1. Using a population-based approach to provide care to the community
- Release date:
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This webinar will be available for a limited time after the conference- don't miss it on Wednesday October 25th during the conference!
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- Style: Presentation (information provided to audience, with opportunity for audience to ask question)
- Focus: Research/Policy (e.g. Presentation of research findings, analysis of policy issues and options)
- Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.) , Clinical providers
Learning Objectives
Participants will learn:
- How an FHT can use their expertise with team-based care to expand an NP-led program for complex older adults into non-FHT primary care with the support of an OHT, hospital, and community programs.
- Gain hands on experience with the use of a standardized digital patient-self-reported tool that helps triage and define care goals for complex older adults
- How specialists' wait times and efficiency improves when embedded in a primary care team
Summary/Abstract
In 2023 the New Vision FHT in Kitchener, Ontario led an expansion of the Complex Care Program for older adults to support 18 new non-FHT primary care practices. Nurse Practitioners in this model are used to their full scope effectively assessing, diagnosing and initiating treatment for geriatric syndromes and cognitive conditions with geriatrician consultation available formally and informally to support the team. With direct access to each primary care provider’s EMR the FHT team could embed themselves into the non-FHT practices and seamlessly accept digital referrals, chart within their EMR, case manage patients and facilitate access to community supports and specialist consultation. The use of the InterRAI Check-up, a patient self-report digital tool, helps to assess risk, gather information and determine care priorities in collaboration with patients and their care partners. More than 10 community support service organizations review cases in round table format weekly led by the FHT. This FHT primary care team also serves as a referral destination for non-FHT patients identified through the ED, in hospital (ALC or risk of becoming ALC), through SCOPE program, from SGS central intake and others when complex older adults are identified that would benefit from their primary care medical home having the support of a multidisciplinary team.
Presenters
- Sarah Gimbel MD, Family Physician New Vision Family Health Team
- Chantelle Mensink NP New Vision Family Health Team
- George Heckman MD, Geriatrician
- Adam Morrison Project Manager