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.