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Can Fam Physician. Jul 2004; 50: 998–1003.
PMCID: PMC2214633
Enhancing primary care for complex patients. Demonstration project using multidisciplinary teams.
Karen B. Farris, Isabelle Côté, David Feeny, Jeffrey A. Johnson, Ross T. Tsuyuki, Sandra Brilliant, and Sherry Dieleman
College of Pharmacy, University of Iowa, Iowa City 52240, USA.
Karen B. Farris: karen-farris/at/uiowa.edu
Abstract
PROBLEM BEING ADDRESSED: Communication between community-based providers is often sporadic and problem-focused. OBJECTIVE OF PROGRAM: To implement collaborative community-based care among providers distant from one another and to improve or maintain the health of high-risk community-dwelling patients, with a focus on medication use. PROGRAM DESCRIPTION: Six primary health care teams were formed of a family physician, a pharmacist, and a home care case manager (nurse). Three of these teams also had a family physician's office nurse. Teams received training and decided on processes of care that included a home visit, medication history, and weekly 1.5-hour face-to-face team meetings. In 151 team conferences, 705 medication or health issues were identified for 182 patients over 6 months. Medication adherence was improved at 3 and 6 months. After 6 months, all providers had a greater understanding of the roles of the other providers. CONCLUSION: Primary health care teams developed in this study require few structural changes to existing health care systems, but will require more reimbursement options.
Articles from Canadian Family Physician are provided here courtesy of
College of Family Physicians of Canada