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Coordinating Complex Care for Older Adults

What is the initiative?

The Coordinating Complex Care for Older Adults Initiative supports communities to improve coordination of care for older adults with complex medical conditions in community settings, with particular emphasis on: 

  1. Medication Management
  2. Referral protocols and communication
  3. Coordinated care plans and responsibilities

These quality improvement activities are intended to align at the local level with Patient Medical Home and Primary Care Networks being implemented across BC through Divisions of Family Practice in partnership with regional health authorities.  

Why is this important?

Older adults with complex health issues require significant levels of services which often include their family physician, specialist physicians, family caregivers, community health services and acute care. Coordinating this care can be a significant challenge for patients, families and providers. Issues often arise relating to communication, roles and responsibilities, access to services, care plans, information sharing and more. Uncoordinated care is detrimental to patient outcomes, family and caregiver well-being, provider satisfaction and system costs. These challenges present several opportunities to improve how we provide more effective patient and family-centred care.  

How can you become involved?

Family Physicians in the community, along with specialist physicians who have interest in improving care coordination for complex adults, are welcome to apply for support for a local improvement project. This includes providing a patient story describing gaps in care; activities to be undertaken, strategies for improvement, and evaluation measures.  

communities involved so far

Fraser: Abbotsford, Fraser Northwest, Langley, Ridge Meadows, Surrey North Delta

Interior: Central Interior Rural, Kootenay Boundary, South Okanagan Similkameen, Thompson Region

Vancouver Coastal: Providence Health Care, Sunshine Coast

Vancouver Island: Campbell River, Cowichan, Victoria

Northern: North Peace, Northern Interior Rural, Pacific Northwest, Prince George, South Peace


  • Funds to support physician (GPs and specialists) engagement, proposal development, project management and evaluation
  • Community partnership coaching 
  • Opportunities to share and learn across communities.


  • Connect with the Shared Care team to learn more about goals and supports available
  • Participate in an optional community partnership coaching session to help focus your approach to partner engagement, and to identify desired outcomes for your community 
  • Complete an Expression of Interest to access funds for physician and stakeholder engagement, and proposal writing
  • Submit a detailed proposal
  • Once funds have been approved and allocated, you’ll be ready to get underway with your quality improvement activities.  


For more information, please email Shared Care.