Written by Katayoon (Kathy) Riyazi, Project Leader, Primary Health Care

This primary and community care collaboration pilot in Surrey-North Delta is aligned with the Primary Care Network - a concept recently introduced by the Ministry of Health.

The health care system is changing. People want health care that is accessible, coordinated and understandable – no matter where or by whom they are cared for. In our Transforming the Health Care System series, we share the stories of how we are changing the system and achieving positive outcomes for people and health care providers in our communities.

On October 12, Fraser Health begins testing a collaborative care model in partnership with the Surrey-North Delta Division of Family Practice and a community family physician. The model involves a Fraser Health registered nurse providing home care to the frail senior patients of a family physician.

Services provided by the registered nurse include: clinical assessments, direct care, chronic disease management and shared care planning. Support also includes care coordination and advocacy, education, follow-up, caregiver support, involvement with hospital discharge planning, referral as well as facilitating the patient’s access to other services.

This project aims to reduce hospitalizations of seniors who are frail, assist patients with timely access to clinical and community services, improve patient health outcomes, and ensure patients, family members and care providers have a positive care experience.

We look forward to sharing the results of the pilot with you!

For more information about this project, contact Margaret Meloche or Kathy Riyazi.

How are you transforming the health care system? Tell us in the comments. Read more stories about how we’re changing the health care system.

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