North Shore Division of Family Practice

Long-term Care Initiative

Complex and Frail Elderly Patients

Aim: Improve medical care for residential care patients by implementing five best practices:

  • 24/7 availability and on-site attendance when required
  • Proactive visits to residents
  • Meaningful medication reviews
  • Completed documentation
  • Attendance at case conferences

Physician Leads: Dr Alireza Sameny & Dr Kathy Rahnavardi
Lead, Strategic Initiatives: Claudia Frowein
Project Coordinator: Meghan Burrows
Partner: VCH
Funding Sources: GPSC

The GPSC introduced the Long-term Care Initiative (LTCI) in response to the growing senior population and a downward trend in the number of physicians providing services to seniors in long-term care. The GPSC is supporting local groups of physicians to build local, scalable, and sustainable solutions.

The North Shore LTCI was launched in June 2016 and 12 facilities are now involved. Approximately 23 local physicians are participating in the program.