Interprofessional and integrated care of the elderly in a family health team

Abstract

Problem addressed: 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 of program: 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.

Program description: 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.

Conclusion: 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.

Figure 1

Care path for pilot study patients NP—nurse practitioner, RD—registered dietitian, RPN—registered practical nurse, SW—social worker.