Objective: To examine the impact of an interdisciplinary, collaborative practice intervention involving a primary care physician, a nurse, and a social worker for community-dwelling seniors with chronic illnesses.Methods: A concurrent, controlled cohort study of 543 patients in 18 private office practices of primary care physicians was conducted. The intervention group received care from their primary care physician working with a registered nurse and a social worker, while the control group received care as usual from their primary care physician. The outcome measures included changes in number of hospital admissions, readmissions, office visits, emergency department visits, skilled nursing facility admissions, home care visits, and changes in patient selfrated physical, emotional, and social functioning.Results: From 1992 (baseline year) to 1993, the two groups did not differ in service use or in self-reported health status. From 1993 to 1994, the hospitalization rate of the control group increased from 0.34 to 0.52, while the rate in the intervention group stayed at baseline (P=.03). The proportion of intervention patients with readmissions decreased from 6% to 4%, while the rate in the control group increased from 4% to 9% (P = .03). In the intervention group, mean office visits to all physicians fell by 1.5 visits compared with a 0.5-visit increase for the control group (P = .003). The patients in the intervention group reported an increase in social activities compared with the control group's decrease (P=.04). With fewer hospital admissions, average per-patient savings for 1994 were estimated at $90, inclusive of the intervention's cost but exclusive of savings from fewer office visits. Conclusions:This model of primary care collaborative practice shows potential for reducing utilization and maintaining health status for seniors with chronic illnesses. Future work should explore the specific benefit accruing from physician involvement in the collaborative practice team.
This study provides data on changes in the functional status of older patients that are associated with acute hospitalization. Seventy-one patients over the age of 74 admitted to the medical service of Stanford University Hospital between February and May 1987 received functional assessments covering seven domains: mobility, transfer, toileting, incontinence, feeding, grooming, and mental status. Assessments were obtained by report from the patient's caregiver (or the patient when he or she lived alone) for 2 weeks before admission; from the patient's nurse on day 2 of hospitalization and on the day before discharge; and again from the caregiver (or patient) 1 week after discharge. The sample had a mean age of 84, covered 37 Diagnostic Related Groups, and had a median length of stay of 8 days. Between baseline and day 2, statistically significant deteriorations occurred for the overall functional score and for the individual scores for mobility, transfer, toileting, feeding, and grooming. None of these scores improved significantly by discharge. In the case of mobility, 65% of the patients experienced a decline in score between baseline and day 2. Between day 2 and discharge, 67% showed no improvement, and another 10% deteriorated further. These data suggest that older patients may experience a burden of new and worsened functional impairment during hospitalization that improves at a much slower rate than the acute illness. An awareness of delayed functional recovery should influence discharge planning for older patients. Greater efforts to prevent functional decline in the hospitalized older patient may be warranted.
Managed health care has forced psychologists and primary care physicians to expand their practices into areas for which they have traditionally lacked training or experience. This article describes a training program designed to foster collaboration and to bridge the gap between the 2 specialties by having psychology interns and medical residents comanage patients in a primary care setting under the joint preceptorship of a psychologist and a physician. Are we training psychologists to work effectively with physicians in diverse health care settings? Are we training generalist physicians to competently assess and manage the biopsychosocial aspects of their patients' complaints? This article describes a training program designed to bridge the gap between psychology and medicine by having psychology interns and medical residents comanage patients in a primary care setting.Professional psychology is undergoing "the greatest resocialization... since the explosion of clinical psychology hi the post-World War II era" (Cummings, 1995, p. 10). To remain viable and competitive in the current health care marketplace, established practitioners as well as new graduates have had to increase the breadth and diversity of training to function more flexibly in various professional settings (Cummings, 1986;Nickelson, 1995;VandenBos, DeLeon, & Belar, 1991). The same market environment has forced primary care physicians to function in broader capacities. Indeed, it is estimated that approximately 25% of all primary care visits are for psychosocial-psychiatric needs that compromise health status (Brody & Larson, 1992;Kamerow,
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