Supporting Patients, Care Partners and Physicians in Care Coordination and Navigation

Award Date: 2018

Project Lead(s): Lori Watts

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

The Red Deer Primary Care Network developed an Elder Care Assessment Clinic, which opened in June 2017. The project is part of a larger initiative involving five Central Zone Primary Care Networks, two Strategic Clinical Networks, Alberta Health Services, patients and families, and community stakeholders. Outcomes include a coordinated approach to service provision and support, increased knowledge and capacity with the health and social teams, and increasing the role and clinician satisfaction regarding serving the senior population. The ECAC is staffed by family physicians and other health care professionals, including registered nurses, a nurse practitioner, pharmacists and psychologists and social workers. This multidisciplinary team received advanced training in order to provide assessment of cognitive health for patients with uncomplicated dementia and other geriatric syndromes, and make recommendations to patients, caregivers, and referring physicians for ongoing care. Follow-up support is a vital piece of the care to overcome barriers that patients, care partners and physicians may experience in carrying out the recommendations. This part time staff position, Elder Care Case Coordinator, supports caregivers and physicians on care coordination and navigation, and works to find collective solutions so patients are able to age in place. The staff member will join with other system partners, and the Alzheimer Society of Alberta and Northwest Territories, to work collectively to improve care coordination.