Model of Care

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Using a professional team,  we endeavour  to deliver all of a person’s primary medical care  in the home environment. We start with a comprehensive geriatric assessment looking for reversible factors that may adversely affect a person’s health.  We then try to optimize the medical care and improve functional status by using a team of a physician, nurse and physiotherapist.

Why in the Home?

We go to the home to improve access to care for people who may have  difficulty getting to a physician’s office or have multiple complex problems that may be difficult to assess in an office setting.  At home,  we can observe people in their own environment and  determine how their health status impacts on their daily function and quality of life. We always start with a Comprehensive Geriatric Assessment

What is a Comprehensive Geriatric Assessment?

Many elderly people develop frailty syndromes such as memory impairment, balance problems, weakness, chronic pain and difficulties with bladder control. These syndromes often have multiple causes. Geriatric assessment involves a comprehensive assessment of all of the medical, physical and psychosocial factors that may impair a person’s daily function and reduce their quality of life. It involves a detailed medical history, examination and functional assessment looking for reversible factors. This assessment is often done by a Team of professionals using standardized assessment measures and interventions. Medicine and Health Care are rapidly changing. We try to keep up-to-date with the latest developments and try to base our interventions on the best evidence from current and past research.

Why Use a Team?

“Interdisciplinary” means care delivered by more than one type of health care professional or “discipline” in an integrated fashion. Research suggests that Teams of professionals may be more effective than traditional medical care. Our Team consists of a physician who leads the Team, a nurse and a physiotherapist. The physician is responsible for diagnosing specific conditions , prescribing and adjusting medications and referring to specialists. The physician meets with patients and families to discuss prognosis , counsel them and help plan care. The nurse assesses and monitors a person’s condition, educates and advises them about managing chronic diseases and syndromes.  The nurse  helps with problems related to hearing, bowel and bladder function, mood and memory and administers immunizations. The nurse will also assess patients when they are acutely ill. The physiotherapist assesses and helps manage problems related to pain, weakness, mobility and balance.

We also believe that the patients, families and caregivers are important, if not the most important, members of the Team. We encourage timely communication about changes in someone’s health status or problems with care so that we can act quickly. We do this by phone, secure email and in person. We also believe that the final decision about health care interventions rests with the patient in consultation with family or health representatives.

Effective Teams require leadership, excellent communication, coordination and integration. Our Team is in daily communication with one another. Every day we share information about each encounter with patients seen in this practice.

What is Primary Care and Ongoing Management?

Primary Medical Care means the first point of contact with the health care system and responsibility for delivering and coordinating clinical care. We take over the care from a person’s family physician when they enter our practice. After completing the Comprehensive Geriatric Assessment and stabilizing a person’ condition, we regularly monitor  their health status and adjust the care accordingly. Our team will respond to acute illnesses as well as other problems that arise and treat these in the home when possible. When people near the end of their lives, we try to set up support services that allow them to die peacefully in their homes.

What are the Goals of Home Team Medical Healthcare?

Our goals are to:

1. Maximize Quality of Life and Reduce Disabling Symptoms

2. Improve and Maintain Physical and Mental Function

3. Prevent Hospitalization

4. Prevent or  Delay Nursing Home Placement

5. Facilitate Home Death

6. Give Elderly people informed choices about the intensity of their medical care

7. Reduce Caregiver Burden

Is there any Research to Support the Home Team Medical Model of Care?

A study published in the Journal of the American Geriatric Society demonstrated a 39% reduction in annual hospital admissions compared to the year before people entered this practice. 47% of deaths during the study year occurred at home. This study was not a randomized controlled clinical trial, the gold standard for evaluating health care interventions, but does suggest that Home Team Medical can be an effective model of health care. Read this study.


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