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PubMed · 15317232

Enhancing primary care for complex patients. Demonstration project using multidisciplinary teams.

Karen B Farris·Isabelle Côté·David Feeny·Jeffrey A Johnson·Ross T Tsuyuki·Sandra Brilliant·Sherry Dieleman
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Abstract

PROBLEM BEING ADDRESSED: Communication between community-based providers is often sporadic and problem-focused. OBJECTIVE OF PROGRAM: To implement collaborative community-based care among providers distant from one another and to improve or maintain the health of high-risk community-dwelling patients, with a focus on medication use. PROGRAM DESCRIPTION: Six primary health care teams were formed of a family physician, a pharmacist, and a home care case manager (nurse). Three of these teams also had a family physician's office nurse. Teams received training and decided on processes of care that included a home visit, medication history, and weekly 1.5-hour face-to-face team meetings. In 151 team conferences, 705 medication or health issues were identified for 182 patients over 6 months. Medication adherence was improved at 3 and 6 months. After 6 months, all providers had a greater understanding of the roles of the other providers. CONCLUSION: Primary health care teams developed in this study require few structural changes to existing health care systems, but will require more reimbursement options.

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AgedCase ManagementChronic DiseaseCommunicationFamily PracticeFemaleHumansInterprofessional RelationsMaleMiddle AgedNurse's RolePatient Care TeamPharmacistsPrimary Health CareRisk FactorsEvaluation StudyJournal ArticleResearch Support, Non-U.S. Gov't

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Karen B Farris, Isabelle Côté, David Feeny, Jeffrey A Johnson, Ross T Tsuyuki, Sandra Brilliant, Sherry Dieleman. 2004. Enhancing primary care for complex patients. Demonstration project using multidisciplinary teams.. https://pubmed.ncbi.nlm.nih.gov/15317232/

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