Document Type

Capstone Experience

Graduation Date

5-2018

Degree Name

Master of Public Health

Department

Health Promotion

First Committee Member

Armando De Alba Rosales, MD, MPH

Second Committee Member

Kristine McVea, MD, MPH

Third Committee Member

Lea Pounds, PhD, MBA

Abstract

The purpose of this project was to identify opportunities for quality improvement in the care of geriatric patients at OneWorld Community Health Centers (OneWorld) by applying the principles of Community Oriented Primary Care (COPC) in the implementation of the Medicare Annual Wellness Visit (AWV).

Specific objectives were to better understand factors affecting geriatric health risk assessment and management (including implementation of the Medicare AWV) in federally qualified health centers (FQHCs) and to utilize data from pilot visits to better understand patient health needs in one FQHC, with emphasis on fall risk, cognitive loss, activities of daily living, and compliance with United States Preventive Services Task Force (USPSTF) recommendations. To meet these goals, this project utilized semi-structured interviews with key staff, a provider survey, and electronic health record (EHR) review.

Over the course of pilot implementation, a total of 71 visits were completed using the AWV template. This included 58 visits with patients aged 65 and older, which were subsequently analyzed for health data. Nearly all (89.7%) of these 58 visits identified a patient need in at least one of the above-mentioned health domains (fall risk, cognitive loss, functional status, and compliance with USPSTF recommendations). Examined as separate outcomes, each of these four domains was identified as a need in at least one-fourth of patients.

Semi-structured interviews with providers and clinic staff during the implementation process revealed several core themes in attitudes and suggestions regarding these visits, which were defined as opportunities, streamlining, and buy-in. AWVs were seen as an opportunity for improving quality of care, but interviewees were also concerned about the potential to disrupt clinic workflow and offered some suggestions to avoid this (e.g., EHR elements, broader staff 2 training, reference sheets for clinic staff). Several respondents also expressed concern that not all patients, providers, and staff fully understood or recognized the importance of these visits.

In a survey of FQHC providers, most respondents (67%) stated that they saw multiple older patients over the course of an average work day. The vast majority (91.7%) rated themselves as “mostly confident” or “very confident” in recognizing fall risk and polypharmacy, but fewer expressed these levels of confidence in recognizing cognitive loss or nutritional deficits, or in managing any of the four conditions. Asked about their knowledge of community resources for older adults, one-fourth of respondents denied adequate knowledge. Regarding familiarity with the Medicare AWV, 41.7% stated that they had performed at least one of these visits. This project demonstrates significant value of the Medicare AWV as a tool for geriatric assessment in FQHCs and highlights important considerations for implementation. The results also illustrate potential new roles for FQHCs in serving the rapidly-growing geriatric patient demographic.

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