Enhancing primary care for complex patients. Demonstration project using multidisciplinary teams.

PROBLEM BEING ADDRESSED: Communication between community-based providers is often sporadic and problem-focused. OBJECTIVE OF PROGRAM: To implement collaborative community-based care among providers distant from one another and to improve or maintain the health of high-risk community-dwelling patients, with a focus on medication use. PROGRAM DESCRIPTION: Six primary health care teams were formed of a family physician, a pharmacist, and a home care case manager (nurse). Three of these teams also had a family physician's office nurse. Teams received training and decided on processes of care that included a home visit, medication history, and weekly 1.5-hour face-to-face team meetings. In 151 team conferences, 705 medication or health issues were identified for 182 patients over 6 months. Medication adherence was improved at 3 and 6 months. After 6 months, all providers had a greater understanding of the roles of the other providers. CONCLUSION: Primary health care teams developed in this study require few structural changes to existing health care systems, but will require more reimbursement options.