Project Completion Date: March 31, 2023

Project Contact: April Bonise

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The Coordinated Complex Care for Older Adults (CCCOA) project was created to support the coordination of care for seniors aged 65+ who are considered pre-frail as well as for seniors who are frail and living with complex care conditions. 

This project had two components. One was done in collaboration with Home Health and the other with the Specialized Seniors Clinic (SSC). The CCCOA project set out to achieve the following in both components of the project:

1. Improve communication and collaboration as a multi-disciplinary care team as seniors transition through various providers and parts of health system.
2. Support seniors to stay at home as long as possible by connecting with home health and community supports.

The project also aimed to assist Family Physicians with clinical support such as education around early intervention and clinical assessments to delay frailty, and improved communication and referral processes with community partners such as Home Health, the JPOCSC Seniors Clinic, Community Action and Resources Empowering Seniors (CARES), and the Assertive Community Treatment (ACT) team.   

Key Home Health Activities Completed by the Project Team: 

1. Hosting of meet and greet events with FPs and home health nurses
2. Creation of a Home Health CHN fax cover sheet and Patient List
3. A Wound Care CME for Family Physicians was delivered

Key Specialized Seniors Clinic Activities Completed by the Project Team:

1. Communication process mapping, gap analysis, and change recommendations
2. Revision of referral form and referral acknowledgment process
3. Creation of a KPI data dashboard. 
4. Revision of the complex care rounds toolkit

The CCCOA project aligns with the Primary Care Network vision in that it strengthens the patient medical home and provides Family Physicians with a team to support them in providing primary care to seniors. It is a model of collaboration which is foundational for the Primary Care Network – offering seamless transition as a patient goes from their family physician to a specialist or receive home care through the health authority or medications from a pharmacist.

This model supports a more collaborative system of care that surrounds the patient/family with appropriate care through services available in the Primary Care Network, as well as specialized community services. 

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JPOCSC Specialized Seniors Clinic --> Visit Site

FRASER HEALTH Home Health --> Visit Site