The traditional model of medical care only accounts for 10% of health outcomes, whereas social determinants of health account for over 60%. Since older adults are commonly diagnosed with multiple chronic illnesses, effective care for these patients requires meaningful collaboration between medical and community-based care providers. We will describe an integrated interprofessional collaborative model of care between a health system and the local Area Agency on Aging (AAoA) called the Care Management Interdisciplinary Team (CMIT). CMIT is both a real-world functioning interprofessional team and an inclusive educational model for diverse learners, including patients, families and caregivers. Through CMIT, AAoA care managers present cases of community-dwelling older adults that have complex interactions between medical illness, medications, social and behavioral health issues. The team, which includes nursing, social work, geriatric medicine, and geriatric pharmacy, meets weekly for case presentations and interprofessional care planning. Care plans are implemented by the care manager and the consumer's primary care physician. 80 consumers were presented to the CMIT team over a 1-year period. The interprofessional collaborative care planning process resulted in recommendations for fall prevention interventions for 15 (19%) of consumers, medication changes for 57 (71%) of consumers, safety interventions for 49 (61%) of consumers, and behavioral health interventions for 19 (24%) of consumers. By conducting team meetings virtually, we are able to use these meetings not only for real care planning, but also as an educational team mentoring experience for students and workforce development. The CMIT approach integrates medical, academic, and community-based providers and employs telehealth to optimize the patient experience and maximize value for community-dwelling consumers.
In support of improving patient care, this activity is planned and implemented by The National Center for Interprofessional Practice and Education Office of Interprofessional Continuing Professional Development (OICPD). The OICPD is accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.
The National Center OICPD is approved by the Board of Certification, Inc. to provide continuing education to Athletic Trainers (ATs). This program is eligible for Category A hours/CEUs. ATs should claim only those hours actually spent in the educational program.
This activity was planned by and for the healthcare team, and learners will receive Interprofessional Continuing Education (IPCE) credit for learning and change.
Physicians: The National Center for Interprofessional Practice and Education designates this live activity for AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with their participation.
Physician Assistants: The American Academy of Physician Assistants (AAPA) accepts credit from organizations accredited by the ACCME.
Nurses: Participants will be awarded contact hours of credit for attendance at this workshop.
Nurse Practitioners: The American Academy of Nurse Practitioners Certification Program (AANPCP) accepts credit from organizations accredited by the ACCME and ANCC.
Pharmacists and Pharmacy Technicians: This activity is approved for contact hours.
Athletic Trainers: This program is eligible for Category A hours/CEUs. ATs should claim only those hours actually spent in the educational program.
Social Workers: As a Jointly Accredited Organization, the National Center is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. The National Center maintains responsibility for this course. Social workers completing this course receive continuing education credits.
IPCE: This activity was planned by and for the healthcare team, and learners will receive Interprofessional Continuing Education (IPCE) credits for learning and change.