How the Program Works
The Comprehensive Care for Older Adults With HIV is a team-based approach to the assessment and care planning for older adults living with HIV developed by Mount Sinai Health System’s Brookdale Department of Geriatrics and Palliative Medicine and the Institute for Advanced Medicine. Each team member has a specific role and everyone works together to provide the best possible care. Patients meet one-on-one with each of the core team members: a community health worker (CHW), a pharmacist, a geriatrician, a social worker, and a nurse.
This guidance focuses on the CHW’s special role in helping patients navigate their health care. The geriatrics team dedicates one day a week to seeing older adults with HIV. Each patient visit is scheduled for 30 or 60 minutes (30 minutes for follow-up visits, and 60 minutes for new patient appointments). Patients come to the program either on their own or are referred by a health care provider. Typically, patients speak with the CHW before, during, and after each visit. The new patient visit has several parts, as follows.
Pre-Visit Calls
The CHW will call the patient twice before the scheduled visit. The first time will be five to six days before the visit. The CHW will call again the day before the visit.
First Pre-Visit Call
The goal is to provide an orientation to the program and see if the patient has transportation to and from the visit.
- Script for the orientation: Script: My name is [CHW’s name] and I’m a community health worker at [name of clinic]. I currently work with Dr. [name of geriatrician] who is a geriatrician, a doctor who works with older adults. She specializes in evaluating memory problems, such as remembering appointments and taking medications. She will also check to see if you have any balance issues such as feeling unsteady on your feet or feeling like you might fall. She will review all your medications as many older adults take too many drugs. She will ask how you are functioning and whether you need help with day-to-day activities. She will also talk to your family members to get a sense of whether you are having any memory issues. She will discuss other medical issues like high blood pressure or diabetes. We want to help you deal with all your concerns and feel stronger and more stable. We’ll also ask about what matters most to you so we can try to help with any other problems or concerns. We work in a team. Our team also has a nurse, a pharmacist, and a social worker, whom you will meet with if needed. The initial visit with the doctor is about one hour. Does that sound ok? Is there anything else you would like to discuss about your health and aging?
Check on any transportation for the clinic visit. Script: Can you come to the clinic for your scheduled appointment on [date and time of appointment]? Do you have a way to get here?
- If needed, refer the patient to clinic social worker for transportation assistance (such as MetroCard or ride assistance).
- Document the conversation in the electronic medical record (EMR). Route the note to the doctor and social worker if transportation assistance is needed.
Second Pre-Visit Call
The goal of this call is to remind the patient about the appointment date and time, identify patient’s priority for the visit, and complete the functional status screen.
- Remind the patient of the appointment date/time. Script: My name is [CHW’s name] and I’m a community health worker at [name of clinic]. I work with Dr. [name of geriatrician] who is a geriatrician, a doctor who works with older adults. I am calling to remind you about your scheduled visit with our team on [date and time of appointment]. Does this appointment date and time still work for you?
- If appointment needs to be cancelled, ask why and offer to have the appointment rescheduled. If patient is interested in rescheduling the appointment, send a message to the front desk staff to reach out to patient to reschedule.
- Identify the patient’s priority for the visit. Script: What is most important for you to discuss at your visit with Dr. [name of geriatrician]?
- Document as free-text in the electronic medical record.
- Complete Activities of Daily Living and Instrumental Activities of Daily Living screens
The First Patient Visit
The geriatrics team should conduct the geriatric patient visit as usual, with the addition of the CHW. The visit begins when the nurse and CHW greet the patient in the waiting room and explain the process of the visit. They may introduce themselves and other team members, including the geriatrician, pharmacist, and social worker, if they are available.
Introduction: Script: Hi. My name is [name] and I am the nurse at this clinic. You may have seen me in the office before. I would like to introduce you to [CHW’s name], who will help you navigate your clinic visit today, assist with your check-out if needed, and help you coordinate care after today’s visit.
The CHW should greet the patient: Script: Hello. I am [name]. I’m looking forward to working with you today.
The nurse and CHW will lead the patient to the nurse triage station. Either the nurse or CHW will continue. Script: We will start with having a nurse review your health care proxy and screen for falls, mood, and other health factors. Then the CHW will assess you for anxiety and depression and the pharmacist will review your medications. Next, you will meet with the doctor for your comprehensive assessment to identify your care priorities and develop a care plan. You may also meet the social worker. At the end of the appointment, the CHW will help you make any follow-up appointments you need.
Next, the nurse will check the patient’s vitals (blood pressure, heart and respiration rate, oxygen saturation level, and weight). They will screen for falls by asking the following. Script: In the past 12 months, have you had a fall? In the past 12 months, have you been afraid that you would fall because of balance or walking problems?
These questions are also available in the electronic medical record. If the answer to either question is yes, the geriatrician should follow up.
The nurse will also check on the health care proxy. Script: Do you have a health care proxy? A health care proxy is someone who you choose to make medical decisions for you if you're unable to make them for yourself.
Check to see if there is a copy of the health care proxy in the electronic medical record. If not, ask them to fill out a form in the office or bring copy from home to the next visit with their doctor or with the geriatrics team. The health care proxy form must be witnessed by two members of the team, then we can scan the completed form into the electronic medical record and give the patient back their hard copy.
The nurse will also ask these questions, record the responses in the electronic medical record, and route the information to the geriatrician:
- Hospitalization or emergency department visits. Script: Have you had any recent emergency room visits or hospitalizations in the past year or since your last visit (if a follow-up visit)?
- Exercise/physical activity: Script: Do you exercise? What do you do for exercise? How frequently and how long are these exercise sessions?
- Socialization. Script: Do you socialize? What do you do for socialization? How frequently do you spend time with others?
Next, the CHW will ask questions about the visit and complete any additional screenings indicated. The CHW will accompany the patient from the nurse triage station to an examination room, and ask questions as below:
- How is your visit so far?
- Do you have any questions or concerns I can help with?
- Do you have specific questions for any team members that I can help to communicate?
The CHW will then perform the depression screening (PHQ-4), FRAIL screen, and coordinate meetings with the other team members as necessary.
Meeting the Pharmacist
After these screenings, the CHW will bring the patient to the pharmacist. If the CHW has time, they will remain with the patient during this conversation. The pharmacist will review all medications that the patient is taking. The pharmacist will go over the indications, side effects, any medication allergies, and pill management (weekly pill box or individual bottles) for each. Then the pharmacist will look at all lab test results, including renal function (creatinine clearance/eGFR), liver function, and CD4 lymphocyte count/viral load. The pharmacist will follow the standards of care as usual, as highlighted below.
The pharmacist will complete:
Medical review:
- Medication reconciliation
- Assess polypharmacy
- Total number of medications
- Chronic medications
- PRN medications (drugs taken as needed)
- Total number of medications on Beers Criteria
- Total number of medications with risk of QTc prolongation
- Anticholinergic burden score
- Drug-drug interactions
- Medication recommendations
Document in the electronic medical record and route to doctor:
- Assessment
- Management
- Recommendations
Meeting the Doctor
After the pharmacist interview, the patient will meet with a doctor who specializes in older patients, called a geriatrician. The CHW will bring the patient to the doctor’s office and remain until the doctor arrives. At that point, the CHW will leave so the patient can feel comfortable sharing private information. The doctor will conduct the geriatric screens. Patients can discuss what matters most to them. The key aspects of the assessment are below. Click here for further details:
- Screenings
- Veterans Aging Cohort Study Index (assesses frailty)
- FRAIL Scale questions four to five (the CHW asked questions one to three during the visit)
- Review systems including appetite, sleep, hearing, vision, cognition, and constipation.
- Finalize and review results of comprehensive geriatric assessment, including screening results completed by the CHW and nurse.
- Develop care plan.
- Adjust medications based on pharmacist recommendations.
- Make referrals to address geriatric vulnerabilities (e.g., imaging studies or specialty appointments). The doctor will tell the CHW, who will facilitate coordination.
- Document all assessment, management, and recommendations in the electronic medical record.
Meeting the Social Worker
If the screenings indicate that the patient needs to meet with the social worker, the CHW will coordinate. This may involve making an appointment for another day. The CHW will arrange the appointment, accompany the patient to the social worker’s office, and stay until the social worker arrives.
Patient Check-Out
When the patient is ready to leave, they will make a follow-up appointment at the front desk. If the CHW is available, they can escort the patient and assist in scheduling post-visit services.
Based on the patient’s care plan, the CHW will provide follow-up phone calls and care coordination. This involves a post-visit phone call one to two weeks after the visit. During this phone call, the CHW will:
- Review the patient chart to ensure that any needed appointments have been scheduled.
- Offer assistance if appointments haven’t been scheduled.
- Work with the social worker to help coordinate any transportation assistance.
- Connect the patient to community-based services that were identified.
- Document these activities in the electronic medical record.
- Discuss the case during supervision conferences with the geriatrician and social worker.
- The CHW will meet weekly with the:
- Geriatrician—to review the care plan
- Social worker—to discuss any social/community needs
- The CHW will meet weekly with the: