Table 3.

Most Commonly Reported Patient-Aligned Care Team Practices Used in Geriatric Patient-Aligned Care Team (N = 36)

Access and Scheduling (average practices implemented = 6.89/10)
provides non-face-to-face clinical guidance to patients36
schedules each patient with a personal clinician except when the clinician is unavailable35
provides a same-day appointment if clinically indicated, excluding emergency department31
Care Coordination (average practices implemented = 17.9/22)
reviews information received from other facilities to identify what follow-up support a patient needs36
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 chart35
reviews charts in advance of visits to anticipate patient needs34
Population Management (average practices implemented = 8.05/13)
incorporates evidence-based guidelines into everyday workflows for important conditions seen by Geriatric Patient-Aligned Care Team32
identifies patient on particular medications who need monitoring or evaluation and reminds them of this need28
identifies patient who might benefit from additional coordination/care management services and contacts them about these options27
Care Processes (average practices implemented = 11.38/20)
involves patients in their own decision making36
offers patients information about Advance Directives36
routinely determined whether a patient has difficulty with hearing, vision, or other barriers to communication35
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 processes27
Organizational Elements (average practices implemented = 9.36/14)
works as a team36
notifies patients of all abnormal results36
manages findings of lab tests and imaging procedures34