Table 9: Components of Specialized community-based Care Interventions in Family Practice*.
| Study | Team | Home Visit | Care Plan | Components of Care Plan | Types of Interaction | Role of Team Members | Frequency of Patient Interactions |
|---|---|---|---|---|---|---|---|
| Boult et al, 2011 and Marsteller et al, 2010 (USA) (46;50) |
PCP, nurse | Yes (nurse) | Yes (care guide and action plan) | Patient identifies priorities for optimizing health; care guide is for providers; action plan is for patient to set goals | Telephone; home visits; PCP office; group sessions to learn about designing action plan | Coordinating care; smoothing transitions between care sites; promoting self-management; educating and supporting caregivers; linking to community services | At least monthly |
| Hogg et al, 2009 (Canada) (51) |
PCP, NP, pharmacist | Yes (nurse and pharmacist) | Medication management review (pharmacist); care plan (NP) | Medication review identifies potential drug-related problems; care plan identifies active health issues and outlines management goals for patient and team | Telephone; home visits; PCP office (mostly PCP) | Pharmacist identifies potential drug-related issues; NP coordinates care | Not reported |
| Counsell et al, 2007 (USA) (52) |
PCP, NP, SW, geriatrician | Yes (nurse or SW) | Yes (care plan) | Discussed with PCP; - set targets and treatment strategies | Telephone; home visits; PCP office | NP and SW meet with patients and liaise with PCP and geriatrician | At least monthly telephone or in-person visit, and in-person visit after ED visit or hospitalization |
| Scott et al, 2004 and Coleman et al, 2001 (USA) (47;48) |
PCP, nurse, pharmacist | No | No | No care plan | Group session (education and caregiving component) (8–12 patients); one-on-one appointments | Provide education to the group and offer one-on-one support as needed | Monthly 90-minute group sessions with PCP and nurse |
| Sommers et al, 2000 (USA) (49) |
PCP, nurse, SW | Yes (nurse or SW) | Yes (risk reduction plan) | Set target objectives (e.g., reduce arthritis pain); treatment strategies (e.g., 4 short walks daily) | Telephone; home visit; small group session; PCP office | Nurse and/or SW assess new problems, check disease status, coach on self-management skills, and promote use of community-based services | At least every 6 weeks |
*
Abbreviations: ED, emergency department; NP, nurse practitioner; PCP, primary care physician; SW, social worker.