IMPACT Clinic (Interprofessional Model of Practice for Aging and Complex Treatments)

The initial diagnosis and ongoing management of chronic disease most often occurs in the primary care setting. Indeed, chronic disease management is one of the most common reasons for primary care visits. Recent research suggests that the management of common chronic diseases is becoming increasingly complex and challenging, yet little is known about the magnitude of the problem in primary care practice. 

To reduce this risk, we have built a comprehensive interprofessional team dedicated to improve chronic disease management.

The results of this project will impact patients, their families, medical trainees, and health care providers. The expected outcomes include:

1. enhanced patient health and well-being which includes an innovative patient-centered model of care that provides effective management of multiple chronic medical conditions while maximizing the patients quality of life;
2. improved patient safety and fewer drug errors;
3. more effective and efficient care to this patient population, which will result in less provider frustration and burnout, contributing to a more sustainable primary health care system;
4. improved functional status and increased capacity to live independently in the community; and
5. medical trainees will be exposed to a more collaborative and satisfying clinical learning environment; these role models may result in increased interest in choosing primary care and elder care as career choices.

Operations

The interprofessional team meets to discuss the background of the patient and to update each other on changes to forms or processes. The team consists of a physician faculty member, a resident physician, a geriatrician (when available), a pharmacist, a physiotherapist, a social worker, a dietitian, a CCAC coordinator and a care coordinator. 

The patient and/or caregiver's interactions with the various team members are observed via closed circuit television by the entire team in real time. The clinic begins with the resident "unpacking" the concerns and coping needs of the patient through guided interview questions. The initial patient-resident interview is a way for the team to get a general overview of the patient's needs and concerns, independence level, day-to-day living status, advanced planning status and health and social supports. Afterwards the team debriefs and prioritizes the patient's list of problems. In order to have a fuller understanding of the concerns that were touched upon during the unpacking, various team members may go in individually or in groups according to their scopes of practice.

At the end of the clinic, the patient should have a comprehensive care plan with suggestions from the team with follow up as necessary. 

Prior to the visit, patients are advised:

• to bring all medications to the appointment (not just a list, but the actual medications, including vitamins and alternative medications)
• to bring any readings as well (e.g. BP, blood sugars, etc)
• to take morning meds as per usual routine
• that this will be a longer appointment (expect to be here for approx. 120 minutes)
• parking costs will be covered by the clinic
• that this is a new team-based clinic (doctor, pharmacist, social worker, PT, dietitian, care coordinator)
• that they can expect to be seen by several members of the team