The Old Elderly, those aged 80 and older, are the fastest growing age subset of the population. They are more likely to have chronic illness, more likely to be using multiple medications and are more likely to visit their physician. However, a physician is not always necessary to address the many concerns of the elderly; other venues of care may be more cost and time effective. This study will implement and evaluate a nurse-based program of home-delivered care, linked directly with the family physician or primary care team.
The main objectives are to improve Quality of Life for the old elderly and lessen the burden on the primary health care system. These improvements will be made through an intervention called the ElderCare Program. An ElderCare Plan will be developed for each patient using Goal Attainment Scaling methodology and will provide education and information about chronic disease self-management, available community resources, activities of daily living help and any other needs the patient may have. Goals and other needs will be determined based on patient, family member (where applicable), and physician input, and on information from a variety of assessments carried out at baseline. Assessments at 6 months and 12 months will test the outcomes of the program. To date, 40 family physicians from 14 different clinics have enrolled in the study. Patient recruitment currently sits at 230 with patients in various stages of follow up. Follow-up of the final participants will occur in October 2011.