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Top Stroke Rehabil. 2002 Autumn;9(3):75-86.

Bridging to family and community support for older adults and the domain management model.

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Geriatric Social Work, Geriatric Medicine Unit, Massachusetts General Hospital, Boston, USA.


Older adults with chronic illness and functional impairment require continuous and long-term monitoring and supervision. Changes in the health care system make this harder to accomplish. Social work assistance can help identify issues and provide help through counseling, patient advocacy, resource utilization, and education. Tools that help include the Domain Management Model and well-organized team care. This article describes these interventions in a senior primary care practice and community-based screening and education program. Both programs bridge from acute illness care to improved chronic illness management in the community.

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