The IAFP has developed the concept of delivering the Senior Medical Home to provide optimal care for seniors. IAFP is partnering with Group Practice Forum to utilize their software application in practice sites for collecting, tracking, and reporting patient Annual Medicare Wellness visits. The reports generated from these visits will give physicians a comprehensive assessment of patients' health risks and a 5-year out risk stratification guide for future prevention.

Through this pilot, the IAFP seeks to:

• Pilot this program at residency programs and physician practice sites
• Coordinate the medical care piece with the social services piece by doing health services mapping  (in geographic region or by distinct populations, i.e. Native American, Hispanic) to improve care coordination for seniors
• Gather, organize, and analyze data on the population health management of seniors

The Senior Medical Home pilot will assess current senior care protocols and recommend appropriate resources that reinforce the established best practices in senior medical care.  GPF's software solution, Polygon Health, enables health care providers to easily conduct the CMS Annual Wellness Visit for Medicare patients by promoting the following:

• Enhanced patient engagement and patient activation among the elderly
• Increased access to medical care for seniors through a strategic reorganization of the care team
• Improved population management through data collection and reporting
• Increased opportunities to take advantage of financial incentives
• Risk stratification protocols that will tier senior patients and provide customized care plans