1. 1. Age-Friendly Health Systems: Initiative to encourage age-friendly evidence-based practices to align with what Matters to older adults and their family caregivers, using the 4Ms framework: What Matters, Medication, Mentation, and Mobility.
      https://www.ihi.org/networks/initiatives/age-friendly-health-systems
      https://institute.agefriendly.com/
   2. Agency for Community Living (ACL) Community Care Hubs: Community care hubs aim to help community-based organizations and health care payers increase the community’s capacity to address health-related social needs to support aging community members. See also Community Care Hub IT Playbook in Health IT Tools below.
      https://acl.gov/programs/strengthening-aging-and-disability-networks/improving-business-practices
   3. American College of Physicians training modules: The ACP offers training modules on many topics relevant to clinicians (continuing education and maintenance of certification available). The linked tool from Patient Priorities Care can help patients identify their health priorities.
      https://www.acponline.org/clinical-information/clinical-resources-products/decision-making-for-patients-with-multiple-chronic-conditions-patient-priorities-care
   4. Collaborative Care Model: This model supports integration of physical and behavioral health care.
      Brief related to CCM – https://www.chcs.org/media/HH_IRC_Collaborative_Care_Model__052113_2.pdf
      Delivery through Janus Health: https://janushcp.com/
   5. Community Aging in Place Advancing Better Living for Elders (CAPABLE): The program supports aging community members to remain in their homes through occupational therapy, nursing, home safety, and handy worker services.
      https://capablenationalcenter.org/
      Training: (https://capablenationalcenter.org/training-overview/)
   6. Contextualizing Care: Research program that uses direct observations to characterize the pattern of errors in physicians’ ability to provide patient-centered, or contextualized, care.
      https://www.contextualizingcare.org/
   7. Neighborhood Nursing: Brings care directly to where people live to support and strengthen communities.
      https://nursing.jhu.edu/faculty-research/research/areas-of-expertise/community-global-health/center-community-innovation-scholarship/neighborhood-nursing/
      Stories: https://www.npr.org/sections/shots-health-news/2024/06/11/nx-s1-4997717/nurses-primary-care-community-baltimore-costa-rica
      Stories: https://www.pbs.org/newshour/show/neighborhood-nursing-brings-healthcare-to-peoples-doorsteps-in-vulnerable-communities
   8. Patient Priorities Care: Patient Priorities Care delivery uses the 4 Ms framework of Age-Friendly Health Systems and includes multiple resources to enable care settings to use the materials.

Tools for patients/caregivers (electronic manual, tips), clinicians (electronic manuals, materials, publications, and key definitions) https://patientprioritiescare.org/
Decisional guidance (tips & scripts) tool http://decisionguide.patientprioritiescare.org/
Self-directed health priorities identification https://myhealthpriorities.org/

• Program to Encourage Active, Rewarding Lives (PEARLS): PEARLS helps older adults understand depression and develop self-sufficiency skills
  https://depts.washington.edu/hprc/programs-tools/pearls/
• Trager Institute: Helps people have positive aging experiences and includes primary care, palliative care, caregiver support, wellness services, and legal services. This Geriatrics Workforce Enhancement Program (GWEP) site utilizes the GUIDE model.

 

https://www.tragerinstitute.org/

• VA Whole Health: The Whole Health movement at the VA centers around What Matters most for veterans. Resources are available for veterans and clinicians. See also Medical Care Special Issue, December 2024.
  https://www.va.gov/WHOLEHEALTH/veteran-resources/Well-Being-Programs.asp
  Personal Health Inventory: https://www.va.gov/WHOLEHEALTH/docs/PHI_Jan2022_Final_508.pdf
• World Health Organization’s ICOPE (Integrated care for older people) program: The ICOPE guidance helps community health and care workers put care plans into practice.
  Citation: Integrated care for older people (ICOPE): guidance for person-centred assessment and pathways in primary care, second edition. Geneva: World Health Organization; 2024. Licence: CC BY-NC-SA 3.0 IGO.