July 14, 2016
(Edmonton, AB) An innovative new program in Edmonton is allowing seniors to better manage their health at home. The Seniors’ Community Hub is an initiative designed to improve the quality, efficiency and coordination of care for seniors over the age of 65 who are living in the community.
Dr. Marjan Abbasi, an expert in care of the elderly, along with Dr. Sheny Khera, site director of the Misericordia Family Medicine Center, are both members of the Edmonton O-day’min Primary Care Network (PCN). As recipients of a grant from Covenant Health’s Network of Excellence in Seniors’ Health and Wellness Innovation Fund, they have designed a holistic approach to senior care in the primary care setting.
The Seniors’ Community Hub is an integrated, interprofessional, shared-care geriatric program within the Edmonton O-day’min PCN. This model fosters active involvement of the patient and their caregiver, the patient’s primary care physician and primary care network team members. It promotes and maintains continuity and creates a team-based, patient-centered care plan for vulnerable seniors. The care and support plan will also be available on a portal, accessible to other health providers, to allow for improved decision-making and transition across the continuum of care.
“The Seniors’ Community Hub is a health system redesign. We’re moving from a reactive care model to a community-centric, proactive care model,” explained Dr. Khera. “We’re emphasizing health promotion and preventative measures to enable healthy aging of our seniors. We expect this approach will enhance quality of life and mitigate frailty in seniors, and reduce system pressures.”
Frailty is a state of vulnerability that puts patients at risk of adverse outcomes like falls, disability, hospitalization and institutionalization after even minor stressors such as an infection or change in medication. Dr. Abbasi explained that early recognition of frailty, using validated tools such as FACT (Frailty Assessment for Care Planning Tool), can assist healthcare providers to be proactive in seniors’ care, help seniors build resilience and prevent decline, and support caregivers. Early intervention with the creation of appropriate care and support planning, along with active engagement of patients and their caregivers, can improve health experiences.
“The goal is to have a consistent way for all healthcare providers to evaluate the health status of patients and then be able to monitor their health and collaborate to offer the best care,” said Dr. Abbasi. “We want to identify problems early, before they become serious health concerns that require hospitalization. And if a patient is hospitalized, we want to ensure the right supports are in place to help them return to their home.”
A pilot is underway in the first two clinics, and the Edmonton O-day’min PCN will be rolling out the Seniors’ Community Hub to 35 other member clinics across Edmonton. The hope is that the model may eventually be implemented in other areas of the province and perhaps for other vulnerable populations.
“This will be the first program in Alberta that brings acute care, home care and primary care systems together on a single platform in a way that allows all of a patient’s healthcare providers to collaborate,” said Colleen Enns, executive director of the Edmonton O-day’min PCN. “Not only that, it will encourage patients and their caregivers or family to participate in the care plan and take a role in actively managing their health.”
About the Edmonton O-day’min Primary Care Network
The Edmonton O-day’min Primary Care Network serves over 170,000 patients in 35 family physician clinics in Edmonton. The network’s family physicians and clinic staff work with a multi-disciplinary team of health professionals to provide coordinated care for patients and support healthy lifestyle choices.
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Media inquiries may be directed to:
Debbie Anderson
Acting Executive Director
Edmonton O-day’min Primary Care Network
Phone: 780-453-3757 Ext 101