Most Commonly Reported Patient-Aligned Care Team Practices Used in Geriatric Patient-Aligned Care Team (N = 36)
| N | |
|---|---|
| Access and Scheduling (average practices implemented = 6.89/10) | |
| provides non-face-to-face clinical guidance to patients | 36 |
| schedules each patient with a personal clinician except when the clinician is unavailable | 35 |
| provides a same-day appointment if clinically indicated, excluding emergency department | 31 |
| Care Coordination (average practices implemented = 17.9/22) | |
| reviews information received from other facilities to identify what follow-up support a patient needs | 36 |
| assesses barriers when patients do not move toward their treatment goals (eg, medication adherence, costs of care, and lack of family support). | 35 |
| incorporates external records into the practice chart | 35 |
| reviews charts in advance of visits to anticipate patient needs | 34 |
| Population Management (average practices implemented = 8.05/13) | |
| incorporates evidence-based guidelines into everyday workflows for important conditions seen by Geriatric Patient-Aligned Care Team | 32 |
| identifies patient on particular medications who need monitoring or evaluation and reminds them of this need | 28 |
| identifies patient who might benefit from additional coordination/care management services and contacts them about these options | 27 |
| Care Processes (average practices implemented = 11.38/20) | |
| involves patients in their own decision making | 36 |
| offers patients information about Advance Directives | 36 |
| routinely determined whether a patient has difficulty with hearing, vision, or other barriers to communication | 35 |
| provides a list of agencies, community-based organizations, or other entities to patients/families that support patient self-management (when appropriate). | 28 |
| Quality Improvement (average practices implemented = 9.69/19) | |
| measure or receive data on the performance of the practice on key clinical and administrative processes | 27 |
| Organizational Elements (average practices implemented = 9.36/14) | |
| works as a team | 36 |
| notifies patients of all abnormal results | 36 |
| manages findings of lab tests and imaging procedures | 34 |