Geriatrics team works intensively with patient and family/caregiver for few months (dependent on various factors) and then transitions the patient back to their primary team. PCP remains assigned as PCP and helps co-manage.
Criteria that may make your patient appropriate for ALIGN:
High risk for hospitalization or ED use
Frequent phone calls out of proportion to illness
Safety risk
Declining health with significant shift in baseline ( New diagnosis, worsening diagnosis requiring frequent follow up/coordination of care/education out of proportion to usual chronic care -needs with risk of decompensation)
Poor patient engagement
“Rising Risk”
To Refer: Order "AMB REF TO ALIGN High Risk Geriatrics Program" in Epic and complete the prompts
To reach the ALIGN team: send epic chat to "MSH GERI ALIGN" or call (929) 373-7444 (available 24/7)