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.