Award Date: 2018

Project Lead(s): Lori Watts, Family Nurse

Project Title: Supporting Patients, Care Partners and Physicians in Care Coordination and Navigation

What is the issue?

It can be overwhelming for people with dementia and their care partners to navigate multiple medical visits and procedures. At the same time, physicians may not be aware of community resources that can help patients with dementia and their care partners manage their care at home.

Since 2017, teams of physicians, nurses, pharmacists, social workers, and mental health counselors at the Red Deer Primary Care Network have been diagnosing people with dementia and geriatric health issues. It has been challenging to help patients stay on track with care plans.

What did we do?

We established a new position for an Elder Care Assessment Clinic Case Coordinator. A nurse practitioner in this role conducted follow up visits or phone calls with patients and care partners at home. They also sent recommendations to physicians. We studied the impact of this new role with 71 older adults with cognitive impairment, their respective care partners, and 53 physicians.

What did we find?

All patients and their care partners were very satisfied with support from the Case Coordinator. The Case Coordinator’s follow ups improved their quality of life. Physicians appreciated receiving direction, especially for patients who were resistant to making changes.