Age-friendly Primary Health Care Centres Toolkit - World Health ...

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AGE-FRIENDLY PRIMARY HEALTH CARE CENTRES TOOLKIT8. Lack of effective community networks and health promoters trained to identify andnegotiate community resources for older adults. Does the contract with healthpromoters include the task of watching and promoting for the health of older adults?9. Ineffective referral systems. Is the PHC centre able to track the effectiveness of theirreferral system?10. Inadequate incentives for the primary level to address the health needs of olderadults. Are health centres monitored and rewarded for improving the health andfunction indicators of the older population in their community?11. Geriatric competences are not developed as part of continuing education of healthpersonnel. Does the centre have explicitly stated the competencies that every healthprofessional working with older adults, need to know? Are there training plans thataddress those competencies?12. Lack of monitoring and quality improvement systems focused on outcomes for olderadults' health. Does the information system at the <strong>Health</strong> Centre include monitoringappropriate indicators for quality improvement of care for older adults?80
AGE-FRIENDLY PRIMARY HEALTH CARE CENTRES TOOLKITIII.2 Patient care coordinatorsIntroductionA PHC centre can be very confusing to the older person who may have difficultynavigating the various services, appointments, providers and lines. Not all PHC centreswill have a designated care coordinator; however, these functions can be done, in somecases, by trained volunteers. Where a volunteer or care coordinator is not available, thelist of key functions should be reviewed and critical functions should be assigned to eachstaff member.Functions of patient care coordinator• Coordinating services within the PHC centre• Coordinating of internal and external referrals.• Working in coordination with clinical team.Key functions:1. Monitor that patients keep appointmentsa. Create follow-up system for “no shows” – patients who do not keepappointment.b. When contacting patient home, do not disclose patient information other thanappointment information2. Ensure correct patient flow within the clinic e.g. between registration, consultation,procedure room, pharmacy, cashier etc.a. Arrange wheelchair or other mobility aids and/or escort when available asneeded.3. Ensure next appointment is at a medically appropriate date and time and whenpatient’s transport and/or caregiver are available.a. Advocate for patient when there are clinic schedule constraints4. For patients who use transport, coordinate with transport service.5. Ensure that medical/social referrals that are affordable to patient are made andfollowed up.a. Advocate for referral subsidized rate for patients e.g. subsidized rate atspecialist clinic.b. Explain purpose, charge and what to expect from referral to patient e.g. eyeclinic will make recommendation on need for cataract surgery.6. Obtain and communicate patient feedback on clinic services in coordination withpatient ombudsman where available e.g. create channel of communication forpatient to express concerns not expressed during consultation e.g. insufficienttime for patient to ask questions about medication.81
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Age-friendly Primary Health Care Centres Toolkit - World Health ...

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