Primary Care Liaison Connects Health Care Providers with Aging Network Services

In 2016, Aging and Disability Services (ADS) joined the Northwest Geriatrics Workforce Enhancement Center (NWGWEC)—a partnership with the University of Washington (UW) Department of Geriatrics and Gerontology; the UW Schools of Nursing, Pharmacy and Social Work; Veterans Affairs; Puget Sound Health Care System; and the Area Agency on Aging and Disabilities of Southwest Washington to support coordination of geriatrics education activities. A third Area Agency on Aging—Aging & Long-Term Care of Southeast Washington—has also joined the partnership.

The NWGWEC’s goal is to optimize primary care of older adults through collaborative education, trainee engagement, and enhanced community-clinical linkages. NWGWEC delivers geriatrics education activities, including telehealth conferences, webcasting, and website archiving of educational materials. This work is made possible by an award from the U.S. Department of Health and Human Services’ Health Resources and Services Administration. 

ADS is thrilled to continue this clinical-community partnership, now funded through 2024 through an extension of the U.S. Department of Health and Human Services award.

Overcoming primary care outreach challenges

I came on board as a new primary care liaison in May 2019. Building on existing efforts, I continue to seek opportunities to raise awareness of local aging and disability services, connecting healthcare teams with resources, and facilitating the referral process.

In 2020 the COVID-19 pandemic dramatically changed people’s priorities and needs and placed unprecedented strain on our health care system. Clinics and hospitals were and continue to be concerned about healthcare providers’ fatigue and staff capacity.

As happened in many programs in our network, I pivoted to provide virtual outreach to healthcare providers, initially relying on telephone and e-mail contact. Identifying a new point of contact or re-connecting with clinics that experienced staff turnover was challenging. Phone systems were difficult to navigate and wait times were long. Sometimes clinic administrators and call center staff were unable to provide a specific follow-up contact and occasionally they were unresponsive.

In September 2020, I found success connecting with healthcare practices through mutual connections in the Community Living Connections network. I began regular virtual presentations to audiences of 60–100 service providers, including primary care providers at Kaiser Permanente Northgate and Rainier medical centers, Swedish First Hill Campus, and Country Doctor Community Health Clinic. I had the opportunities to speak more in depth about Area Agency on Aging core services—nutrition, family caregiver support, health and wellness, elder rights, and supportive services. The network meetings also opened doors for collaboration among clinics.

In March 2021, I initiated a virtual meeting with a former Swedish geriatric medicine fellow who is now the new Specialty Director of Geriatrics at HealthPoint Redmond clinic. We connected quickly due to our NWGWEC partnership. It was exciting to contribute a recorded Area Agency on Aging overview presentation and community resources for geriatric patients that at least 14 clinic locations have accessed to date. One HealthPoint clinic reported, “[Your presentation] was so informative. I already have patients I will be referring using the online form.”

Despite COVID-19 obstacles, we saw an increase in virtual outreach visits to clinics, hospitals, and other healthcare practices compared to the previous year. Virtual outreach visits have allowed me to share information with multiple clinics and healthcare teams across a healthcare system in a single virtual space at the same time. Video conference meetings also allowed flexibility for clinical teams to participate from their office space.

I stay connected by being available, sharing updated information and resources, and mailing out program materials upon request. In addition, I encouraged all providers who serve older adults and people with disabilities to join their local Community Living Connections network.

Virtual practicum transition

Our practicum has also transitioned to virtual delivery for geriatric medicine fellows and nurse practitioner students. In Fall 2020, we developed a virtual practicum curriculum that provides an Area Agency on Aging overview, independent pre-learning materials, and experiential learning opportunities. Nine trainees (five advance practice nurses and four geriatric fellows) completed their virtual practicum between February–June 2021. Trainees participated in experiential visits with ADS staff Carole Bourree, Kristine Broome, Mary Pat O’Leary, Kathi Church, and Gurleen Gulati, and with community partners, including Crisis Connections, Kin On, Kelly-Ross Pharmacy Group, and Adult Protective Services.

The practicum includes access to:

• Family caregiver support program and caregiver phone re-assessment 
• Community Living Connections listening shift with trainer
• Elder abuse prevention care coordination
• Long-Term Services and Supports case management and monthly information sharing session
• Health promotion programs and nursing services
• Enhance Fitness class with instructor and participants
• Adult Protective Services training
• Senior drug education program

A geriatric medicine fellow reflected on her overall experience, saying “[The practicum] was really great! Nice to see how much [ADS] does. [It] opens my eyes to a lot of things. [I] get a good sense of things. I can actually refer a patient [to Community Living Connections] as a provider and learned how to access information myself. I feel more competent in providing information to [patients].” 

When an advance practice nurse observed Carole Bourree, an ADS family caregiver specialist, during a caregiver phone re-assessment using the TCARE Personal Caregiver Survey, she wrote, “[TCARE] was a very detailed and lengthy assessment! From my end, it seemed difficult to do over the phone, so I was very impressed with Carole. It seemed there were many issues to ask about with the caregiver ranging from self-care to mental health and so forth. The family caregiver said they found a lot of meaning in life in their role caregiving for their family member. It was very interesting, and I learned a lot from Carole.” 

Contributor Phung Nguyen is primary care liaison at Aging and Disability Services. To learn more about this project or arrange an outreach visit, contact her at Phung.Nguyen@seattle.gov. For information about other services and resources, call Community Living Connections at (toll-free) 844-348-5464 or e-mail info@communitylivingconnections.org.