Department of Family Medicine, McMaster University, Hamilton, ON.
Can Fam Physician. 2012 Aug;58(8):e436-41.
Family physicians provide most of the care for the frail elderly population, but many challenges and barriers can lead to difficulties with fragmented, ineffective, and inefficient services.
To improve the quality, efficiency, and coordination of care for the frail elderly living in the community and to enhance geriatric and interprofessional skills for providers and learners.
The Seniors Collaborative Care Program used an interprofessional, shared-care, geriatric model. The feasibility of the program was evaluated through a pilot study conducted between November 2008 and June 2009 at Stonechurch Family Health Centre, part of the McMaster Family Health Team. The core team comprised a nurse practitioner, an FP, and a registered practical nurse. Additional team members included a pharmacist, a dietitian, a social worker, and a visiting geriatrician. Twenty-five seniors were evaluated through the pilot program. Patients were assessed within 5 weeks of initial contact. Patients and practitioners valued timely, accessible, preventive, and multidisciplinary aspects of care. The nurse practitioner's role was prominent in the program, while the geriatrician's clinical role was focused efficiently.
The family health team is ideally positioned to deliver shared care for the frail elderly. Our model allowed for a short referral time and easy access, which might allow seniors to remain in their environment of choice.
家庭医生为体弱的老年人群提供大部分医疗服务，但许多挑战和障碍可能导致服务碎片化、低效和无效。
提高社区中体弱老年人的护理质量、效率和协调性，并增强提供者和学习者的老年病学和跨专业技能。
老年人协作护理计划采用了跨专业、共同护理、老年病学模式。该计划的可行性通过 2008 年 11 月至 2009 年 6 月在麦克马斯特家庭健康团队的斯通彻奇家庭健康中心进行的试点研究进行了评估。核心团队由一名护士从业者、一名家庭医生和一名注册实习护士组成。其他团队成员包括药剂师、营养师、社会工作者和来访的老年病学家。有 25 名老年人参加了试点计划。患者在初次接触后 5 周内进行评估。患者和从业者都重视护理的及时性、可及性、预防性和多学科性。护士从业者在该计划中的作用突出，而老年病学家的临床作用则得到了有效集中。
家庭医疗团队非常适合为体弱的老年人提供共同护理。我们的模式允许短时间转诊和便捷的访问，这可能使老年人能够留在他们选择的环境中。
