The Model Home Care Team

Abstract

The homebound elderly have multifaceted problems, and our culture will be challenged to make a tremendous shift to adapt to their needs. This population will require an increasing number of health care providers who distinguish between the normal and abnormal changes associated with aging. The model home care team would consist of practitioners who are skilled in just this manner. Team members would address the chronic illnesses associated with the elderly and function much as interdisciplinary teams do in other settings. Regular and effective care coordination and case communication do not have to be fantasies in the setting of home health care, as evidenced by the success of the Johns Hopkins Home Care Group Geriatric Team. To match its success, home care agencies must organize their teams to encourage regular, ongoing multidisciplinary meetings. These meetings increase immediate attention to current issues and ineffective portions of treatment plans, reducing the cost of providing high-quality care.

Management of complex chronic disease: facing the challenges in the Canadian health-care system

“…For instance, the success of Geriatric Teams at the John Hopkins Home Care Group (JHHCG), an American organization providing a full range of home health services throughout Maryland, demonstrates that regular and effective care coordination is achievable in the setting of home health care. 36 These teams, consisting of a physician, nurse, physical therapist, occupational therapist, speech and language pathologist, and social worker, are located in one location and meet daily to discuss patient progress, medical issues, rehabilitation, social and psychological issues, and family dynamics. The result of such meetings is that care is coordinated and seamless, with all providers communicating the same messages to the patient.…”