Family Medicine led collaborative care model to address gaps in Primary and Palliative care for patients with Advanced Neurological Conditions
Author(s): Nina Yashpal, Melissa Graham
Description:
Literature highlights a growing number of people with advanced neurologic conditions many of whom have unmet primary and palliative needs. Similar observations were made by local neurologists and our team of family physicians receiving referrals for home-based care. In response to these needs, a pilot neuro-palliative program was developed to provide integrated and collaborative care alongside hospital neurologists. The initial goals were to improve access to patient-centered palliative care, support goals of care conversations with patients and families, and support families caring for their loved ones at home. Very quickly we learned that these patients also lacked access to basic primary care.
Program Description: THP neurologists and geriatricians refer patients with limited access to care to the Palliative Team at the Credit Valley FMTU. Patients are triaged for primary care access and urgency of the request. First consultation occurs with staff+/- resident physician and ongoing care is decided on mutually.
Outcomes - We will share a narrative description of our observations as well as data collected (eg, % of referred patients without access to palliative care, % of referred patients referred without access to home-based primary care, referral volume, referral sources, # of patients having a first goals of care conversation, # of referrals made for community resources etc).
Discussion - Strengths, Weakness, Opportunities and Threats of the Pilot Program will be reviewed