C2 Aging Well & At Home: Two Approaches for Primary Care Teams

Theme 2. Planning programs for equitable access to care

Presentation Details

  • Date: Thursday, October 26, 2017
  • Concurrent Session C
  • Time: 8:30am-9:15am
  • Room:
  • 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)

1. Aging At Home: Access to Care for Our Seniors

Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff Learning Objectives
  1. Identify your target population - using key indicators and resources you currently have.
  2. Program Parameters - Who, What and Where - how to meet the need expectations and outcomes, when to make the exception. Future expansion.
  3. Resources - Making this program work without additional monies.
Summary/Abstract Leeds and Grenville CFHT services a large rural region.  It was identified that our patients with advanced age and multiple chronic diseases were facing barriers to meet their healthcare needs within the confines of an average clinic appointment due to the following reasons: mobility issues, advanced disease process, transportation issues and the clinic format itself.   The Aging at Home program was developed and put into practice earlier this year. A Nurse Practitioner is the MRP for this program and delivers primary care to the identified population. The outcomes have been very positive so far in the following areas: patient satisfaction, caregiver relief, reduced emergency room visits, reduced readmissions to hospital, accurate medication reconciliation, improved access to community resources and improved clinic flow. Come learn how to identify your high risk patients, take home templates and a list of resources to make this program work. Learn about our challenges and how we have overcome them. Hear about how this program can and will expand to meet the ever changing needs of our complex patients living in our rural communities. Presenters
  • Nancy Campbell, NP-PHC, GNC (c), Leeds & Grenville Community Family Health Team
  • Jenny Lane, Executive Director, MCNP-PHC, CHE, Leeds & Grenville Community Family Health Team
Authors & Contributors
  • Linda Bisonette
  • Jane Fournier

2. Aging Well, a Team Based Approach to Complex Elder Care

Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Representatives of stakeholder/partner organizations Learning Objectives
  • To address a community care gap, the Barrie and Community Family Health Team (BCFHT) created an Aging Well Clinic for community dwelling seniors that are clinically frail, medically complex or living with dementia.
  • Through this presentation, participants will:
    1. Learn how to use a patient-centered approach to stabilize and improve health status for seniors with multiple chronic illnesses
    2. Learn how to maximize health outcomes and improve access to community resources by assisting patients to navigate the health care system
    3. Learn how to reduce caregiver burden and enhance the ability to age in place
Summary/Abstract The Aging Well Clinic was developed to address the lack of community based geriatric services available in our community and to support family practice offices in the care of their geriatric population. Using an interdisciplinary team approach to care, the BCFHT has been successful in providing comprehensive services to seniors who are clinically frail, medically complex or living with dementia. The interdisciplinary team partners with the patient-caregiver dyad to develop interventions to optimize health, function, independence and start the process of future planning. By focusing on capacity building, ‘aging in place’ is facilitated. System navigation, community engagement and home visits are essential to our patient first philosophy. This presentation will outline how the Aging Well Clinic has been successful in networking with community partners to provide comprehensive geriatric care to patients of the BCFHT and how this approach can be used in other communities to address the unique needs of their geriatric population. Presenters
  • Catherine Jones, Nurse Practitioner & Clinical Manager Aging Well Clinic, Barrie & Community Family Health Team
  • Jennifer Handley, Pharmacist, Barrie & Community Family Health Team
Authors & Contributors
  • Monique DeRooy, RPN,  Barrie & Community Family Health Team
  • Natalie Kidner, RN, Barrie & Community Family Health Team
  • Catherine McEwan, Occupational Therapist, Barrie & Community Family Health Team
  • Diane Parks, Administrative Assistant, Barrie & Community Family Health Team