Table 1.

Approaches to Restructuring Primary Care to Serve Vulnerable Elders

Structural element	Approach to restructuring
Delivery models
Co-management	A nurse practitioner (NP) or physician assistant (PA) internal to the office practice can co-manage chronic conditions common in older adults (e.g., falls, incontinence, dementia, heart failure, and depression) directly with a primary care clinician or a small group of primary care clinicians. Visits to the NP or PA are earmarked to address a specific chronic condition or conditions and use structured visit notes appropriate to the condition being addressed31
	Nurses, social workers, or psychologists (internal or external to a practice) receive additional specialized training in working with vulnerable elders.15,18,32 These professionals then provide support to a group of primary care clinicians in assessing patients’ and caregivers’ needs, in coordinating care, and in counseling patients or family members about chronic conditions
	An NP/social worker team coupled to a geriatrics interdisciplinary team can provide a high level of external support to the primary care clinician in managing care for low-income vulnerable elders14
Augmented primary care	Provide enhanced decision support for clinicians and new roles for office staff (both check-in staff and those who perform pre-examination vital signs – medical assistants or nurses) in screening for and performing basic assessment for chronic conditions.16,17 See “Flow of Authority” and “Clinical Information Systems/Decision Support” in this table for details
Internal resources
Physical plant	An adjustable-height exam table33 facilitates a good physical examination of a vulnerable elder
	A small amplifier with microphone and headphones34 enables better communication with patients who have hearing loss
	An adjustable walker can be used to check for improvement in gait and balance in response to an assistive device,35 thereby determining whether a prescription for a walker is appropriate
	A bladder ultrasound machine36 provides non-invasive post-void residual measurements in elders with urinary symptoms, easing the detection of urinary retention
	Electronic patient questionnaires allow patient data to be gathered in the waiting room or remotely37
People
Staffing	General clinician/staff education on communicating with vulnerable elders (e.g., for hearing loss, speak slowly and clearly)38 can improve patient satisfaction
Flow of authority	A teamlet physician/nurse model with the nurse handling bulk of care coordination22,23 can help offload physicians to allow more time for medical decision-making
	Empower the registered nurse, licensed practical nurse, or medical assistant who checks patient in through delegation of clinician tasks in specific scenarios (e.g., orthostatic vital signs in patients with a recent fall, cognitive evaluation for patients with a memory complaint)16,39
	Hold brief team meetings to discuss complicated patients40
Communication	Use regularly scheduled combined clinician/staff meetings for solving problems that emerge within the practice40
	Use a secure website for exchanging patient-related information (e.g., related to a medication change) between the primary care office and other clinicians41,42
	Develop a post-visit summary template for patients: this summary can be on paper or via a web-based patient portal available to patient and family (if patient authorizes).26 A post-visit summary may help patients in adhering to recommendations
Workflow management system
Clinical information systems/decision support	Use structured visit notes for paper or electronic health records, including clinical reminders and condition-specific order sets where applicable, to guide clinicians on appropriate data collection for geriatric syndromes17,31
	Take advantage of pre-visit questionnaires (new visit and follow-up) to decrease data gathering needs while clinician and patient are face-to-face31
	Employ digital pen/paper/smart form technology to capture questionnaire information (e.g., PHQ-2) directly from paper into the electronic health record to avoid duplicate data entry43,44
Patient (and caregiver) – clinician communication systems	Use secure electronic communication between patients and clinicians45
	Dictate directly to e-mail to speed e-mail responses to patients46
Administrative systems	Try “block” scheduling to handle patients with predicted late arrival times.47 For example, block a 1-h time period for three patients at the start of an afternoon clinic, and ask all three to arrive at the clinic start time. Then see these patients on a first-come, first-served basis. Clinic may be more likely to start on time (and therefore run on time) using this system
	Consider open access scheduling to improve same-day access.48 (However, see also reference 49)
Community linkages	Ensure easy access for clinicians to community resource handouts and required forms for mandatory reporting (e.g., to Department of Motor Vehicles, Adult Protective Services).50 Forms may be printed from the electronic health record, available as links on the primary care office website, or placed in examination rooms
	Develop formal partnerships with community programs to improve patients’ access to community resources51
Housing	In-home sensor technology allows remote detection of a change in a vulnerable elder’s activities of daily living.52 This could then prompt a response from caregivers or the primary care office
Personal care	Online resources to find a caregiver may be useful for vulnerable elders and their families53,54
Health promotion and disease-specific	Computer-assisted personal exercise may be appropriate for cognitively intact elders55
	Group exercise programs may benefit vulnerable elders across a range of function.50 Exercise ranges from high intensity to low intensity (such as chair exercises)
	Caregiver support groups for vulnerable elders with Alzheimer’s disease and their families56 complement clinicians’ skills in diagnosis and treatment