In response to the growing challenges in meeting the health care needs of frail, medically complex seniors, the difficulties in timely access to primary care, community care and specialty care, and the health care system’s priority to reduce unnecessary Emergency Department utilization by promoting the integration of geriatric care, a unique and innovative Integrated Community Care Team (ICCT) outreach model was developed, implemented and evaluated. The program supports home-bound frail older adults in their homes, and the model consists of three arms including primary care, shared care, and consultation.

In the primary care arm, primary care is assumed for home-bound patients in the community whose primary care physician can no longer manage, or for “orphan” patients with no primary care physician. In the shared care arm, the program works primarily with “solo” primary care physicians in the community (who are not able to make home visits and who do not have the benefit of an interprofessional team to assist them) to support them in managing their complex older adult patients who have difficulty accessing office-based care because of physical, functional and/or cognitive limitations. The consult arm provides interprofessional geriatric assessment consultation for home-bound patients who are referred to the service. Follow-up on the outcomes of the recommendations offered is built in as part of the service.

The ICCT was created as a collaboration among Baycrest Geriatric Centre, Toronto Central and Central Community Care Access Centres (CCACs) and North York General Hospital (NYGH). The ICCT includes nurses, a nurse practitioner, care of the elderly-trained family physicians, geriatricians, community care coordinators, social worker, clinical pharmacist, occupational therapist and physiotherapist. The ICCT model is enhanced with a link to acute care (NYGH) and Baycrest inpatient and outpatient specialty services to ensure that all major components of the patient journey across the full care continuum, including transitions, are integrated as part of the intervention. The ICCT model is unique and innovative in that it is not only patient and family caregiver centred, but it also tailors its services to the specific needs of the “solo” primary care physicians across a range of options.

The ICCT model fosters integration at the point of care. It connects patients and their primary care physicians to a dedicated, interprofessional team of primary and specialty care providers, community services including intensive case management, and specialty care resources.

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Title: Clinical Manager

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