5. Importance and purposes of Geriatric care models

Differentiate among:

Clinical Video Telehealth (CVT) model

GERI Pact

Home-Based Primary Care (HBPC) model

Return to Community Initiative (RTCI) model

STRIDE model

ACE model

Case-finding for Complex Chronic Conditions in 75+ model

Project RED (Re-Engineered Discharge)-based model

 Improving access and quality of care for dementia

Role of nurse in transitions of care

Identify barriers to social support and financial resources

Define care coordination"

The Clinical Video Telehealth (CVT) Model

- This is a technology that facilitates access to medical and health care services for senior citizens through the use of video conferencing.

- Enables elderly people, including those in the rural areas, to receive additional care and professional services while being comforts of their homes.

- The advantage of removing geographic barriers and transportation issues that may hinder access to care.

 GERI Pact Model

- Houses an emphasis of post-hospital care in lowering readmissions once again to the home setting.

- Hire nurse practitioners and social workers to follow up on patient’s status after discharge and offer further support at home.

- Aims are to educate the patient and to achieve adherence in the subsequent follow-up appointments and medication regimen.

 Home Based Primary Care Model

- Focused on delivering primary care to the elderly in the comfort of their homes, with input from multiple specialties.

- Beneficial for elderly people who hardly attend clinic visits either because they are ill or cannot move around due to old age or other related complications.

- For instance, it can decrease cases of ER visits and hospitalization since people with chronic diseases are better monitored when given home visits. 

Return to Community Initiative (RTCI) is a model.

- It aims at providing support for elderly persons who need to go home after being hospitalized or after receiving any form of medical treatment that required close or constant monitoring.

- Entails integrating services which are provided at home and community level to address medical, functional and psychosocial objectives.

- The goals of the service are to re-establish seniors in the community residing preference and minimize hospital admissions.

 STRIDE Model

- STRIVE: A Multi-State intervention to decrease emergency department utilization.

- Screens all high risk seniors and offers complete clinical interventions focused on areas of need.

- They aim at enhancing health care and decreasing avoidable ED and hospitalization.

 ACE Model

- Ambulatory intensive Caring for Elders employs a senior care coordinator who is located in a primary care office setting.

- Patients are enrolled into care coordination, facilitated access to necessary resources, coordination between different providers, and handle of barriers.

- Can be applied to decrease the level of burden and enhance the level of functioning and well-being among caregivers.

 Case-Finding for Complex Chronic Diseases

- Conducts a health risk assessment survey followed by the MDS assessment to target seniors with multiple chronic conditions. 

- Intends to enhance the interdisciplinary model of care delivery, encourage completion of an advance care plan and focus on efforts to promote healthy behaviours.

 Project RED

- Uses time and motion study to identify changes that need to be made to the hospital Discharge processes to enhance patient experiences.

- Stresses the continuum of patient education, proper referral and transfer of care.

- It is also important to mention that goals are set to decrease the number of readmissions and enhance patient’s prognosis. 

 Challenges seen in care are transport, financial constraints with health and medications, loneliness, stress from caregiving, and finding their way. The specific tasks in this domain include assessment, care coordination, patient education, and transition management, and these are predominantly carried out by nurses.

Care coordination is a deliberate attempt to design and integrate patient care across the various health care entities and settings.