.9 yrs. (range 52-72), providing care to older adults, mean age 87.2 years (range 66-97). Respondents unanimously identified learning information pertinent to their care recipient. When asked: Do you feel that direct-to-caregiver research dissemination is useful, all respondents selected yes. Open-ended responses for reasons why revealed two main themes: 1.) Creating informed caregivers: “Caregivers need this information in their toolbox.” and 2.) Empowering caregiver-advocates: “The more we know, the better we can advocate for our loved ones and challenge their health care.” Respondents all planned on sharing information with others, specifically family, friends, and physicians. In conclusion, disseminating geriatrics research direct-to-caregivers is feasible. Researchers, who present their work for scientific conferences, should consider translating their findings into presentations for community-based family caregivers.

Integrated and collaborative care lead to better care. Addressing the behavioral and mental health care needs of patients results in better health outcomes. Interdisciplinary and multi-disciplinary approaches to health care delivery yield more effective health care planning. A holistic approach to healthcare sees the individual as more than the sum of diseases. Research studies have supported these assertions and yet, in actual practice, they are often more aspirational than actualized. The COVID-19 pandemic has made it even more difficult to implement collaborative care delivered by varied professional disciplines. This symposium describes efforts to provide more holistic and multidisciplinary care in the primary care geriatrics practice of the Dept. of Geriatrics & Palliative Medicine, Icahn School of Medicine. This New York City practice has 4,500 patients with diverse backgrounds and a median age of 85. In the first paper, Baharlou and her colleagues describe the establishment of an IMPACT collaborative care depression model in the middle of the COVID-19 pandemic. It was adapted to be provided by telephone and uses a different psychosocial intervention than is usually implemented. Hinrichsen and Leipzig outline the successful integration of Cognitive Behavioral Therapy for Insomnia into geriatrics primary care to improve insomnia in older adults and deprescribe sleep medications. Munoz and her colleagues describe the ALIGN program which is an interdisciplinary team effort, informed by the social determinants of health framework, to facilitate access to an array of services delivered virtually because of the pandemic.

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