Authors
Joomong Park
Published in
Family medicine and community health. Volume 14. Issue 3. Aug 03, 2026. Epub Aug 03, 2026.
Abstract
Fragmented care in older adults often results in duplicated testing, delayed decision-making and unclear clinical responsibility. These challenges are particularly pronounced in community and home-based primary care settings, where multiple providers contribute to care without formal coordination structures. Although comprehensive multidimensional geriatric evaluation is recommended, its complexity limits routine implementation. This article proposes a pragmatic framework integrating assessment of daily functioning, cognitive screening, mood assessment and mobility evaluation with targeted laboratory testing guided by clinical findings. A central principle of this model is clinical accountability, defined as the responsibility of the clinician who performs assessment and interprets findings to integrate diagnostic results into patient management and follow-up. In this framework, accountability refers specifically to responsibility for documenting findings, initiating appropriate follow-up evaluation and ensuring communication of clinically significant results. By linking brief multidimensional assessment, problem-oriented testing and explicit responsibility for follow-up, this practice-informed communication offers a pragmatic, adaptable approach for family physicians and community-based clinicians working in fragmented care environments. It is presented as a practice-informed proposal rather than a validated framework, consensus statement or guideline.
PMID:
42571646
Bibliographic data and abstract were imported from PubMed on 09 Aug 2026.
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