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The INTERCARE Model
Core components of the INTERCARE Model
1. INTERCARE nurse
A registered nurse hired specifically by each LTCF who has at least three years of professional experience in geriatric care.
2. Interprofessional Collaboration
Improving communication between physicians and staff by developing or adjusting internal structures and processes (e.g., interprofessional meetings, adapting physician visits).
3. Advance Care Planning
The following points are discussed with each new resident during an initial consultation: preferences regarding resuscitation, hospital admission, and the use of antibiotics.
4. Evidence-based tools
STOP&WATCH Tool: to improve the detection of early warning signs of a deterioration in residents’ condition (target group: nurse assistants, licensed practical nurses)
ISBAR Tool: to better structure information about clinical situations when communicating with a physician (target group: registered nurses and licensed practical nurses).
5. Comprehensive Geriatric Assessment
Targeted assessment of residents using appropriate assessment tools defined by individual LTCFs when a change in a resident’s condition is detected. Consideration of 5 geriatric dimensions: physical, psychological, functional, socioeconomic, and values & resources.
6. Data-driven quality improvement
Use of routinely collected information to identify problems in the quality of care and to develop a plan to improve the selected quality issue (e.g., polypharmacy) using a PDCA cycle.
Use of a reflection tool: to reflect on every unplanned transfer to an emergency room or to a hospital, so that the team can discuss the reasons for the transfer and whether it could potentially be avoided in future situations.