2011 AFHTO conference presentation
PRESENTER (S): Katherine Campbell, BSc., MHS
FHT/ORG: Dryden Area FHT
ABSTRACT: An innovative program was developed to address senior community service needs providing the opportunity to reduce ER visits while focusing on supporting seniors in their home setting of choice. The Dryden Area FHT in partnership with Patricia Region Senior Services (PRSS) has developed a position that has evolved to assist in service integration through a Community Service Guide (CSG). The CSG attends hospital morning interdisciplinary meetings to discuss patient care within the site and visits with in-patients that may benefit from the FHT and PRSS programs. The CSG attends the ED and collects the referrals for the day which are then distributed for physician/NP follow-up. The CSG receives all referrals for the FHT and navigates the patient through the system. The seniors are then linked into the PRSS community programs for services as identified. In addition, the FHT has developed senior outreach clinics addressing caregiver burnout, education, medication reconciliation, treatment and chronic disease management/prevention.
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