Enhancing primary care for complex patients. Demonstration project using multidisciplinary teams.

Communication between community-based providers is often sporadic and problem-focused.To implement collaborative community-based care among providers distant from one another and to improve or maintain the health of high-risk community-dwelling patients, with a focus on medication use.Six primary health care teams were formed of a family physician, a pharmacist, and a home care case manager (nurse). Three of these teams also had a family...