MOBILE INTERDISCIPLINARY GERIATRIC HEALTHCARE IN THE COMMUNITY

Purpose (a): This is a community-based geriatric primary care model designed to reach Medicaid eligible elders as well as childless adult “near elders” (ages 50-64) using mobile teams and clinics to reduce hospitalizations, increase access to care, and improve patient quality of life. This is a new initiative for UNTHSC that utilizes mobile teams and clinics to increase access to care by providing appropriate care within the community. Medical teams, led by physician assistants (PAs) or nurse practitioners (NPs), that incorporate Community Health Workers (CHWs) and others (pharmacy, physical therapy, social work), will provide care to patients within community settings and clinics. Additionally, CHWs will educate elders about Medicaid and assist with enrollment when necessary. The Community Health Workers will also provide case management to high risk patients.To meet the urgent care needs of our patients and reduce ER utilization, a nurse advice telephone line has been created for patients to call when they have urgent care issues or questions. This enhancement of geriatric primary care services will expand encounters to a significant portion of Medicaid- eligible elders within RHP 10. Methods (b): The MIGHTY Care program will see 3071 patients and roughly 15,000 encounters over the five year grant. Our program goals include decrease in admission rates, decrease in 30 day re-admission rates for preventable causes, increase in patient satisfaction regarding patient involvement in medical decision making, and increases in quality of life. The team identified several steps that must be completed in order to achieve the project goals, which included identifying stakeholders, geocoding population demographics in order to determine the best sites for our standing clinics, proper training on tenets ofshared decision making and customer service, community outreach, and others. Results (c): The primary community stakeholders identified were Senior Citizen Services, Goodwill Industries, and the Community Food Bank. We had several meetings with these facilities to discuss the potential of setting a community based clinic in their locations. Additionally, the team has conducted community talks, flu shot clinics, and other community outreach presentations. In preparation for seeing patients at these sites, we are deepening our relationships by providing educational programs for patients and staff members. At this time we are continuing to develop other possible candidates for alliances. Conclusions (d): The MIGHTY Care program offers an innovative solution to many of the issues that plague our current system. We will provide cost-saving community-based care that will improve patient outcomes and the patients’ satisfaction with their care.