Center on Aging Retreat to Feature Experts in Patient-Centered Medical Home, Transitional Care

Center on Aging Retreat to Feature Experts in Patient-Centered Medical Home, Transitional Care

Feb 17, 2011 1:26 PM

SALT LAKE CITY—The patient-centered medical home (PCMH) is rapidly gaining momentum among many physicians and other providers as a model for more efficient and effective health care.

On Feb. 22-23, 2011, the University of Utah Center on Aging’s (CoA) Fifth Annual Research Retreat will focus on how the PCMH model and providing better transitional care for older patients can lead to improved health outcomes and cost savings in treating the nation’s burgeoning population of people 65 and older. Two experts in these areas – a physician who helped develop a patient-centered medical home model in Indiana, and a social worker who’s heading up a transitional care project at the Rush University Medical Center – will lead a symposium on these timely topics on Wednesday, the 23rd.

The retreat takes place in the Health Sciences Education Building (HSEB) and kicks off at 3:30 p.m. on Tuesday, the 22nd, with a reception and research poster presentations by CoA faculty and graduate students in Alumni Hall. Topics of the presentations will range from, “Using Hair to Monitor Health and Nutrition Among the Elderly” to “Development & Enhancement of a Medical Home Model for Low-Income Older Adult

On Wednesday morning in HSEB room 1750, a symposium, “Geriatric Patient-Centered Medical Home & Transitions of Care,” will address the critical issue of meeting the health care needs of older people. The first baby boomers turned 65 on Jan. 1, and when this “Age Wave” crests in about 20 years, an estimated 78 million people will have turned 65, placing unprecedented demand on the nation’s health care system.

“As the nation’s elderly population grows in the next 20 years, it is critical that our health care system addresses the huge needs this historic demographic shift will bring,” said Mark A. Supiano, M.D., CoA director, chief of geriatrics, and professor of internal medicine at the U School of Medicine. “Center on Aging faculty members are to committed exploring the cutting-edge research that will help meet the challenges of caring for a historic number of older people in our society.”

As providers and others look for ways to give older patients, and all others, better, more efficient health care, the PCMH model has gained wide support. In this model, a team that includes a primary care physician, nurses, pharmacists, physician assistants, medical assistants, social workers, and others oversees all aspects of a patient’s needs – acute, episodic, and preventive care.  This approach helps providers give more personalized care and also can reduce overall health care costs by providing more efficient care.

At 8:30 a.m. on Wednesday, Steven R. Counsell, M.D., Mary Elizabeth Mitchell Professor of Geriatrics, professor of medicine, and director of the Indiana University Geriatrics Program, will present, “GRACE: An Evidence-Based PCMH and Transitional Care Model.” Counsell has gained wide acclaim for a PCMH model he helped develop for low-income older people. Called GRACE – Geriatric Resources for Assessment and Care of Elders – the model is based on a two-team approach: a support team, comprising a social worker and nurse practitioner, and an interdisciplinary team, which includes a primary care physician, physical therapist, pharmacist, and community support liaison.

The support team meets with patients in their homes to assess everything from which medications they take to what they eat. The interdisciplinary team develops an individualized care plan for each patient. The support team then meets with the primary care physician and client to make sure the plan meets the individual’s needs and goals. A clinical trial showed GRACE reduced emergency department visits and hospital admissions, which contributed to better health, improved quality of life, and cost savings to the patients in the study.

At 9:15, Robyn L. Golden, LCSW, director of Older Adult Programs at Rush University Medical Center in Chicago, will discuss a pilot program at Rush that provides transitional care to older patients being discharged from the hospital. It’s estimated that nearly 20 percent of Medicare patients discharged from the hospital are readmitted within 30 days, and much of this is due to poor follow-up, especially within the first 48 hours of discharge.

In 2007, the Rush University Medical Center began an Enhanced Discharge Planning Program to reduce the number of readmissions. Led by Golden, the program uses social workers to follow up with elderly patients to identify potential problems, clear up confusion regarding the discharge plan, and resolve other issues that lead to hospital readmissions. In her presentation, “The Enhanced Discharge Planning Program: A Social Work Model for Transitional Care,” Golden will discuss the program and how it’s working.

“Their hands-on experience with these approaches to transitional care give both of our presenters a valuable perspective on how we can better care for elderly patients,” Supiano said.

Following Golden’s presentation, at 10:15, University of Utah geriatrician Cheri Brunker, M.D., associate professor of internal medicine, will discuss “Providing Tools for the Medical Home: The Role of Care Management Plus.” She’ll be followed by Les Lenert, M.D., M.S., U of U professor of biomedical informatics and internal medicine, who’ll discuss the “The Role of Technology in Supporting Aging in Place,” from 10:45 to 11:15.

The symposium and research retreat will conclude with a panel discussion from 11:15 to noon. For live webcast information, visit or contact The public is invited to both Tuesday’s and Wednesday’s events.   

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