AB2 - Reducing Silos and Improving Health Care Experience: Integrated Care for Seniors with Complex Needs

2. Continuous care: ensuring seamless transitions for patients across the continuum of care

  • Date: Thursday, September 19, 2019
  • Concurrent Session A & B
  • Time: 2:30pm-4:15pm

  • Room: TBA
  • Style: Presentation (information provided to audience, with opportunity for audience to ask question)
  • Focus: Practical (e.g. Presentation on how to implement programs and/or practices in the team environment); Balance between both (e.g. Presentation of a best-practice guideline that combines research evidence, policy issues and practical steps for implementation)
  • Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

Wrapping Team-Based Care Around Complex Geriatric Patients-
Explore how the New Vision Family Health Team used an interdisciplinary model of care to manage the multi-morbidity of complex geriatric patients, to reduce duplicity of services and to improve patient and health-care provider experience. Learn how these principals could be adapted to other FHTs.
Integrated Model of Care for Seniors with Complex Care Needs-
Study and adopt the necessary steps to develop an integrated strategy in providing seniors with community-focused health care and social services to enable clients to maintain enriched lifestyles. Explore ways to advance and deliver possible care initiatives through cultivating a sense of social responsibility and connectedness and establishing inter-professional partnerships with health-care institutions.



Wrapping Team-Based Care Around Complex Geriatric Patients-
Complex geriatric patients account for a large volume of office visits as well as to hospitals and emergency departments, often associated with fragmented care and lack of patient-centered planning. The Geriatric Complex Care program at New Vision Family Health Team was developed to streamline the care of these patients by collaborating between all health care providers including their family physician, IHP team members and home care at a single visit to provide more timely and appropriate access to care when needed. Using a patient-centered model to develop care goals, including earlier introduction of advanced care planning discussions, this program serves to support caregivers and improve patient satisfaction and overall health self-management skills.
Integrated Model of Care for Seniors with Complex Care Needs-
The Carefirst INTEGRATE© model focuses on meeting the needs of medically-socially complex patient groups through intensive case management, inter-professional practice, and a comprehensive chronic care model that provides a full range of services that combine primary and specialty care, and health with social services. Through the implementation of the Mobile Health Unit and adopting technologies within and outside facilities, Carefirst continues to make services and health education more accessible in the neighbourhood. 

INTEGRATE© focuses on establishing independent care initiatives and inter-professional partnerships with existing institutions to ensure seamless service integration so clients can receive quality care in their communities. The results of the model are promising in the Ontario setting and demonstrate how it can be adopted into existing health-care structures on national and international levels.



  • Dr. Sarah Gimbel, MD CCFP, Family physician, New Vision Family Health Team
  • Olja Segedi, BScN MN NP-PHC, Nurse Practitioner, Geriatric Complex Care program lead, New Vision Family Health Team
  • Desirée Leslie, Health Outcomes Assessor, New Vision Family Health Team
  • Helen Leung, M.S.W., R.S.W., Chief Executive Officer, Carefirst Family Health Team
  • Dr. Sheila Neysmith, D.S.W. (Doctor of Social Work), Professor Emerita at the University of Toronto, Board Executive Vice-President at Carefirst, Carefirst Seniors and Community Services Association