The integrated community care team: An innovative care model for frail seniors

BACKGROUND: Complex, frail seniors often receive fragmented care that contributes to high healthcare utilization and poor patient outcomes. METHOD(S): The Integrated Community Care Team (ICCT) connects older adults who have difficulty accessing office-based care to an inter-organizational, inter-professional team consisting of primary, community and specialty care resources. The ICCT model tailors its services to the needs of primary care physicians through the options of consultation, shared care or transfer of care to ICCT. A mixed methods formative evaluation includes the following: data from the Resident Assessment Instrument-Home Care to describe the patient population; process measures to document service provision; the Dimensions of Teamwork Survey to evaluate inter-professional team function; and interviews with patients and their caregivers, primary care physicians and team members to document the implementation experience and satisfaction with care. RESULT(S): The team saw 361 patients from March 2013 to September 2014; 67% consultation, 23% shared care and 10% transfer of care. Mean patient characteristics were age 85.0, Cognitive Performance Scale 2.1, Depression Rating Scale 2.4, IADL 4.9 and ADL 1.7; 69% were female. We have interviewed 4 patients, 3 caregivers, 2 community physicians and 9 team members. Important lessons learned include: operational governance of inter-organizational models poses unique challenges that need to be addressed early; dedicated project management is crucial to timely, successful implementation of complex care models; timely role clarification for providers from different organizations is essential for team cohesiveness and efficiency; community primary care physician engagement is challenging and requires multimodal approaches; and the use of data from the evaluation to inform changes to the model is critical in establishing a workable model. CONCLUSION(S): The ICCT is a novel model of care to meet the needs of complex, frail seniors in the community by supporting their primary care physicians. The model continues to evolve with the use of rapid quality improvement cycles informed by data from the formative evaluation.

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