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Transforming primary care for older Canadiansliving with frailty
Paul Stolee, PhDSchool of Public Health and Health Systems
University of Waterloo
April 2017
Outline
How we got here
Before CFN
With CFN
Where we’re going
What we were doing before CFN
We were doing research
We were listening to people
The Study
We were doing research
Care Transitions for Patients with Hip
Fracture
Retrieved from: http://gtarehabnetwork.ca/downloads/report-hipfracture-nov06.pdf
We were listening to people
Project… Consultations with… Types of Consultations…
Funded Research Projects Health Care Providers (n=456) 34 Focus Group Sessions127 Interviews4 Workshops
Funded Research Projects Patients and Family Caregivers (n=82)
115 Interviews
Large Community Consultation Sessions
Health Care Providers (n=450)Older Adults (n=200)
Community Consultations (5 consultations over 4 years)
Total ~1,156 individuals>240 Individual Interviews34 Focus Group Sessions
9 workshops/consultations
“We’ve been taught, as we go
along, that the doctor is always
right, the doctor knows best, the
doctor knows this. The doctor does
not know best” (SHARP member)
Some of our conclusions
• Older patients are often not very involved in decision-making around their care
• Family caregivers both have and need knowledge, but often have a limited role in care planning and decision-making
• Limited use of technology
• Coordination and communication between providers and services is often inadequate
• Primary care could play a key role in identifying at-risk older persons and coordinating their care, but needs support for this role
Enter
Before CFN / With CFN
Before CFN
We developed an in-depth understanding of health
system challenges for older persons
With CFN
We began to work on solutions for these challenges
What does the evidence say about how to engage older
adults in healthcare decision-making?
CFN-funded Knowledge Synthesis: the CHOICE
project
How can we do “CHOICE” in practice?
CFN-funded Catalyst Grant
Building on CHOICE frameworksHow do the frameworks and principles identified
through the CHOICE project correspond with actual experiences of engagement?
What factors currently facilitate or hinder patient engagement?
What resources, materials and implementation strategies (for patients, caregivers and providers) are needed to support patient engagement?
CFN-funded Frailty Implementation Grant
How to identify at-risk older
patients in primary care?
Frailty Implementation Grant
Worked with three Ontario primary health care
practices to implement and test a brief screening
tool to identify at-risk older patients
CFN-funded Fellowship (Dr. Jacobi Elliott)
Can we develop new methods of care
coordination in primary care?
Fellowship
Co-design approach for implementing a model of
care coordination in primary care
Two sites in Ontario (rural and urban)
Screening tool, patient/caregiver engagement in
decision-making, referral system with connections to
community and specialist services
All of which positioned us for:
CFN Transformative Grant Proposal
Proposed research initiative addresses priorities informed by prior research, consultations and literature review:
Consistent screening and assessment of frailty
Care coordination and system navigation
Patient/caregiver engagement & shared decision-making
Enabling technology support
Research Question: Compared to usual care in primary care settings, does our proposed model improve health, social and economic outcomes for older Canadians living with frailty?
Five Principal Investigators
Principal Investigators
Dr. Paul Stolee (Proj. lead) University of Waterloo
Dr. Anik Giguère Université Laval
Dr. Kenneth Rockwood Dalhousie University
Dr. Joanie Sims-Gould University of British Columbia
Dr. Esther Suter University of Calgary
22 Co-Investigators
Dr. Veronique Boscart Conestoga College
Dr. Andrew Costa McMaster University
Dr. Jacobi Elliott University of Waterloo
Dr. Dorothy Forbes University of Alberta
Dr. Heather Hanson Alberta Health Services
Dr. George Heckman University of Waterloo
Dr. Jayna Holroyd-Leduc University of Calgary
Dr. Ayse Kuspinar University of Waterloo
Dr. Samantha Meyer University of Waterloo
Dr. Josephine McMurray Wilfrid Laurier University
Dr. Olga Theou Dalhousie University
Dr. Holly Witteman Universite Laval
Dr. Mohammad Hajizadeh Dalhousie University
Dr. Wanrudee Isaranuwatchai University of Toronto
Dr. G. Ross Baker University of Toronto
Dr. Kerry Bryne University of Waterloo
Dr. Catherine Burns University of Waterloo
Dr. Kelly Grindrod University of Waterloo
Dr. Lucille Juneau Centre d'excellence sur le vieillissement de Québec du CHU de Québec (CEVQ)
Dr. Edeltraut Kröger Centre d'excellence sur le vieillissement de Québec, Quebec, Centre de recherche FRQ-S du CHU de Quebec
Justine Giosa University of Waterloo
Dr. Marie-Josée Sirois Université Laval
13 Collaborators
Dr. Mary Tinetti Yale Universrity
Dr. John Young University of Leeds
Dr. Dimity Pond University of Newcastle
Dr. Geoff Mitchell University of Queensland
Dr. Nick Goodwin International Foundation of Integrated Care/King's Fund
Dr. Patricia Rodney University of British Columbia
Dr. Dong Woon Han Hanyang University
Dr. Jane Murray Cramm Erasmus University Rotterdam
Arsalan Afzal Waterloo Wellington CCAC
Dr. Peter McPhedran Waterloo Wellington LHIN
Judith Carson SHARP Network
Phyllis Puchyr SHARP Network
Peter Puchyr SHARP Network
15 Knowledge Users
Dr. Duncan Robertson Alberta Health Services
Dr. Michael Hillmer Ontario Ministry of Health and Long-Term Care - Research, Analysis and Evaluation Branch
Susie Gregg Canadian Mental Health Association
Dr. Seigrid Deutschlander Alberta Health Services
France Falardeau Cité-Limoilou area, Independent Living Program for Ederly People, Integrated University Health and Social services Centre of the of the Capitale Nationale
Nancy Drouin MRC de Charlevoix area, Independent Living Program for Elderly People, Integrated University Health and Social services Centre of the of the Capitale Nationale
Carol Anderson Continuing Care - Edmonton Zone; Alberta Health Services
Dr. Jacque Bouchard Regional Departments of General Practice, Integrated University Health and Social services Centre (Centres intégrés universitaires de santé et de services sociaux) of the Capitale Nationale
Carol Annett VHA Home HealthCare
Christine Maika Canadian Foundation for Healthcare Improvement
Nadine Henningsen Canadian Home Care Association
Dr. Kenneth LeClair brainXchange; Division of Geriatric Psychiatry
Sharon Harper Health Canada
David Harvey Alzheimer Society Ontario
Céline Allard Independent Living Program for ederly people Integrated University Health and Social services Centre of the of the CapitaleNationale
48 Partner Organizations
48 Partner Organizations
• 248 Enterprises
• Alberta Health Services, Continuing Care
• Alberta Health Services, Research Priorities
and Implementation
• Alberta Health Services, Seniors Health
Strategic Clinical Network
• Alzheimer Society Ontario
• Assistant Director ILP
• brainXchange
• Calgary West Central Primary Care
Network
• Canadian Gerontological Nurses Association
• Canadian Home Care Association
• Canadian Patient Safety Institute
• Canadian Society of Consulting Pharmacists
• Caredove
• Centre for Hip Health and Mobility
• Le Centre d’excellence sure le vieillissement
de Québec
• Canadian Foundation for Healthcare
Improvement
• Canadian Institute for Health Information
• Canadian Society for Exercise Physiology
• Dieticians of Canada
• Independent Living Program (ILP) for Elderly
People
• Cite-Limoilou
• MRC de Charlevoix
• Université Laval, e-TUDE
• Heart and Stroke Foundation
• InVizzen
• Ontario Ministry of Health and Long Term
Care
• Mount Forest Family Health Team
• New Vision Family Health Team
• Registered Nurses Association of Ontario
• Saint Elizabeth, Research Centre
• Seniors Helping as Research Partners
(SHARP) Network
• Sherwood Park Primary Care Network
(Edmonton Zone)
• University of British Columbia, Institute for
Healthy Living and Chronic Disease
Prevention
• Université Laval, Usability Testing
(Lab)University of Waterloo, Faculty of
Applied Health Sciences
• University of Waterloo, School of Public
Health and Health Systems
• Visiting Homemakers Association (VHA)
• Waterloo-Wellington Self-Management
Program
• Waterloo-Wellington CCAC
• Woolwich Community Health Centre
• Nova Scotia Health Authority
• Public Health Association of Canada
• Health Canada
• Association of Ontario Health Centres
• Community Care of Kawartha Lakes
• Seniors Care Network
• Association of Family Health Teams of
Ontario
• Research Institute of Aging (RIA) – Schelegel
Chair
• Primary Care Lead, Waterloo-Wellington
LHIN, Peter McPhedran
HQPs and Research Staff
Nine Study Sites
Nine primary care sites across Alberta (n=2),
Ontario (n=3) and Quebec (n=4)
Urban and Rural
Four Interventions
Risk screening tool
ideas for health October 15, 2010
Self-reliant Impaired No Yes No Yes No Yes No Yes No Yes
No Yes
Self –reliance Index Person is IMPAIRED if ANY of the following are true:
• B1 = 1 Modified independent or any impairment in Cognitive Skills for Daily Decision Making • B2a = 1 Received supervision or any physical help with bathing • B2b = 1 Received supervision or any physical help with personal hygiene • B2c = 1 Received supervision or any physical help with dressing lower body • B2d = 1 Received supervision or any physical help with locomotion
Family Overwhelmed (Yes if B7b= 1)
Self –rated Health: Excellent or Good (Yes if B4 = 0 or 1)
Unstable Condition (Yes if B5a=1)
Dyspnea OR Unstable Condition
(Yes if B3 = 1, 2, or 3 OR B5a=1)
Support in Personal Hygiene ADL
(Yes if B2b = 1)
2 34
6 1 3
5
Self –rated Mood: Sad, Depressed, Hopeless
(Yes if B6= 1)
4
6
interRAI Assessment Urgency Algorithm (AUA)
Engagement in clinical decision making
CHOICE framework
• Understand situation, patient
characteristics, living situation, family
involvement
• Understand skills and knowledge
• Provider should involve family if patient
wishes; understand wishes and patient
goals
• Understand level patient wishes to be
involved in for decision-making
• Provide information – what to expect,
services to access
• Engagement should be supported while
patients transition within or between
care settings.
Decision Boxes
Giguère et al., 2014
Referrals to Community Services
and Resources with Caredove
Outcomes
Patient Experience – Patient Assessment of Chronic
Illness Care (PACIC)
Quality of Life – EQ-5D-5L
Provider Experience – CIHI Provider Survey
System Level Indicators – healthcare utilization,
economic impact
Research Design
Baseline Data Collection and Tailoring of the Intervention (Sept 2017 – Jun 2018)
Implementing the Intervention (Jul 2018 – Apr 2019)
Evaluation: Data Collection and Analysis (May 2019 – Sept 2019)
Stay Tuned!
Go Oilers!
Catalyst Grant
Building on CHOICE frameworks
Purpose: We will work with patients, caregivers and healthcare providers to answer the following questions:
How do the frameworks and principles identified through the CHOICE project correspond with actual experiences of engagement?
What factors currently facilitate or hinder patient engagement in each setting?
What resources, materials and implementation strategies (for patients, caregivers and providers) are needed to support patient engagement in each setting?
Catalyst Grant
Findings:
Engagement takes time; don’t have time in primary care to have conversations – only have time to address why the patient came in
Primary care providers acknowledge the need to better engage family caregivers
Patients feel intimidated by providers
Health care providers and older adults both identified a need for engagement education – how to improve engagement practices, how can older adults be better advocates for their own health, what questions should providers always ask
Catalyst Grant
Makes engagement easier:
Time and flexibility
Relationship
Open communication
Makes engagement more difficult:
Family dynamics
Lack of trust in the provider or the system
Constraints of health care system (time)
Knowledge Synthesis - CHOICE
patient and citizen engagement has been recognized as a
crucial element in health care reform, limited attention has been
paid to how best to engage seniors
To improve the system for this population, seniors and their
families need to be engaged as active partners in health care
research and planning, and in decision-making for their care.
Purpose: Using a realist approach, synthesize current
knowledge on patient, family, and caregiver engagement to
develop best practice guidelines and recommendations for
engagement older patients and their families and caregivers in
health care research, planning, and clinical decision making.
CHOICE Findings
2 frameworks – clinical decision making and research/planning
Health care providers, researchers/planners and older adults should discuss how the person would like to be engaged given specific situations
Preferences, goals, needs, and expectations need to be discussed.
Communication is key to the development of an open, honest, and trusting relationship
What the literature says we need for an appropriate primary care model…
• Engagement of patients and caregivers in decision-making, supported by evidence
• Appropriate targeting of patients (through screening) with further assessment as appropriate
• Coordination with other health and social services
• Enabling technology
• Informed by evaluation
• Aggarwal & Hutchison, 2012• Aggarwal & O’Shaughnessy, 2014• McCarthy et al., 2015
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