Approximately 40 Richmond Home and Community Care staff attended one of the two engagement sessions held to gather feedback about the new Primary Care Home initiative coming soon to Richmond. Pictured above, Jan Gazely (standing) listens to suggestions about how Home and Community Care staff and the new Primary Care Home team can work effectively together.

A new model of primary & community care coming to Richmond for seniors

As work continues on several fronts to develop Primary Care Homes (PCHs) across Richmond, staff from Richmond Homes & Community Care (HCC) attended engagement sessions in December to learn more about the initiative and provide feedback on the project’s progress to-date.

Approximately 40 Richmond HCC staff attended one of the two engagement sessions.

“The Primary Care Home is a truly an integrated, team-based system of health care,” said Nellie Hariri, director, Primary, Home & Community Care, during her introductory remarks. “The team will consist of patients/family, VCH Richmond HCC staff and the family physicians, all partnering to deliver comprehensive care to the 70+ seniors’ population in Richmond to help them remain in their own homes for longer.”

And, added Hariri, the model has been designed to be able to expand to other high needs and vulnerable populations in the future as well.

Physicians engagement, too, has played an important role in developing the new model of care for Richmond.

Physicians engagement, too, has played an important role in developing the new model of care for Richmond.

The new service has been developed in partnership with the Richmond Division of Family Practice and VCH–Richmond. A number of GPs from across Richmond have expressed interest in partnering with other providers to establish a primary care home model.

Home is best

As with many projects in Richmond, the goal of the PCH initiative is to provide the wrap-around care seniors need through community-based support and VCH services to support both medial and non-medical needs, so they’re able to remain at home, safely, and for longer.

It is estimated that more than 12,000 seniors living with moderate to significant health issues in the community are supported by family and friends and their family doctor and only a small subset become known to VCH community services at any given time. Due to increasing levels of frailty, however, many are just a slip, trip or fall away from landing in the Emergency Department of Richmond Hospital.

By partnering with local physicians to identify vulnerable patients, VCH Richmond and the Division of Family Practice hope to provide proactive upstream access to community services and resources and to prevent or delay the decline of functioning through application of early interventions and supports.

“Once identified, we can wrap services around these vulnerable patients so they feel safe and supported,” added Hariri. “This type of care should prevent the types of acute episodes that ultimately result in a senior’s admission into hospital and, eventually, residential care.”

Alignment with provincial priorities

Development of the Primary Care Home aligns with VCH True North Strategic Priorities and the BC Ministry of Health’s service priorities. Seniors, also, told VCH Richmond directly in a series of engagement sessions last year that it needs to be doing more to help them to live longer in their own homes.

At its most effective, the PCH will shift the system of senior care from a reactive, acute care focus to a proactive, holistic and patent centred approach. To accomplish this, VCH will be hiring, additional Social Workers and Primary Care Nurses to support PCH’s first-phase implementation.

“Seniors across Richmond have told us that they want to remain in their own homes for as long as possible,” added Robert Gill, program manager, Home & Community Care. “In partnership with our Family Physicians, the development of the PCH is the foundation by which we will help them do just that.”

Watch for more about the PHC’s first-phase launch, from Steveston, in the New Year. Two other phases in two other community areas are, also, being targeted for the 2017 calendar year.

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