Elder care: The need for interprofessional collaboration between Family Physicians, Clinical Pharmacists, and Physiotherapists in home-based primary care teams

Abstract

Background: Elderly patients with pain and falls are commonly seen in family practice. Aims: (1) Highlight the role of a physiotherapist in the primary care team; (2) Discuss the collaboration between a family physician clinical pharmacist dyad and the physiotherapist that emerged; and (3) Share practice tools that emerged from our teamwork. Settings and Design: Home Based Primary Care Practice (a core component of family practice). We have described our home based primary care practice model in earlier publications. Our model utilizes a team based approach to address the prevention of diseases, promotion of health, provision of care for acute and chronic conditions (especially concurrent multi morbidity), and delivery of rehabilitation services in the home setting. Methods and Materials: Selection of three cases from our daily practice. Reflective discussion and learning towards arriving at novel insights and improving our care model. Results: Case discussion from the perspectives of the family physician, clinical pharmacist, and physiotherapist reveal important insights on the roles, responsibilities, benefits and tensions. A process flow to facilitate team based care is also outlined along with a referral communication tool. Conclusion: For our population of the elderly with falls and pain, there was a need for a physiotherapist, as part of the team, instead of a mere referral service. This was felt because of the growing needs of patients, multiple gaps in communication with external referrals, mismatch of values and approaches, and missed opportunities for high quality care. This enhances access, optimizes clinical outcomes, delivers patient centred care, reduces unnecessary hospitalizations, and avoids catastrophic and unwarranted costs. The paper highlights the critical need for interprofessional collaboration between family physicians, clinical pharmacists and Physiotherapist in elder care.