• Study Design: Quasi-experimental, intention-to-treat, longitudinal (30 months)
• Inclusion Criteria: 66+ years of age; Medicare FFS or Medicare PPO (discounted FFS) payer
• Primary research question: Does the interdisciplinary team model of a specialized senior primary care center (Barger Senior Health & Wellness Center) improve outcomes for older adults in an integrated health care system?
• Principal Investigator: Ron Stock, M.D., Geriatrician.

The PHOR Center for Senior Health was awarded a grant from the John A. Hartford Foundation of New York City to perform a four year intervention and measurement study. The purpose of the study is to demonstrate the impact of interdisciplinary team care on health outcomes for older adults and organizational outcomes evidenced at PHOR and the Barger Senior Health and Wellness Center (SHWC) in Eugene, Oregon. The PeaceHealth study will compare the impact of an interdisciplinary team model of geriatric care with two comparison groups, a physician-care manager model and a traditional physician practice model for geriatric care. It is hypothesized that the interventions will significantly improve patients’ clinical and functional outcomes and their satisfaction with care, while reducing their use of acute services (e.g., emergency and acute hospitalizations). In addition, the interventions are expected to be cost-effective in the long run relative to usual care, i.e. the rate of decline for elders in the SHWC model will be slower than in other primary care modalities. Medicare cost data will be utilized to analyze the costs. Outcome data is being collected at baseline, 6 months, 18 months, and 30 months. Additionally, caregiver satisfaction and caregiver burden will be measured using caregivers from each of the three study groups.

Intervention
The SHWC interdisciplinary team approach will be integrated into all aspects of the senior health service delivery model, particularly those 
portions of the model that pertain to chronic illness.

The core team includes a Geriatrician, Nurse Practitioner (NP), clinic resource nurse (RN), medical social worker, pharmacist, physical therapist, dietician, and chaplain. Others involved in team activities include office nursing support staff, receptionists, home health staff, and a geriatric psychiatrist. All team members and clinic staff will receive senior sensitivity, team building, and self-management skills training. Geriatric syndrome protocol training will be provided. Individual members will develop their own work process and care protocols to support the team approach. Protocols will include dementia, urinary incontinence, falls/gait disturbance, diabetes, congestive heart failure, and care of the osteoarthritic knee/hip.

The Senior Health Center model aims to enhance coordination and continuity along the continuum of care, including outpatient primary care, inpatient acute care, skilled nursing facility care, and skilled home care. The HART (Health Assessment and Risk Test) screen will be used to identify two groups of elderly patients - well or low-risk elderly and frail or high-risk elderly. Moderate or high risk patients and their caregivers will be invited to participate with the team in developing care plans that include specific self-management and behavioral goals. Software application tools will be used for tracking, monitoring, and visit planning. A registry of patients known to be frail and at “high risk” will assist team members provide planned, proactive care. Planned interventions include 1) self-management interventions; 2) planned, proactive care interventions; and 3) geriatric-specific clinical interventions.

Back to TOP

For more information:

Research Proposal (ORIGINAL - Oct. 2000, full text)

Progress Reports (a listing of PDF documents)

Timeline (PDF document)

Outcomes Measurement

• Table of Study Outcomes Measurement (PDF document)
• Measurement Tools

Health Assessment and Risk Tool (HART)

PeaceHealth Physical Function (PPF-13)

PeaceHealth Depression Scale (PDS-11)

Simple Quality of Life (SQL-24)

Patient Satisfaction

Caregiver Satisfaction

Caregiver Burden Scale

Recruitment of Study Participants

Senior Health Clinic Outcome Study Publications (PDF file)

You may view and print out the PDF documents on these pages if you have Adobe Acrobat Reader software. If you do not have this software, please go to the Adobe website to download a FREE copy for your computer.

Back to TOP

Contact us via e-mail: SeniorStudy@peacehealth.org

Senior Health Clinic Outcome Study Home Page

Voice of the Senior / Senior Clinic / The Interdisciplinary Team / 
Leadership / Research / Hartford Foundation / Resources-Links