The interagency care team: A new model to integrate social and medical care for older adults in primary care

To integrate management of social drivers of health with complex clinical needs of older adults, we connected patients aged 60 and above from primary care practices with a nurse practitioner (NP) led Interagency Care Team (ICT) of geriatrics providers and community partners via electronic consult. The NP conducted a geriatric assessment via telephone, then the team met to determine recommendations. Thirteen primary care practices referred 123 patients (median age = 76) who had high rates of emergency department use and hospitalization (28.9% and 17.4% respectively). Issues commonly identified included medication management (84%), personal safety (72%), disease management (69%), food insecurity (63%), and cognitive decline (53%). Referring providers expressed heightened awareness of older adults' social needs and high satisfaction with the program. The ICT is a scalable model of care that connects older adults with complex care needs to geriatrics expertise and community services through partnerships with primary care providers.