title: Supporting frail seniors through a family physician and Home Health integrated care model in Fraser Health.
abstract: BACKGROUND
  A major effort is underway to integrate primary and community care in Canada's western province of British Columbia and in Fraser Health, its largest health authority. Integrated care is a critical component of Fraser Health's planning, to meet the challenges of caring for a growing, elderly population that is presenting more complex and chronic medical conditions.
  An integrated care model partners family physicians with community-based home health case managers to support frail elderly patients who live at home. It is resulting in faster response times to patient needs, more informed assessments of a patient's state of health and pro-active identification of emerging patient issues.
  
  
  RESULTS
  The model is intended to improve the quality of patient care and maintain the patients' health status, to help them live at home confidently and safely, as long as possible. Preliminary pilot data measuring changes in home care services is showing positive trends when it comes to extending the length of a person's survival/tenure in the community (living in their home vs. admitted to residential care or deceased).
  
  
  CONCLUSIONS
  Fraser Health's case manager-general practitioner partnership model is showing promising results including higher quality, appropriate, coordinated and efficient care; improved patient, caregiver and physician interactions with the system; improved health and prevention of acute care visits by senior adult patients.
authors.affiliation: Home Health, Fraser Health, Surrey, BC, Canada.
authors.forename: Grace
authors.initials: G
authors.lastname: Park
authors.affiliation: Primary Health Care & Aboriginal Health, Fraser Health, Surrey, BC, Canada.
authors.forename: Diane
authors.initials: D
authors.lastname: Miller
authors.affiliation: Lead, Evaluation, Integrated Primary Community Care, Fraser Health, Surrey, BC, Canada.
authors.forename: George
authors.initials: G
authors.lastname: Tien
authors.affiliation: Home Health Program, Fraser Health, Surrey, BC, Canada.
authors.forename: Irene
authors.initials: I
authors.lastname: Sheppard
authors.affiliation: North Vancouver, BC, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Bernard
keywords: family physician–case manager partnership; home health–primary care integration; integrated care for frail seniors; integrated primary and community care