Connecting Care for Frail Older Adults

Host Institutions: North York General Hospital and Baycrest Health Sciences

The Integrated Community Care Team (ICCT) is a joint initiative of North York General Hospital, the Toronto Community Care Access Centre and Baycrest, created to combat the fragmented care that frail seniors with complex needs often receive and that often results in poor outcomes and unnecessary use of healthcare system resources.

The ICCT connects frail, older adults to an inter-professional team that includes registered nurses, a social worker, a physiotherapist, an occupational therapist, geriatricians, a nurse practitioner, family physicians with training in elderly care and care coordinators.

This project evaluated the service, processes and overall effectiveness of three different streams of care offered by the ICCT: (1) in-home consultation on specialty geriatric and nursing services; (2) shared-care, co-managed with patients’ primary care physicians; and (3) primary care where ICCT assumes responsibility for primary care on a temporary or permanent basis. A variety of evaluations measured how these approaches better met the care needs of complex, frail patients living in the community and their caregivers, and of “solo” doctors trying to manage patients.

Preliminary results among over 250 patients show that the ICCT helps frail, older patients with increasingly complex healthcare needs to continue living at home. In addition to providing medical and emotional care and support, the ICCT approach reduces stress among caregivers and provides knowledge to help them manage patients’ conditions. Solo community care physicians report they are also benefitting from ICCT support. We will report full results in the summer of 2017.