This document discusses gaps in primary care for older adults and proposes ways to bridge those gaps. It identifies three main gaps: 1) lack of communication between all those involved in a patient's care, 2) an overemphasis on immediate needs rather than coordinated long-term care, and 3) lack of clarity around who is ultimately in charge of and responsible for a patient's health. It proposes putting more control and responsibility into the hands of patients, using motivational interviewing and care transition coaches. Integrated primary care networks and databases are mentioned as current initiatives, but increasing patient numbers and aging providers are challenges.

1. "Pulling it All Together: Bridging the Gaps in Primary Care". Marcia Carr (RN,BN,MS,GNC(C),NCA) Clinical Nurse Specialist

2. Stating the Obvious Reality?

6. Gaps

7. #1: Communication Every time a patient receives care or services from a different provider, the potential for a sentinel event increases

8. Communication PATIENT Primary Care Provider Family, Significant Others, community Health Authorities’ Services Social Services Gov’t, Others Components connect to patient but not to each other

9. #2: Immediate Need Responsive Both patients and systems are in urgent, crisis, rescue mode

11. #3: Control, In Charge Who should or actually holds the control or is in charge of the patient’s health and illness?

13. The PATIENT? Are we as health care providers responsible for their health/illness or is the patient?

14. Bridging or Eliminating the Gaps

18. Propose PATIENT And Primary Care Providers Family, Significant Others, Community Social Services Gov’t Services Health Authorities’ Services Private Providers Patient and PCP partnership assures centralized communication

20. Propose: PCP Database Central tracking for trending for prevention and services Other Social Issue Mental Emotional Issue Physical Issue Health Age Other palliative chronic management acute curative diagnostic preventive

23. However, … Increasing numbers with fewer providers doing lion’s share of work to bridge gaps

24. The Here and the Now Time to Dialogue

25. Thank you [email_address]