Interprofessional and integrated care of the elderly in a family health team.
OBJECTIVE
Family physicians provide most of the care for the frail elderly population, but many challenges and barriers can lead to difficulties with fragmented, ineffective, and inefficient services.


OBJECTIVE
To improve the quality, efficiency, and coordination of care for the frail elderly living in the community and to enhance geriatric and interprofessional skills for providers and learners.


METHODS
The Seniors Collaborative Care Program used an interprofessional, shared-care, geriatric model. The feasibility of the program was evaluated through a pilot study conducted between November 2008 and June 2009 at Stonechurch Family Health Centre, part of the McMaster Family Health Team. The core team comprised a nurse practitioner, an FP, and a registered practical nurse. Additional team members included a pharmacist, a dietitian, a social worker, and a visiting geriatrician. Twenty-five seniors were evaluated through the pilot program. Patients were assessed within 5 weeks of initial contact. Patients and practitioners valued timely, accessible, preventive, and multidisciplinary aspects of care. The nurse practitioner's role was prominent in the program, while the geriatrician's clinical role was focused efficiently.


CONCLUSIONS
The family health team is ideally positioned to deliver shared care for the frail elderly. Our model allowed for a short referral time and easy access, which might allow seniors to remain in their environment of choice.
Department of Family Medicine, McMaster University, Hamilton, ON. amoore@mcmaster.ca
Ainsley
A
Moore
Christopher
C
Patterson
Joy
J
White
Shelly T
ST
House
John J
JJ
Riva
Kalpana
K
Nair
Allison
A
Brown
Amjed
A
Kadhim-Saleh
David
D
McCann
D000368:Aged; D000369:Aged, 80 and over; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D005194:Family Practice / Q000458:organization & administration*; D005260:Female; D006297:Health Services Accessibility; D006299:Health Services for the Aged / Q000458:organization & administration*; D006801:Humans; D008297:Male; D017146:Models, Organizational; D009864:Ontario; D010348:Patient Care Team / Q000458:organization & administration*; D017060:Patient Satisfaction / Q000706:statistics & numerical data; D010865:Pilot Projects; D011314:Preventive Health Services / Q000458:organization & administration; D015397:Program Evaluation; D012017:Referral and Consultation