Abstract
Summary On Lok Senior Health Services provides community-based comprehensive care for the frail elderly and is the prototype of the PACE (Program of All-Inclusive Care for the Elderly) model of care. Comprehensive care includes all aspects of acute care and long term care under one capitated health delivery system. The cornerstone of care at On Lok is the interdisciplinary team that performs a comprehensive assessment of all participants at intake and at regular intervals after enrollment. The team consists of physician, social worker, nurse, physical therapist, occupational therapist, dietitian, home care nurse, geriatric aide, driver, recreation therapist and other specialists as needed. The team uses standardized instruments, develops treatment plans for each participant and meets at least four times per week to discuss cases. The case presented illustrates the benefits of the On Lok model of interdisciplinary care through the end of life of a frail elderly person.
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