Implementation of a Geriatric Patient-Centered Medical Home: the Geriatric Patient – Aligned Care Team (GeriPACT)

Powers, James S.; Xie, Catherine F.; Moseley, Michelle; Abraham, Lovely; Buckner, Jennifer; Azubike, Nkechi

doi:10.21926/obm.geriatr.1803008

Cited by 7 publications

(3 citation statements)

References 10 publications

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“…The Department of Veterans Affairs (VA) operates Tennessee Valley Healthcare System (TVHS), an integrated healthcare system of over 100,000 patients in Middle Tennessee comprised of 2 medical centers located 40 miles apart, and 12 community-based outpatient clinics. In 2011, TVHS developed a geriatric patient-centered medical home model for geriatric primary care-the geriatric patient-aligned care team (GeriPACT) [4,5]. The GeriPACT Team consists of the GeriPACT provider (geriatrician or geriatric nurse practitioner with an outpatient panel size of approximately 800), a social worker, a clinical pharmacist, a registered nurse care manager, a licensed vocational nurse, and clerical staff.…”

Section: Contextmentioning

confidence: 99%

The GeriPACT Initiative to Prevent All-Cause 30-Day Readmission in High Risk Elderly

et al. 2021

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Background: Suboptimal care transitions increases the risk of adverse events resulting from poor care coordination among providers and healthcare facilities. The National Transition of Care Coalition recommends shifting the discharge paradigm from discharge from the hospital, to transfer with continuous management. The patient centered medical home is a promising model, which improves care coordination and may reduce hospital readmissions. Methods: This is a quality improvement report, the geriatric patient-aligned care team (GeriPACT) at Tennessee Valley Healthcare System (TVHS) participated in ongoing quality improvement (Plan, Do, Study, Act (PDSA)) cycles during teamlet meetings. Post home discharge follow-up for GeriPACT patients was provided by proactive telehealth communication by the Registered Nurse (RN) care manager and nurse practitioner. Periodic operations data obtained from the Data and Statistical Services (DSS) coordinator informed the PDSA cycles and teamlet meetings. Results: at baseline (July 2018–June 2019) the 30-day all-cause readmission for GeriPACT was 21%. From July to December 2019, 30-day all-cause readmissions were 13%. From January to June 2020, 30-day all-cause readmissions were 15%. Conclusion: PDSA cycles with sharing of operations data during GeriPACT teamlet meetings and fostering a shared responsibility for managing high-risk patients contributes to improved outcomes in 30-day all-cause readmissions.

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Section: Contextmentioning

confidence: 99%

The GeriPACT Initiative to Prevent All-Cause 30-Day Readmission in High Risk Elderly

et al. 2021

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“…In 2011, TVHS developed a geriatric patient-centered medical home model for geriatric primary care -the Geriatric Patient-Aligned Care Team (GeriPACT). 6 The GeriPACT Team consists of the GeriPACT provider (geriatrician or geriatric nurse practitioner with an outpatient panel size of approximately 800), a social worker, a clinical pharmacist, a registered nurse care manager, a licensed vocational nurse, and clerical staff. These individuals are experienced in working as a coordinated unit delivering patientcentered assessments and managing medically complex and vulnerable elderly individuals.…”

Section: Healthcare System Descriptionmentioning

confidence: 99%

Use of a Clinically Derived Risk Calculator to Assess Advance Care Planning for Elderly Veterans in the Outpatient Setting

Powers¹,

Gandelman²

2018

Palliat Med Hosp Care Open J

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Background Only a third of Americans have completed an advance directive, however completion of advance directives helps to protect patient autonomy and promotes engagement and discussion of goals of care. Primary care physicians have the ability to longitudinally engage patients in effective conversations about their wishes toward end-of-life care. Electronic health record (EHR) tools can help clinicians to identify high-risk patients appropriate for advance care planning (ACP). Over 60% of deaths are out of hospital deaths. Methods We utilized the care assessment of need (CAN), an electronic medical record (EMR) dashboard tool available for all primary care patients treated at the Department of Veterans Affairs, to risk-stratify the 101,000 Tennessee Valley Healthcare System patient population. Patients identified as highest-risk individuals appropriate for ACP were assessed for completion of advance directives. Results For patients with a score of CAN-99 (12-month probability of hospitalization or death=44.8%), N=341, 63.6% had documented advance directives. Some 13.8% of CAN-99 patients received palliative care consults with 77% of these delivered during an inpatient stay. Another 10.5% of CAN-99 patients expired within 6 months and 39% of these received palliative care consults. Patients enrolled in the geriatric patient centered medical home (GeriPACT) were more likely to receive a palliative care consult (33% versus 12%, p<0.001) and to have completed advance directives compared to patients paneled in primary care (80% versus 58%, p<0.05). Conclusion A clinically derived risk calculator can identify patients appropriate for ACP. High-risk patients enrolled in a geriatric clinic have a higher likelihood of palliative care consultation and ACP completion. A minority of ACP for these high-risk patients is performed in the outpatient department, suggesting an opportunity to expand ACP for high-risk patients in the outpatient setting.

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“…In recent years, the VA has developed dashboards for providers to identify patients who are likely to benefit from LTC services so that HCBS can be targeted toward these patients. One such dashboard was created for the Geriatric Patient Aligned Care Team (GeriPACT) program, which provides frail, elderly Veterans and their caregivers access to multidisciplinary geriatric care through a single point of contact (Powers et al, 2018). This dashboard shows providers which patients might benefit from HCBS based on information that is currently available in administrative data sets, such as age and computed risk scores.…”

Section: Introductionmentioning

confidence: 99%

Improving Prediction of Long-Term Care Utilization Through Patient-Reported Measures: Cross-Sectional Analysis of High-Need U.S. Veterans Affairs Patients

et al. 2021

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This article examines the relative merit of augmenting an electronic health record (EHR)-derived predictive model of institutional long-term care (LTC) use with patient-reported measures not commonly found in EHRs. We used survey and administrative data from 3,478 high-risk Veterans aged ≥65 in the U.S. Department of Veterans Affairs, comparing a model based on a Veterans Health Administration (VA) geriatrics dashboard, a model with additional EHR-derived variables, and a model that added survey-based measures (i.e., activities of daily living [ADL] limitations, social support, and finances). Model performance was assessed via Akaike information criteria, C-statistics, sensitivity, and specificity. Age, a dementia diagnosis, Nosos risk score, social support, and ADL limitations were consistent predictors of institutional LTC use. Survey-based variables significantly improved model performance. Although demographic and clinical characteristics found in many EHRs are predictive of institutional LTC, patient-reported function and partnership status improve identification of patients who may benefit from home- and community-based services.

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Implementation of a Geriatric Patient-Centered Medical Home: the Geriatric Patient – Aligned Care Team (GeriPACT)

Cited by 7 publications

References 10 publications

The GeriPACT Initiative to Prevent All-Cause 30-Day Readmission in High Risk Elderly

The GeriPACT Initiative to Prevent All-Cause 30-Day Readmission in High Risk Elderly

Use of a Clinically Derived Risk Calculator to Assess Advance Care Planning for Elderly Veterans in the Outpatient Setting

Improving Prediction of Long-Term Care Utilization Through Patient-Reported Measures: Cross-Sectional Analysis of High-Need U.S. Veterans Affairs Patients

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