TOPLINE:<\/h2>\n
Community health workers were integrated into primary care to deliver age-friendly care services to rural older adults. Initial results indicated a reduction in hospitalizations, with positive feedback received from patients, caregivers, and primary care providers (PCPs).<\/p>\n
METHODOLOGY:<\/h2>\n\n- Researchers conducted a pilot study of a program in rural Oregon that embedded community health workers into primary care teams to implement age-friendly care protocols aimed at improving the quality of care and engagement of rural older adults.<\/li>\n
- The study enrolled 388 medically frail patients (average age, 77 years; 63% women; 82% White) referred by 79 PCPs across seven clinics.<\/li>\n
- Community health workers conducted home or clinic visits and made patient phone calls.<\/li>\n
- Protocols comprised a conversation tool for patient priorities, support for completing the advance directive, in-home reviews of medications, information on brain health and cognitive concerns, and fall risk reduction assessments with safety checklists and exercise resources.<\/li>\n
- Community health workers documented outcomes and social conditions in electronic health records for review by PCPs.<\/li>\n<\/ul>\n
TAKEAWAY:<\/h2>\n\n- The Connected Care for Older Adults pilot expanded from a single federally qualified health center in 2022 to seven sites serving 250 patients annually by June 2025. Surveys were completed by 120 patients, 17 caregivers, and 19 referring PCPs.<\/li>\n
- Overall, 95% of responding patients reported a positive impact on their lives, with community health workers providing support and engagement.<\/li>\n
- All PCPs who completed the survey reported satisfaction with the program and appreciated community health workers for facilitating resource connections, addressing social isolation, and engaging patients and families in care.<\/li>\n
- Emergency department visits decreased from 32.26% to 7.74% and hospitalizations decreased from 15.05% to 2.08% from 3 months prior to the intervention to 12 months postintervention.<\/li>\n<\/ul>\n
IN PRACTICE:<\/h2>\n
\u201cOur results indicated that CHWs [community health workers], when trained in well-developed 4Ms [what matters, mentation, medication, and mobility] protocols and given appropriate clinical supervision, feel confident in assisting the implementation of all 4Ms, even in rural, under-resourced settings where it may be most challenging but critical to foster age-friendly care,\u201d the authors wrote.\u00a0<\/p>\n
SOURCE:<\/h2>\n
The study was led by Bryanna De Lima of the Division of General Internal Medicine and Geriatrics at Oregon Health & Science University in Portland, Oregon. It was published online on January 10, 2026, in the Journal of the American Geriatrics Society<\/em>.<\/p>\nLIMITATIONS:\u00a0<\/h2>\n
The survey response rates were low, and there were limited data on usage. The use of different frailty definitions by PCPs may have led to inconsistencies in patient selection.<\/p>\n
DISCLOSURES:<\/h2>\n
The study was supported by grants from the PacificSource Foundation for Health Improvement, Oregon Health Authority, and the Oregon Community Foundation, among others. The authors declared no conflicts of interest.<\/p>\n
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.<\/em><\/p>\n<\/div>\n<\/div>\n
\n
<<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"
TOPLINE: Community health workers were integrated into primary care to deliver age-friendly care services to rural older adults. Initial results indicated a reduction in hospitalizations, with positive feedback received from patients, caregivers, and primary care providers (PCPs). METHODOLOGY: Researchers conducted a pilot study of a program in rural Oregon that embedded community health workers into […]<\/p>\n","protected":false},"author":1,"featured_media":11001,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_daextam_enable_autolinks":"","jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":true,"jetpack_social_options":{"image_generator_settings":{"template":"highway","default_image_id":0,"font":"","enabled":false},"version":2}},"categories":[2],"tags":[],"class_list":["post-11000","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-health"],"jetpack_publicize_connections":[],"jetpack_featured_media_url":"https:\/\/diyhaven858.wasmer.app\/wp-content\/uploads\/2026\/01\/gty-260126-nurse-senior-patient-800x450.jpg","jetpack_sharing_enabled":true,"jetpack-related-posts":[],"_links":{"self":[{"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/posts\/11000","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/comments?post=11000"}],"version-history":[{"count":0,"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/posts\/11000\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/media\/11001"}],"wp:attachment":[{"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/media?parent=11000"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/categories?post=11000"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/tags?post=11000"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
TAKEAWAY:<\/h2>\n\n- The Connected Care for Older Adults pilot expanded from a single federally qualified health center in 2022 to seven sites serving 250 patients annually by June 2025. Surveys were completed by 120 patients, 17 caregivers, and 19 referring PCPs.<\/li>\n
- Overall, 95% of responding patients reported a positive impact on their lives, with community health workers providing support and engagement.<\/li>\n
- All PCPs who completed the survey reported satisfaction with the program and appreciated community health workers for facilitating resource connections, addressing social isolation, and engaging patients and families in care.<\/li>\n
- Emergency department visits decreased from 32.26% to 7.74% and hospitalizations decreased from 15.05% to 2.08% from 3 months prior to the intervention to 12 months postintervention.<\/li>\n<\/ul>\n
IN PRACTICE:<\/h2>\n
\u201cOur results indicated that CHWs [community health workers], when trained in well-developed 4Ms [what matters, mentation, medication, and mobility] protocols and given appropriate clinical supervision, feel confident in assisting the implementation of all 4Ms, even in rural, under-resourced settings where it may be most challenging but critical to foster age-friendly care,\u201d the authors wrote.\u00a0<\/p>\n
SOURCE:<\/h2>\n
The study was led by Bryanna De Lima of the Division of General Internal Medicine and Geriatrics at Oregon Health & Science University in Portland, Oregon. It was published online on January 10, 2026, in the Journal of the American Geriatrics Society<\/em>.<\/p>\nLIMITATIONS:\u00a0<\/h2>\n
The survey response rates were low, and there were limited data on usage. The use of different frailty definitions by PCPs may have led to inconsistencies in patient selection.<\/p>\n
DISCLOSURES:<\/h2>\n
The study was supported by grants from the PacificSource Foundation for Health Improvement, Oregon Health Authority, and the Oregon Community Foundation, among others. The authors declared no conflicts of interest.<\/p>\n
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.<\/em><\/p>\n<\/div>\n<\/div>\n
\n
<<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"
TOPLINE: Community health workers were integrated into primary care to deliver age-friendly care services to rural older adults. Initial results indicated a reduction in hospitalizations, with positive feedback received from patients, caregivers, and primary care providers (PCPs). METHODOLOGY: Researchers conducted a pilot study of a program in rural Oregon that embedded community health workers into […]<\/p>\n","protected":false},"author":1,"featured_media":11001,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_daextam_enable_autolinks":"","jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":true,"jetpack_social_options":{"image_generator_settings":{"template":"highway","default_image_id":0,"font":"","enabled":false},"version":2}},"categories":[2],"tags":[],"class_list":["post-11000","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-health"],"jetpack_publicize_connections":[],"jetpack_featured_media_url":"https:\/\/diyhaven858.wasmer.app\/wp-content\/uploads\/2026\/01\/gty-260126-nurse-senior-patient-800x450.jpg","jetpack_sharing_enabled":true,"jetpack-related-posts":[],"_links":{"self":[{"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/posts\/11000","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/comments?post=11000"}],"version-history":[{"count":0,"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/posts\/11000\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/media\/11001"}],"wp:attachment":[{"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/media?parent=11000"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/categories?post=11000"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/tags?post=11000"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
IN PRACTICE:<\/h2>\n
\u201cOur results indicated that CHWs [community health workers], when trained in well-developed 4Ms [what matters, mentation, medication, and mobility] protocols and given appropriate clinical supervision, feel confident in assisting the implementation of all 4Ms, even in rural, under-resourced settings where it may be most challenging but critical to foster age-friendly care,\u201d the authors wrote.\u00a0<\/p>\n
SOURCE:<\/h2>\n
The study was led by Bryanna De Lima of the Division of General Internal Medicine and Geriatrics at Oregon Health & Science University in Portland, Oregon. It was published online on January 10, 2026, in the Journal of the American Geriatrics Society<\/em>.<\/p>\n The survey response rates were low, and there were limited data on usage. The use of different frailty definitions by PCPs may have led to inconsistencies in patient selection.<\/p>\n The study was supported by grants from the PacificSource Foundation for Health Improvement, Oregon Health Authority, and the Oregon Community Foundation, among others. The authors declared no conflicts of interest.<\/p>\n This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.<\/em><\/p>\n<\/div>\n<\/div>\n TOPLINE: Community health workers were integrated into primary care to deliver age-friendly care services to rural older adults. Initial results indicated a reduction in hospitalizations, with positive feedback received from patients, caregivers, and primary care providers (PCPs). METHODOLOGY: Researchers conducted a pilot study of a program in rural Oregon that embedded community health workers into […]<\/p>\n","protected":false},"author":1,"featured_media":11001,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_daextam_enable_autolinks":"","jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":true,"jetpack_social_options":{"image_generator_settings":{"template":"highway","default_image_id":0,"font":"","enabled":false},"version":2}},"categories":[2],"tags":[],"class_list":["post-11000","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-health"],"jetpack_publicize_connections":[],"jetpack_featured_media_url":"https:\/\/diyhaven858.wasmer.app\/wp-content\/uploads\/2026\/01\/gty-260126-nurse-senior-patient-800x450.jpg","jetpack_sharing_enabled":true,"jetpack-related-posts":[],"_links":{"self":[{"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/posts\/11000","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/comments?post=11000"}],"version-history":[{"count":0,"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/posts\/11000\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/media\/11001"}],"wp:attachment":[{"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/media?parent=11000"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/categories?post=11000"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/diyhaven858.wasmer.app\/index.php\/wp-json\/wp\/v2\/tags?post=11000"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}LIMITATIONS:\u00a0<\/h2>\n
DISCLOSURES:<\/h2>\n
\n
<<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"