Baycrest Health Sciences & Baycrest Foundation Publications
Issue link: http://baycrest.uberflip.com/i/876680
MEDICAL SERVICES SUPPORT KL-CARE Annual Report 2016-2017 Page 14 INTEGRATED COMMUNITY CARE TEAM (ICCT) A comprehensive evaluation of the ICCT at Baycrest The ICCT was created to combat the fragmented care that complex, frail seniors living in the community frequently receive; such care often results in poor outcomes and unnecessary healthcare utilization. The ICCT provides a unique, comprehensive spectrum of inter-organizational, integrated care for frail, older adults at high risk for emergency department visits, acute hospitalization, and institutionalization. The ICCT provides patient-centred care aimed at strengthening the relationship between primary, specialty, community, and acute care providers in an effort to integrate care delivery for the most medically challenging older patients across the care continuum. This study examined the overall effectiveness of the ICCT to better meet the needs of complex, frail patients in the community and their family caregivers. The ICCT was interested in exploring a number of parameters to inform service delivery and improve program outcomes. As part of a continuous assessment of the ICCT program, KL-CARE has been conducting a program evaluation to ensure that ICCT services are being provided to homebound, frail, older adults. This initiative provides support to those community physicians who are not associated with a Family Health Team or Community Health Centre, and who lack the necessary resources to provide care to these medically complex seniors. The evaluation identified patient characteristics, examined key process measures, and determined how well the team functioned. KL-CARE involvement strengthened and clinically validated the impact of this innovative, interdisciplinary approach on ICCT members, patients, caregivers, and community-based physicians. The ICCT model encourages other centres to replicate this care delivery approach. KL-CARE project support identified that this underserved population of frail, older adults is now accessing geriatric care, establishing Baycrest as a leading care provider for this patient group.