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.
Tuesday, September 13, 2022, 2:30 pm - 3:30 pm CDT
Keyword: integrated care