Innovations in seniors' care: home care/physician partnership

The Innovations in Seniors' Care (Primary Care Partnerships) Project was implemented in 2000 in the Calgary Health Region, Alberta, to look at integration of services for seniors. The goal was to develop a sustainable collaborative partnership between family physicians and Community Care Coordinators--RNs (Home Care). The design and model were established in Stage I of the project. Stage II addressed implementation, challenges, barriers, evaluation, learnings and successes to date. Stage III looked at refinement, revision, final evaluation of the processes and dissemination of learnings. This paper describes startup procedures and implementation (selection of participants, educational sessions, evolution of partnerships and development of the evaluation framework). As the focus of the project was quality improvement, the section on implementation will discuss how and why changes occurred in the course of the process. Key challenges related to the restructuring of Home Care, creating tools and fostering unique individualized partnerships are also discussed. The conclusion evaluates the project's benefits in relation to (1) participant satisfaction, (2) sustainability and (3) impact on the system. The initial partnerships were formed in May 2001. New partnerships continue to be developed and constitute a key strategy in the Calgary Health Region's Primary Care Initiative.