Team-based network helps seniors with limited mobility stay in their own homes

May 4, 2016
Woman helping senior A group of family doctors have spearheaded an initiative that provides vulnerable, homebound seniors with access to health and community supports through a single point of connection at their doctor’s office.
Funding from the provincial A GP for Me initiative enabled Dr Monk and other family doctors from the Fraser Northwest Division of Family Practice to create the Sunshiners Network. 
The prototype was launched in spring 2015. Local family doctors can refer senior patients with unmet needs to the network. An on-the-go registered nurse acts as the lynchpin between the family physician and other supports. The Sunshiners Network also incorporates an electronic medical record (EMR) in which the nurse does her charting and uploads images. An OSCAR integrator enables the sharing of information between the nurse and team of doctors across participating medical offices.
Dr Tracy Monk is one of the doctors who has seen the benefits of this collaborative approach “Many of my patients who are either homebound or have trouble getting around were being seen by a variety of support people. But there was no connection between them,” Dr Monk explains. “Care staff often work within specific parameters and don’t know a lot about the patient as a person. I believe that depth of knowledge is central to giving the best care and curbing costs to our health system.”
A key enabler of the network is a partnership between the Division and Fraser Health which allows for a more seamless integration of patients with family doctors and home and community-based services.
“Whoever came up with this deserves a gold star,” says Geraldine, a Burquitlam senior whose mobility challenges prevent her from leaving home unassisted. Geraldine is able to stay in her own home, thanks to the Sunshiners Network. “One phone call to my doctor’s office and Nurse Debbie is right here. She makes sure I get everything I need.”
Thanks to the prototype’s success, the Fraser Northwest Division of Family Practice and its partners are exploring ways to continue and sustain the service on an ongoing basis.  
Read about A GP for Me team-based care projects on the Divisions BC website, here
A GP for Me is a joint provincial initiative of the Government of BC and Doctors of BC.