{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,12]],"date-time":"2026-05-12T10:45:46Z","timestamp":1778582746828,"version":"3.51.4"},"reference-count":19,"publisher":"Wiley","issue":"3","license":[{"start":{"date-parts":[[2026,1,10]],"date-time":"2026-01-10T00:00:00Z","timestamp":1768003200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"},{"start":{"date-parts":[[2026,1,10]],"date-time":"2026-01-10T00:00:00Z","timestamp":1768003200000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"funder":[{"DOI":"10.13039\/100000909","name":"John A. Hartford Foundation","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000909","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100025747","name":"PacificSource Foundation for Health Improvement","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100025747","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100030605","name":"Oregon Health Authority","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100030605","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100012516","name":"Oregon Community Foundation","doi-asserted-by":"publisher","award":["440418"],"award-info":[{"award-number":["440418"]}],"id":[{"id":"10.13039\/100012516","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100027903","name":"Roundhouse Foundation","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100027903","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100021816","name":"National Association of County and City Health Officials","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100021816","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"publisher","award":["1OT2OD038368\u201001"],"award-info":[{"award-number":["1OT2OD038368\u201001"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100006108","name":"National Center for Advancing Translational Sciences","doi-asserted-by":"publisher","award":["UL1TR002369"],"award-info":[{"award-number":["UL1TR002369"]}],"id":[{"id":"10.13039\/100006108","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["agsjournals.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["J American Geriatrics Society"],"published-print":{"date-parts":[[2026,3]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Aging in a rural setting presents unique challenges including limited access to in\u2010home care, lack of social support, language and cultural barriers, and the lack of transportation. We conducted a pilot study embedding community health workers (CHWs) into rural primary care teams to assist with implementation of the 4Ms of the Age\u2010Friendly Health System: What Matters, Mentation, Medication, and Mobility.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>The Connected Care for Older Adults model embeds CHWs in primary care and they conduct home visits to implement 4Ms protocols for patients 55 and older, living independently, and considered to be \u201cmedically frail\u201d by a PCP, or meet criteria by the Edmonton Frail Scale. Patients complete the program in approximately 90\u2009days. Feedback was collected from patients, caregivers, providers, and CHWs; health care impact was collected from electronic health records.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      We enrolled 388 patients from 79 PCPs at 7 clinics. Patients were 63% female with an average age of 77\u2009years. Over 95% were public payer, 49% had been to the ED in the past 12\u2009months, and 34% had been hospitalized. The program made a positive difference for 95% of responding patients (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u2009120) and 100% of responding providers (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u200919) were \u201cvery satisfied\u201d with the program. Clinicians cited the CHWs' ability to support resource connections, address social isolation and social needs, provide regular check\u2010ins, and help to get patients and families engaged in care as positive components of the model. Early data suggests this program may reduce health care utilization.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Connected Care for Older Adults incorporates CHWs in primary care settings to deliver age\u2010friendly care to rural, underserved adults 55 and older. Early findings and feedback from participating patients, caregivers, providers, and CHWs suggest that this is a promising approach to delivering age\u2010friendly care.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/jgs.70279","type":"journal-article","created":{"date-parts":[[2026,1,10]],"date-time":"2026-01-10T16:50:12Z","timestamp":1768063812000},"page":"705-711","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Connected Care for Older Adults: A Pilot Intervention Engaging Community Health Workers to Advance Age\u2010Friendly Care in Rural Oregon"],"prefix":"10.1111","volume":"74","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4603-4084","authenticated-orcid":false,"given":"Bryanna","family":"De Lima","sequence":"first","affiliation":[{"name":"Division of General Internal Medicine and Geriatrics Oregon Health and Science University  Portland Oregon USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lindsay","family":"Miller","sequence":"additional","affiliation":[{"name":"Lindsay Miller Consulting LLC  Hood River Oregon USA"},{"name":"Columbia Gorge Health Council  The Dalles Oregon USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Elizabeth","family":"Foster","sequence":"additional","affiliation":[{"name":"Columbia Gorge Health Council  The Dalles Oregon USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jodi","family":"Ready","sequence":"additional","affiliation":[{"name":"Columbia Gorge Health Council  The Dalles Oregon USA"},{"name":"Providence Hood River Internal Medicine  Hood River Oregon USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Elizabeth","family":"Eckstrom","sequence":"additional","affiliation":[{"name":"Division of General Internal Medicine and Geriatrics Oregon Health and Science University  Portland Oregon USA"},{"name":"Oregon Clinical and Translational Research Institute  Portland Oregon USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2026,1,10]]},"reference":[{"key":"e_1_2_9_2_1","unstructured":"AHR \u201cExplore Population Ages 65+\u2014Rural in Oregon \u201daccessed November 18 2025 https:\/\/www.americashealthrankings.org\/explore\/measures\/rural_senior\/OR."},{"key":"e_1_2_9_3_1","doi-asserted-by":"publisher","DOI":"10.1177\/19375867231209501"},{"key":"e_1_2_9_4_1","unstructured":"Institute for Healthcare Improvement \u201cAge\u2010Friendly Health Systems \u201daccessed July 21 2025 https:\/\/www.ihi.org\/partner\/initiatives\/age\u2010friendly\u2010health\u2010systems."},{"key":"e_1_2_9_5_1","unstructured":"Institute for Healthcare Improvement \u201cAge\u2010Friendly Health Systems Recognized Health Care Sites \u201daccessed July 21 2025 https:\/\/www.ihi.org\/partner\/initiatives\/age\u2010friendly\u2010health\u2010systems\/recognized\u2010health\u2010care\u2010sites."},{"key":"e_1_2_9_6_1","unstructured":"Economic Research Service \u201cRural\u2010Urban Commuting Area Codes \u201daccessed November 19 2025 https:\/\/www.ers.usda.gov\/data\u2010products\/rural\u2010urban\u2010commuting\u2010area\u2010codes."},{"key":"e_1_2_9_7_1","doi-asserted-by":"publisher","DOI":"10.1080\/02701960.2022.2151443"},{"key":"e_1_2_9_8_1","doi-asserted-by":"publisher","DOI":"10.1111\/jgs.19077"},{"key":"e_1_2_9_9_1","unstructured":"NRHA. 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