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For many older adults, ambulatory care is a central setting of health care delivery. In response to climbing costs and health care policy changes, including the passage of the Patient Protection and Affordable Care Act in the United States in 2010, there is significant interest in improving primary care, especially for the most medically and psychosocially complex older adults, in order to achieve the Triple Aim of improving patient experience, cost, and population health. In this chapter, we will review models for ambulatory primary care for community-dwelling older adults, including the Patient-Centered Medical Home (PCMH), the Geriatric Resources for Assessment and Care of Elders (GRACE) Team Care model, the Programs of All-Inclusive Care for the Elderly (PACE) model, as well as ambulatory specialty and consultative geriatrics models. In addition, we will discuss geriatrics assessment in the ambulatory setting and the role of care coordination and quality and safety when delivering care to older adults in this setting.


Primary care, as defined by the Institute of Medicine in 1996, is “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” Older adults require high-quality primary care to oversee chronic disease management, preventative care, and management of geriatric syndromes.

One model that aims to provide high-quality primary care is PCMH. PCMH is a care delivery model in which treatment is coordinated through a primary care physician to match the following five functions and attributes: comprehensive care, patient-centered care, coordinated care, accessible services, and commitment to quality and safety. PCMH aims to deliver team-based coordinated care, rather than fragmented care, which many patients struggle to navigate. Although this care delivery model is not specific to the older adult population, it naturally fits with the care of complex older adults. Many principles of geriatrics ambulatory care, such as strong patient-provider relationships that recognize the role of family and caregivers, interprofessional team-based care, advance care planning, and continuous care throughout life stages and health care settings, are aligned with PCMH’s five functions and attributes. In the medical home, an interprofessional team of providers, discussed further in Chapter 3, is responsible for assessing and meeting each individual’s health needs and providing comprehensive care. For example, team members with training in mental health, including social workers, psychologists, and psychiatrists, may screen patients for cognitive impairment, depression, loneliness, social isolation, and substance use. Physical therapists perform gait and balance testing and evaluate the need for treatments or assistive devices to prevent falls and improve function. Occupational therapists on the team assess how much assistance each patient requires for their daily activities in order to design the most appropriate care plan, including level of supervision and environment. Pharmacists and physicians work together to ...

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