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