The Geriatric Workforce Enhancement Program (GWEP) advances rural northern New England's regional capacity to address the healthcare needs of older adults and informs national geriatric workforce improvement.
要了解更多关于GWEP研究计划的信息，请参阅 新英格兰北部老年劳动力增强计划 章节 家庭医学资助研究 页面.
目前正在进行的全球环境行动计划项目如下:
- 初级保健老年跨专业团队转型(GITT-PC): A model developed by NNEGEC that focuses on workforce culture change to empower primary care teams to achieve best practice in geriatrics in primary care.
- 预防跌倒教育: The Geriatric Center of Excellence (GCOE) Falls Prevention team works within the 十大博彩推荐排名卫生 system and partners throughout New England to screen individuals for fall risk and help them engage in effective falls prevention intervention.
- SNF POLST项目: The SNF (Skilled 护理 Facilities) POLST (Provider Orders for Life-Sustaining Treatment) Project uses a model that systematically and significantly reduces unwarranted and unwanted use of the Emergency Department by residents of Skilled 护理 Facilities.
- 学生POLST专题该项目旨在通过关注POLST表格来培养重要的技能, a national document to clarify and codify a vulnerable patient's wishes for treatment in the event of an acute illness or decline.
初级保健老年跨专业团队转型(GITT-PC)
初级保健老年跨专业团队转型(GITT-PC), NNEGEC开发的模型, moves away from traditional training methodologies by focusing on workforce culture change to empower primary care teams to achieve best practice in geriatrics in primary care. This goal is accomplished by training healthcare professionals from multiple disciplines on:
- 团队技能和最佳团队功能
- 质量改进(QI)工具和方法
- 医疗保险可报销服务和访问的最佳实施, 以及相关的计费代码
As we work toward value-based healthcare and improving the coordination of care for older adults, team effectiveness is a critical component to achieving the desired outcomes for older adults.
This program uses a person-centered approach to focus on how patients can help transform the work of all primary care team members, 包括医疗助理, 护士, 高级临床医生, 医生, 办公室经理, 支持人员.
We focus on best practices for Medicare-reimbursable visits such as the Annual Wellness Visit, 慢性护理管理, 过渡性护理管理, 和预先护理计划. Reimbursable visits allow participating practices to sustain their investment in implementing this model through effective billing and reimbursement.
预防跌倒教育
The Geriatric Center of Excellence (GCOE) Falls Prevention team works within the 十大博彩推荐排名卫生 system as well as with partners throughout New England to screen individuals for fall risk and help them engage in effective falls prevention intervention.
The Falls Prevention team works closely with teams in the following 十大博彩推荐排名卫生 departments and programs:
GCOE团队提供领导并与 新罕布什尔州降低风险特别工作组这是一个全州范围的预防跌倒联盟.
The Falls Prevention team delivers training and implementation support to community-based organizations and primary care providers on falls risk screening, 转诊路径, 以及可持续发展的能力建设, 有效的预防跌倒计划. This training aligns with efforts to integrate primary care with community-based organizations and to promote 老年人友好型卫生系统.
SNF POLST项目
The current SNF (Skilled 护理 Facilities) POLST (Provider Orders for Life-Sustaining Treatment) Project has been adapted from a previous program, 减少可避免的设施转移或RAFT. RAFT is a model of healthcare delivery developed at Dartmouth Hitchcock Medical Center in 2016-2018, which systematically and significantly reduces unwarranted and unwanted use of the Emergency Department by residents of Skilled 护理 Facilities. Below are the core elements from RAFT that will be used in our current model.
RAFT的核心要素包括:
- “SNFists”——由老年医生组成的小团队, NPs, 负责日间和非工作时间护理设施病人的护理人员.
- Systematic discussions with patients/families about goals of care documented using the POLST form.
- 增加了提供者与患者的接触, 工作人员, families and ED 工作人员 during an acute decline with emphasis on matching care delivery to care goals.
This training emphasizes the systematic elicitation of care goals using POLST as a means to improve care, 确保与目标一致并降低成本. 最终, 通过常规, 与训练有素的设施工作人员进行系统的对话, each patient proactively identifies the responses to an acute illness or injury that most closely matches his/her goals and values.
学生POLST专题
该项目旨在通过关注POLST形式来培养重要的技能, a national document to clarify and codify a vulnerable patient's wishes for treatment in the event of an acute illness or decline. 在表格上, 4 specific options ranging from unlimited curative interventions to comfort care are listed. 病人 and families select one of the options that best corresponds with their values and wishes.
本课程包括两个部分. 第一种是以虚弱为重点的教学和体验式培训, 住宅保健, 痴呆症和预先指示. The second is student participation in three mock conversations with the goal of completing the POLST form followed by formal feedback/critique.
这些对话对学生来说有三个目的:
- To listen attentively and compassionately with attention on values and priorities.
- To clearly and effectively explain the POLST and the 4 options under consideration ranging from aggressive unlimited interventions to exclusively comfort focused care.
- To assist and guide the actor in the selection of one of the options in the context of values identified.
我们发现这个模型和POLST表格的使用有助于实现“护理目标”,这是许多临床医生觉得模糊和吓人的东西, appear more approachable and concrete and thereby provides a more comfortable and effective context in which to improve the skills needed for challenging conversations of all kinds.