Can the Chronic Care Model Be Used to Design Geriatric Services?
Connie Davis, David Gayton, Lori Godin, Irene Sheppard, Patty Lomas, Seniors Clinic, Fraser Health, Abbotsford, BC. Introduction: The Chronic Care Model (CCM) describes essential elements for delivery of care to people with chronic illnesses. The purpose of the CCM is to improve functional and clinical outcomes. We used the CCM as the design template for the Seniors Clinic in Abbotsford. Methods: Literature about the Chronic Care Model was reviewed as well as literature about successful delivery models and clinical emphases for outpatient geriatric care. Community members were involved in the design of the clinic. Based on this review, the clinic uses a population outreach approach and traditional referral from family physicians for case finding. Care is delivered by a small team consisting of nurses and geriatricians. Clinic participants undergo screening for common geriatric syndromes, prioritize their concerns and work with nurses using evidence-based worksheets written in lay terms
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