Table 2

Description of the Collaborative Team Model – COPA[24]
Aims of COPA

This CTM (COPA –Coordination Personnes Âgées), implemented in France (Paris), was designed to provide a better fit between the services provided and the needs of older patients with multiple diseases in order to reduce excess healthcare use, including emergency room (ER) visits and hospitalizations. COPA targets community-dwelling older patients with multiple diseases recruited through their PCP.

The originality of the CTM [24] lies in: (1) the integration of Primary Care Physicians (PCPs) and nurses, who act as a core team and collaborate closely in the patient care process (e.g. needs assessments, individualized care plans, follow-up) in order to provide patient-centered and coordinated care; (2) their ad-hoc reliance on the expertise of other community-based professionals (social workers, a psychologist, an occupational therapist, etc.) and (3) the integration of primary medical care and specialized care through the introduction of community-based geriatricians and palliative care specialists (who intervene when a PCP requests advice or a planned hospitalization).

Context In France, PCPs are typically solo practitioners paid on a fee-for-service basis. The nurses are salary workers in community-based services; their role is to provide both case management and direct care. PCPs and nurses in France do not collaborate on a routine basis. They usually do not have access to training programs on inter-professional collaboration.
Key components of the COPA model

Under COPA, older patients (65 years old or above) benefit from a multidisciplinary comprehensive geriatric needs assessment, an individual care plan, care management programs, evidence-based protocols, and regular reassessments of their needs.

The model integrates health care professionals into a multidisciplinary primary care team. This multidisciplinary primary care team is formed around a two-person team consisting of a nurse-case manager collaborating closely with a PCP in order to provide patient-centered care. For instance, case managers and PCPs develop and implement the care plan and coordinate health and social services across the different settings and among the numerous care providers. Case managers organize inpatient visits and hospital discharge in collaboration with the hospital team. This core team could call on the expertise of other health professionals (various medical specialists, home health nurses, social workers, a psychologist, an occupational therapist, etc.).

Implementation For the implementation of the CTM, all the PCPs and the nurses practicing in this borough of Paris - 175 PCPs and 59 nurses - were identified using a professional directory and contacted. All of them were invited to participate in the model in September 2006. They were free to participate or not.
Monitoring the implementation process A central activity database was maintained by the clinical administrators who recorded data related to: (1) the health professionals’ participation in the model (e.g. date of formal agreement as reported on a consent form) and (2) the collaborative behaviour of the healthcare professionals during the care they provided to each patient (e.g. needs assessment process, individualized care plan development, phone contacts and multidisciplinary meetings).

Vedel et al.

Vedel et al. BMC Family Practice 2013 14:3   doi:10.1186/1471-2296-14-3

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