title: Perceptions of care among high-risk geriatric patients, families, and caregivers in a patient-centered medical home.
abstract: OBJECTIVE
  A survey was conducted by the pharmacy team to identify improvement areas in the delivery of care in high-risk patients at a patient-centered medical home (PCMH) at the University of Pittsburgh Medical Center (UPMC).
  
  
  METHODS
  This survey was a quality improvement project.
  
  
  METHODS
  The survey was conducted at UPMC Senior Care, a level-three accredited PCMH.
  
  
  METHODS
  The survey was conducted in a sample of preidentified high-risk patients.
  
  
  METHODS
  Pharmacy performed a survey, analyzed responses for common themes, and conducted follow-up phone calls to determine the degree of goal-achievement and efficacy of educational materials provided during the initial survey.
  
  
  METHODS
  The primary goal for conducting the survey was to identify needed areas for improvement in three specific domains, namely, medication decisions, communication with providers, and goals of care.
  
  
  RESULTS
  Medication reviews were provided for 23 of 24 surveyed, leading to medication discrepancy resolution in 58%. Almost 80% of the respondents were satisfied with the team's communication. More than 85% of respondents verbalized the goals they wanted to achieve in three months. The follow-up phone calls were conducted in 20 of those initially surveyed. Only 5 patients did not meet their goals. The following improvement areas were identified: need to provide medication lists and correct medication inaccuracies, need for medication review, patient goals documentation, and patient education and the appropriate medium of education.
  
  
  CONCLUSIONS
  Future appointments for high-risk patients at the PCMH should include the pharmacist. The team should focus education on families/caregivers and utilize alternate patient education methods.
authors.affiliation: State University of New York-Downstate Medical Center, Brooklyn, New York, USA.
authors.forename: Madhavi
authors.initials: M
authors.lastname: Gavini
authors.forename: Amelia S
authors.initials: AS
authors.lastname: Gennari
authors.forename: Christine M
authors.initials: CM
authors.lastname: Ruby
mesh_terms: D000368:Aged; D017028:Caregivers; D005190:Family; D006801:Humans; D010348:Patient Care Team; D010353:Patient Education as Topic; D018802:Patient-Centered Care; D010465:Perception; D012306:Risk