The community activity of a hospital geriatrics service: a practical example of coordination between primary and specialized care

OBJECTIVES: To describe the management of the geriatric hospital home assessment team to support at primary care in the need of health of geriatric patients. DESIGN: Prospective observational study. SETTING: 5-North health district from Madrid. PARTICIPANTS AND METHODS: All patients evaluated at home and the coordination activities between primary care and hospital geriatric service, developed by the geriatric assessment team between january 1997 at december 1999. Inquiry to primary care physicians about the usefulness of geriatric hospital home assessment team. MAIN RESULTS: 524 patients was assisted at home by the geriatric assessment team to request primary care (58.4% at all patients attended), 83.24 +/- 7.21 years old (68.1% females), with pluripathology (4.02 +/- 1.86 diagnostics) and polypharmacy (4.95 +/- 2.8), moderate-severe functional disability (Barthel Index < 60 at 65% and Red Cross functional disability > 2 at 74.4%) and frequently cognitive impairment (41.2% with Pfeiffer > 5). The main reasons of primary care to consult was functional impairment (28.4%), medical process assessment (16.2%), geriatric assessment (13.2%), skin ulcers (13.2%) and behavioral disorders (10.8%). 865 telephone call and 178 meeting in health center of primary care for consultation or medical management or for coordinating medical management was attended. 62% of primary care physician inquired to answer back. The belief of 100% answers was about de usefulness of the geriatric assessment team activity, mainly because their specialization on geriatric care (76.7%) and their responsibility of the hospital resources (65.1%).

Baztán JJ, Gil L, Andrés E, Vega E, Ruipérez I. The community activity of a hospital geriatrics service: a practical example of coordination between primary and specialized care. Aten Primaria. 2000; 26(6):374-82.

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