Key features of the Proposed Intervention in Elderly Care | |
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Objectives: | • Improve care for older persons with complex and multidimensional chronic conditions |
• Prevent unwanted institutionalization and unnecessary use of services | |
Clinical, collaborative and organizational means: | Strengthen primary care |
• Maintain the PCP as the main medical practitioner | |
• Integrate health professionals into a multidisciplinary team | |
• Introduce a case manager collaborating with PCPs | |
• No translocation to secondary care | |
Coordinate primary and secondary care | |
• Better communication | |
• Access to geriatric expertise for PCP (a community-based geriatrician) | |
• Direct access to hospitalization | |
No change in funding mechanisms |