Poster Presentations

P-24: Interprofessional Outreach Team for High Risk Patients: Who is Served?

Ms. Lindsay Donaldson

Linda Lee*,
Loretta M.
Hillier Kelly Niall,
Maria Bohem,
Kay Weber,
Jillian Bauer

Centre for Family Medicine FHT

Topic: Population and Public Health

In efforts to better serve individuals who are high users of health system resources (e.g. greater than four Emergency Department visits per year, high home care service users) an interprofessional outreach team (physician assistant, nurse practitioner, social worker, pharmacist, and community service case manager) was created to conduct home assessments and tailor interventions according to risk level.

Objective: To better understand the patient population served by this outreach team.

Design: Chart audit.

Setting: Community.

Participants: Fifty consecutively served patients.

Using a case management approach, screening with standardized measures was conducted to identify risk for psychosocial conditions and complex medical conditions.

Outcome Measures
Demographic information included age, gender, available family physician and caregiver, living situation, financial security, available transportation, personal safety. Health information collected included incidence of frailty, dementia, heart failure, COPD, falls, depression, anxiety, substance abuse, social isolation.

Mean patient age = 66.5 years (range=21-99); 68% were female. The majority (88%) did not have a family physician and 26% lived alone. Although 76% had a reliable source of food, fewer had financial stability (52%), stable community transportation (32%), or very safe personal security (30%). The average number of comorbid health conditions was 7.7; 24% were cognitively impaired, 8% had heart failure, 46% smoked and 22% had COPD, 50% identified as high falls risk, 52% had a history of depression, 30% had a history of anxiety  26% a history of substance abuse, and 37% were identified as frail based on gait speed. There were significant age differences in frailty, dementia, COPD, and substance abuse.

Patients deemed at high risk for acute care use are very complex and many do not have access to consistent primary care. Information on the social determinants of health provide insights into the challenges experienced by this population.