IMPROVE RESIDENT FUNCTIONING & PREVENT NURSING HOME PLACEMENT
Aging patients who are relatively fit require less ER visits, hospital care and nursing home placements than those that are frail. They require overall less healthcare services in general. There are specific evidence-based strategies that can be deployed to prevent frailty and dementia in high risk patients. These strategies are currently not deployed within primary care.
Primary care team currently do have the capacity to measure, monitor or treat the major primary determinants for frailty, dementia and for healthcare utilization in general. 80% of these determinants require the self-management of:
Pre-frail and frail patients at risk for falls, dementia, hospitalization and nursing home placement can now receive a referral for telehealth support from a prevention team of physiatrists and pharmacists within ILFs and ALFs. This telehealth support is facilitated by a prevention navigator who visits the patient at their apartment.
Patients receive a rehabilitation medicine consult that identifies any barriers that are effecting fitness and functional capacity like pain. The physiatrist then prescribes a successful aging care plan along with pharmacist support for:
In addition, patients receive specialized telehealth tablets for home that enable the physiatry-pharmacy teams to deliver frailty prevention utilizing best practices from proven models that include cardiac rehabilitation, pulmonary rehabilitation and the Lancet commission for dementia prevention. Families are also engaged and receive support for caregiving when requested.
