Just for Us: An Academic Medical Center–Community Partnership to Maintain the Health of a Frail Low-Income Senior Population

Yaggy, Susan D.; Michener, J. Lloyd; Yaggy, Duncan; Champagne, Mary T.; Silberberg, Mina; Lyn, Michelle; Johnson, Fred; Yarnall, Kimberly S. H.

doi:10.1093/geront/46.2.271

Cited by 39 publications

(47 citation statements)

References 8 publications

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“…The same assistant contacts the patient after the visit and before the next visit. 61 Phelan et al 63 found that a interdisciplinary geriatric team model screened for more syndromes and improved care at 12 months, although there was little significant improvement thereafter. Disease-specific team models produce good results for the focal disease but are less successful with comorbidities.…”

Section: Supporting Literaturementioning

confidence: 99%

The Medical Home: Growing Evidence to Support a New Approach to Primary Care

Rosenthal¹

2008

The Journal of the American Board of Family Medicine

448

341

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Introduction:A medical home is a patient-centered, multifaceted source of personal primary health care. It is based on a relationship between the patient and physician, formed to improve the patient's health across a continuum of referrals and services. Primary care organizations, including the American Board of Family Medicine, have promoted the concept as an answer to government agencies seeking political solutions that make quality health care affordable and accessible to all Americans.Methods: Standard literature databases, including PubMed, and Internet sites of numerous professional associations, government agencies, business groups, and private health organizations identified over 200 references, reports, and books evaluating the medical home and patient-centered primary care.Findings: Evaluations of several patient-centered medical home models corroborate earlier findings of improved outcomes and satisfaction. The peer-reviewed literature documents improved quality, reduced errors, and increased satisfaction when patients identify with a primary care medical home. Patient autonomy and choice also contributes to satisfaction. Although industry has funded case management models demonstrating value superior to traditional fee-for-service reimbursement adoption of the medical home as a basis for medical care in the United States, delivery will require effort on the part of providers and incentives to support activities outside of the traditional face-to-face office visit.Conclusions: Evidence from multiple settings and several countries supports the ability of medical homes to advance societal health. A combination of fee-for-service, case management fees, and quality outcome incentives effectively drive higher standards in patient experience and outcomes. Community/ provider boards may be required to safeguard the public interest.

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Section: Supporting Literaturementioning

confidence: 99%

The Medical Home: Growing Evidence to Support a New Approach to Primary Care

Rosenthal¹

2008

The Journal of the American Board of Family Medicine

448

341

View full text Add to dashboard Cite

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“…For example, the Duke University program "Just for Us" provides care for seniors with chronic and complicated medical conditions. 33 The team is led by a physician and includes PAs (who get paid through the local federally qualified health center), social workers (provided through county services), case workers (paid through the "Just for Us" program and the insurer), and a dietitian (paid through private insurance and Medicaid). Medical care is coordinated by the patient's PCP.…”

Section: Team-based Approaches For Diabetes Carementioning

confidence: 99%

Managing Diabetes with Integrated Teams: Maximizing Your Efforts with Limited Time

Kruger

Lorenzi

Dokken

et al. 2012

Postgraduate Medicine

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The importance of glycemic control has been well established. In response, the American Diabetes Association has established goals for glycemic control and other cardiovascular parameters, including blood pressure and low-density and high-density lipoprotein cholesterol. However, the National Health and Nutrition Examination Survey has shown that only about half (57%) of patients with diabetes meet a glycated hemoglobin A(1c) (HbA(1c)) goal of < 7%, approximately 45% meet blood pressure and total cholesterol goals, and only 12% achieve all 3 treatment goals. While treating hyperglycemia remains the primary treatment goal, careful selection of pharmacotherapies that do not adversely affect cardiovascular risk factors or long-term glycemic control is an important consideration for patients with type 2 diabetes mellitus. During the past 5 years, the number of treatment options and the complexity of treatment guidelines for diabetes have increased markedly, which makes treatment decisions more complicated and time-consuming, and greatly impacts the workload of the primary care physicians who deliver care to the majority of this population. To provide optimal diabetes care when time and resources are limited, primary care physicians may want to enlist the support of other providers, such as nurse practitioners, physician assistants, diabetes educators, dietitians, and social and case workers. The use of team care, coupled with appropriately chosen pharmacologic therapy and patient education that fosters the development of critical thinking skills and the ability to make self-management decisions, have been shown to improve glycemic control and cardiovascular outcomes.

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“…46 Furthermore, Dr. Lloyd Michener encouraged ingesting community-level data ("community vital signs") into EHRs to better understand a patient's neighborhood context and potentially to guide the development of coordinated, multisectoral interventions. 47,48 For example, the Just for Us program was launched after identifying increased needs of elderly patients in low-income housing in Durham, North Carolina 49 , partnering primary care, county health departments, and housing agencies to bridge clinical medicine with public health and social services. Other bright spots that were highlighted include documenting patient experiences in the EHR 50 and supplementing monitoring patients' SDHs in the EHR, with social needs identified by community advisory councils.…”

Section: Sdhs In Primary Carementioning

confidence: 99%

Revisiting Primary Care's Critical Role in Achieving Health Equity: Pisacano Scholars' Reflections from Starfield Summit II

Park

Coutinho²,

Doohan

et al. 2018

J Am Board Fam Med

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The second Starfield Summit was held in Portland, Oregon, in April 2017. The Summit addressed the role of primary care in advancing health equity by focusing on 4 key domains: social determinants of health in primary care, vulnerable populations, economics and policy, and social accountability. Invited participants represented an interdisciplinary group of primary care clinicians, researchers, educators, policymakers, community leaders, and trainees. The Pisacano Leadership Foundation was one of the Summit sponsors and held its annual leadership symposium in conjunction with the Summit, enabling several Pisacano Scholars to attend the Summit. After the Summit, a small group of current and former Pisacano Scholars formed a writing group to highlight key themes and implications for action discussed at the Summit. The Summit resonated as a call to action for primary care to move beyond identifying existing health inequities and toward the development of interventions that advance health equity, through education, research, and enhanced community partnerships. In doing so, the Summit aimed to build on the foundational work of Dr. Starfield, challenging us to explore the significant role of primary care in truly achieving health equity. (J Am Board Fam Med 2018;31:292-302.)

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Just for Us: An Academic Medical Center–Community Partnership to Maintain the Health of a Frail Low-Income Senior Population

Abstract: Just for Us is becoming a financially sustainable way of creating a "system within a nonsystem" for low-income elderly persons in clustered housing.

Cited by 39 publications

References 8 publications

The Medical Home: Growing Evidence to Support a New Approach to Primary Care

The Medical Home: Growing Evidence to Support a New Approach to Primary Care

Managing Diabetes with Integrated Teams: Maximizing Your Efforts with Limited Time

Revisiting Primary Care's Critical Role in Achieving Health Equity: Pisacano Scholars' Reflections from Starfield Summit II

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