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Coordinated Seniors Care Initiative

The Challenge: Coordinating Care for Moderately Complex Patients

Recognizing that older adults with complex chronic conditions require the involvement of their primary care provider, specialist physicians, family caregivers and community health services - the challenge for providers is to effectively coordinate care for a more seamless experience.   

There is also a need to recognize changing circumstances, medical issues that may arise, and the need to transition to care that focuses on goals of care for end of life. Specialists involved  may participate in different ways – providing consultative, episodic or even longitudinal care.    

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?

  • Inform Margaret English, menglish@doctorsofbc.ca of your interest in getting involved in the initiative.
  • Participate in one-on-one calls with the Shared Care team to learn more about goals and supports available.
  • 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.
  • Complete an EOI to outline your proposal and which specialists and stakeholders will be involved.

For further information contact

Margaret English, Director, Shared Care Committee

menglish@doctorsofbc.ca