OPTIMIZING CARE FOR COMPLEX OLDER ADULTS: A PRIMARY CARE-BASED INTEGRATED TEAM MODEL

Abstract

The growing population of older adults with complex health needs presents significant challenges to healthcare systems. Traditional models of care often struggle to meet these multifaceted needs, resulting in fragmented care, preventable hospitalizations, and poor health outcomes. This study describes the development, implementation, and preliminary outcomes of an innovative primary care-based integrated team model designed specifically to address the needs of complex older adults. The model leverages interprofessional collaboration within the Patient's Medical Home framework, incorporating standardized assessment tools, risk stratification, and coordinated care planning. Early results suggest improvements in care coordination, reduced emergency department visits, and enhanced patient and provider satisfaction. The model demonstrates the potential for primary care transformation to better serve vulnerable older populations through structured team-based approaches that optimize the skills of diverse healthcare providers while maintaining continuity of care. Practical insights and lessons learned are offered for healthcare leaders and policymakers seeking to implement similar models in their settings.