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Coordinated Seniors Care

Earl, Elder, Nitnaht Nation

The Challenge: Coordinating Care for Moderately Complex Patients

Recognizing that moderately complex patients often require involvement of multiple Specialist physicians, the challenge for providers is to effectively coordinate care for a seamless experience, where the specialist provides consultative, episodic or longitudinal care.

Also, for these patients, families are often actively involved in daily care, but not recognized as part of the care team.

The Opportunity: Complementing the work of Patient Medical Home (PMH)/Primary Care Networks (PCN)

As planning for Patient Medical Homes (PMH) and Primary Care Networks  (PCN) gets underway, the Shared Care Committee is allocating resources for interested communities to better connect Specialist physicians to other providers and family caregivers, to create an integrated approach to care at the community level. The initiative will focus on older adults with multiple complex conditions such as diabetes, COPD, dementia, arthritis and heart failure.

Who Can Become Involved?

Communities already selected for developing Primary Care Networks OR communities who have a particular interest in improving care coordination for complex adults, are welcome to apply for support from this initiative.

Support offered through this Initiative

  • Project development, project management, physician engagement, and other improvement activities
  • Community Partnership Coaching
  • Participation in Provincial Learning Sessions
  • Principles of Care-based evaluation

We're interested — what are the next steps?

  1. Inform Margaret English, Lead, Shared Care of your interest in getting involved in the initiative.
  2. Participate in one-on-one calls with the Shared Care team to learn more about goals and supports available.
  3. Participate in an optional pre-EOI community partnership coaching session to help focus your approach to engaging partners and to hone in on the desired outcomes your community would like to achieve as part of this initiative.
  4. Complete an EOI to outline your proposal and which specialists and stakeholders will be involved.

For further information contact Margaret English, Lead,