As the older adult population in the United States increases and diversifies, understanding and reducing risks for hospitalization and institutionalization can reduce burdens for this vulnerable population. Using evidence-based assessment tools to understand medical, psychosocial, pharmacologic, and functional status can aid an interprofessional team to best evaluate older adults at risk. By providing culturally competent care for a diversifying older adult demographic, attention to social determinants can improve health equity for this population. This article describes in a case study exemplar, how one such interprofessional collaborative practice program, Geriatric Outreach and Training with Care (GOT Care!) provides a comprehensive assessment for high-risk older adults, identifies and documents these risks, and shares recommendations and rationale with the primary care provider toward risk reduction and improvement of outcomes.
Alexandra Schain, MS, AGNP-BC, APRN, is GOT Care! Project Curriculum Development Coordinator, University of Connecticut School of Nursing, Storrs, Connnecticut.
Catherine Rees, MPH, is Director of Community Benefit, Middlesex Hospital, Middletown, Connecticut.
Catherine Medina, PhD, LCSW, is an Associate Professor, University of Connecticut School of Social Work, Hartford, Connecticut.
Rachel Eyler, PharmD, is an Assistant Clinical Professor, University of Connecticut School of Pharmacy, Storrs, Connecticut.
Susan Glenney, DPT, is a Clinical Assistant Professor in Residence, University of Connecticut College of Agriculture, Health and Natural Resources, Storrs, Connecticut.
Eric Rodko, LMSW, is Executive Director, St. Luke's Community Services, Middletown, Connecticut.
Jason Cassese, MA, MSW, is a GOT Care! Project: Benefits and Case Coordinator, St. Luke's Community Services, Middletown, Connecticut.
Juliette Shellman, PhD, RN, APHN-BC, is a GOT Care! Project: Program Evaluator, and Associate Professor, University of Connecticut School of Nursing, Storrs, Connecticut.
Millicent Malcolm, DNP, APRN, GNP-BC, FAANP, is a GOT Care! Project: Principle Investigator and Project Director, and Assistant Clinical Professor, University of Connecticut School of Nursing, Storrs, Connecticut.
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number HRSA-14-070 Nurse Education, Practice, Quality and Retention-Interprofessional Collaborative Practice for $1,400,688 with no other nongovernmental funding. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.
The authors declare no conflicts of interest.
Address for correspondence: Millicent Malcolm, DNP, APRN, GNP-BC, FAANP, University of Connecticut School of Nursing, 231 Glenbrook Rd. U-4026, Storrs, CT 06269-4026 (Millicent.Malcolm@uconn.edu).