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Group #1 Integrating Geriatrics into Primary Care

Common Problems….

Patients: Access to providers and resources – including transportation

Increased coordination

Inadequate health literacy

Medicinal help

Social support

Providers: Adequate time for visit

Care coordination with non-practice assets

Advance directive education/ counseling

Assessing/Providing support

Staff: Education on how to help elderly

Need access to more tools/skills

Authority/standing orders – Overall improved Team Communication

Leveraging team Communication

Next Steps…

Needs Assessment – providers & staff

Moncure, Benson – and other online resources

Process Mapping

Patient/caregiver relationship

Group #2 Community Continuing Education


  • Lack of Coordinated Care
  • Provider communication does not follow good health literacy guidelines
  • Never asking what the patient wants
  • Lack of respect
  • Access to community services is hindered by following the medical model
  • Ability to navigate the system – insurance claims, etc.
  • Lack of services available in rural areas
  • IPE – time to complete tasks, not considered fun
  • Knowledge of Community Services
  • Primary care must OWN Geriatrics, but they avoid screening for geriatric syndromes if there are no interventions
  • Cost
  • Palliative Care
  • Mental Health
  • CNA training in geriatrics is poor
  • Dementia

Patient Needs…

  • Respect
  • Sometimes there is a conflict between the family’s wish that patients be safe and the patient’s wishes for a full life

Next Steps…

  • NC State plan to address dementia to consider including recommendations supporting the integration of geriatrics into primary care
  • Take advantage of community access points: Senior centers, Fire stations, Libraries to deploy training
  • Practice-based continuing education
  • Caregiving Conference
  • Online Resources – www.NC-AGE.com
  • Programs such as 211 (or other concierge services)
  • Data availability

Group #3 IPE Fellowship

What we learned:

-Currently have 1 nursing (BSN-DNP) student has been selected for fellowship

-3 possible candidates for dental fellowship—all currently employed at Piedmont

-PACE site in Pittsboro—currently medical team is doing some oral assessment if problem Katrina Mattison (Dental Director for Piedmont is called)

-Piedmont location at Moncure currently has a large older adult population with Medicare

-Recruitment would be much easier with a one year possible 2 year student commitment to fellowships, with option to renew second year

-Clinical contracts already in place at Piedmont Health

What we discussed:

-Didactic structure

  • Core structure—learning will be gained from existing core curriculum for geriatric fellows
  • Learning at sites—fellows will present topics to site staff on over arching topics such as (falls, dementia, nutrition, food consistency)

-Process issues

  • Incorporating interprofessional and each discipline competencies into the curriculum
  • We also discussed the potential to do webinars so fellows, faculty and staff in different sites and participate together from a distance

-Dental Fellowship

  • Dental assessments at PACE site in Pittsboro if treatment need will be able to refer directly to Piedmont Moncure site for treatment
  • Possible schedule at PACE for dental fellow MTW (dental sit in morning sessions 8:30/9 a then assessment begin after 10 a)
  • What we need to figure out is # patients that will need tx and how much time needed if referred to Moncure
  • Time at PACE would be considered off site time for fellows

-Medical Fellowship

  • Possible recruitment from Family Medicine at Piedmont


1) Have a one year optional 2 year fellowship

2) Pilot Site will be Pittsboro PACE—Amy Denam. Meeting will be scheduled with Amy to visit PACE site and explore this possibility

3) Key is starting didactics together as IPE team

4) Recruitment and start—if January start will request Amy to Help deliver geri didactic core onsite for new fellows. If this is not possible will start July 1 as fellows will follow already existing geri core

5) Nursing fellow will start January 2016 and will hopefully complete remaining geri core and be brought up to speed by Amy at PACE

6) Need to understand the evaluation plan outlined in the grant application