System redesign: The value of a primary care liaison model to address unmet social needs among older primary care patients

Jungyoon Kim, Valerie Pacino, Hongmei Wang, April Recher, Isha Jain, Vaibhavi Mone, Jihyun Ma, Mary Jo Spurgin, Daniel Jeffrey, Stephen Mohring, Jane Frances Potter

Research output: Contribution to journalArticlepeer-review

2 Scopus citations

Abstract

Assessing and addressing social determinants of health can improve health outcomes of older adults. The Nebraska Geriatrics Workforce Enhancement Program implemented a primary care liaison (PCL) model of care, including training primary care staff to assess and address unmet social needs, patient counseling to identify unmet needs, and mapping referral services through cross-sectoral partnerships. A PCL worked with three patient-centered medical homes (PCMHs) that are part of a large integrative health system. A mixed-methods approach using a post-training survey and a patient tracking tool, was used to understand the reach, adoption, and implementation of the PCL model. From June 2020 to May 2021, the PCL trained 61 primary care staff to assess and address unmet social needs of older patients. A total of 327 patients, aged 65 years and older and within 3–5 days of acute-care hospital discharges, were counseled by the PCL. For patients with unmet needs, support services were arranged through community agencies: transportation (37%), in-home care (33%), food (16%), caregiver support (2%), legal (16%), and other (16%). Our preliminary results suggest that the PCL model is feasible and implementable within PCMH settings to address unmet social needs of older patients to improve their health outcomes.

Original languageEnglish (US)
Article number11135
JournalInternational journal of environmental research and public health
Volume18
Issue number21
DOIs
StatePublished - Oct 23 2021

Keywords

  • Health promotion
  • Older adult
  • Primary care liaison
  • Social determinants of health
  • What matters
  • Home Care Services
  • Humans
  • Patient-Centered Care
  • Workforce
  • Aged
  • Primary Health Care
  • Geriatrics

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health
  • Pollution
  • Health, Toxicology and Mutagenesis

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