Team profiles :

New Vision Family Health Team, in collaboration with Lawson Research Institute

At a Glance   

Region: Ontario 

Setting: Urban

EAIP program principle(s): 

• Access to specialized healthcare services 
• Access to social and community supports 
• Access to system navigation and support 

Implementation (new, spread, and/or expand):  

• Spread

Team Profile  

The New Vision Family Health Team Complex Care Program is a primary care-based support model that provides older adults with complex health conditions with direct access to a specialized geriatric integrated care team embedded within a primary care setting. The Integrated Care Team (ICT) provides integrated and geriatrician-supported multidisciplinary health and social care to older adults with complex care needs to provide person-centred and efficient care. The team is led by a nurse practitioner, supported by a geriatrician, geriatric psychiatrist, clinical pharmacist and other care professionals with geriatric expertise.  

Community 

• This initiative is targeted towards older adults who reside in the Kitchener-Waterloo region.   
• Within the KW4 Ontario Health Team region there are 62, 811 people who are 65 years or older.
• Only 18% of family physicians in the region have access to a multidisciplinary care team.

Program Focus 

Program Description 

• The New Vision Family Health Team’s Integrated Care Team (ICT) Complex Care Program aims to support the needs of older adults with complex health challenges early in their frailty journey to avoid urgent specialist intervention or institutionalization. The program aims to do this by: 
  • stabilizing at risk older adults,
  • providing chronic disease/ geriatric symptom management and education,
  • supporting system navigation and connecting patients/ caregivers to community resources
  • providing mental health support for at risk older adults.

The ICT Complex Care Program also supports patients of primary care providers outside the New Vision Family Health Team that do not have access to a multidisciplinary care team for older adults. By providing integrated care the program supports efficient access to necessary care and services, streamlined primary care, improved prescribing practices and reduced emergency department visits.

Implementation Approach: 

• Expedite Assessment and Referral to Community Resources: Older adults and care partners receive supports from the ICT which significantly improves the timeliness of receiving a Comprehensive Geriatric Assessment and referral to appropriate community resources. 
• Person-Centred and Efficient Care: The program provides integrated and geriatrician-supported multi-disciplinary health and social care to older adults with complex care needs to provide person-centred and efficient care. The co-location and interprofessional philosophy of the team ensures that care is coordinated, with the patient’s goals and wishes known to all, such that care gaps, duplication, and mistakes are averted.
• Support of Primary Care Providers: Supports primary care providers who do not currently have access to a multidisciplinary team for older adults to reduce the primary care burden through a shared model of care provided through the integrated care team.