TY - JOUR TI - Enhancing primary care for complex patients. Demonstration project using multidisciplinary teams. AU - Farris KB AU - Côté I AU - Feeny D AU - Johnson JA AU - Tsuyuki RT AU - Brilliant S AU - Dieleman S AB - 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. LA - English T2 - Canadian family physician Médecin de famille canadien VL - 50 SP - 998-1003 SN - 0008-350X PY - 2004 DA - 2004 U1 - 15317232[pmid] DB - EPISTEMONIKOS UR - http://www.epistemonikos.org/documents/c626c831b48ee7e10a9e369cfbdc38986a6f8a8b ER -