Developing a process of risk-stratified care coordination for older adults in primary care

BACKGROUND Older Canadians with chronic diseases are the highest users of the health care system. Primary health care (PHC) could play a central, coordinating role in assessing older adults and managing their care, but at present lacks specific strategies to fulfil this role. Priorities for enhanced care coordination in PHC include: 1) consistent processes to identify and assess older persons and create individual care plans aligned with risk levels; 2) improved care coordination and system navigation; 3) improved access to appropriate services; and 4) improved patient and caregiver engagement (Heckman et al., 2013; World Health Organization, 2008; Wagner, 2000; Goodwin et al., 2013). This dissertation project aims to understand how a process of risk-stratified care coordination for older adults can be developed and implemented in primary care. Information gathered to answer this question will provide an in-depth understanding of: i) the local context where the process is implemented, including available health and support services; ii) the process of implementing a screening and referral process in primary care, and iii) the experiences of providers, patients and caregivers with implementation to see how the process might be modified and to understand what factors are important for future spread. METHODS The Chronic Care Model (Wagner et al., 1999), a framework to guide care improvements and a multi-level (environmental, organizational, patient, provider, and program) framework for implementation of health innovations (Chaudoir et al., 2013) were used to guide the three study phases. Overalldata collection and analysis followed a mixed methods design, within a developmental evaluation approach. Data were collected using ethnographic observations (phases 1,2,3), informal feedback (phase 2), individual and focus group interviews (phases 1 and 3), and survey (phases 1 and 3) and tracking forms (phase 3). Data were analyzed using appropriate qualitative and quantitative techniques. Patients, family caregivers, and health care providers were purposefully sampled from two Family Health Teams in Ontario (rural and urban). RESULTS Through focus group interviews with health care providers, lack of care coordination, information sharing, patient engagement, and service awareness were identified. To address these concerns, a process of risk-screening and care coordination for patients 70 + years of age was developed and implemented through an iterative process, in two primary care clinics. 512 patients were screened for level of risk using the interRAI Assessment Urgency Algorithm (AUA) and care was coordinated for individuals based on level of need. Among those screened, 70% of individuals screened as low risk, 25% were screened as moderate risk, and 5% were screened as high risk. As a result, service referrals were made to self-management, community programs, and specialized geriatric services using an online referral mechanism. Although the screening and referral process is time consuming, health care providers, patients and caregivers identified many benefits including early identification of service need, greater awareness of services available in the community, and improved relationships between patients and providers. CONCLUSIONS A process of risk-stratified care coordination was developed and implemented in primary care through an ongoing, iterative process with older adults, caregivers, and health care providers. Future research activities should focus on testing these findings in other models of care (e.g. solo-physician practice) and in other regions

Engaging older adults in healthcare research and planning: a realist synthesis

Background The importance of engaging the community in healthcare research and planning has been widely recognized. Currently however, there is a limited focus on older adults, Canada’s fastest growing segment of the population and biggest users of the healthcare system. Objective This project aimed to develop an understanding of engagement of older adults and their caregivers in healthcare research and planning. Method A realist synthesis was conducted of the available knowledge on engagement in healthcare research and planning. The search methodology was informed by a framework for realist syntheses following five phases, including consultations with older adults. The synthesis included theoretical frameworks, and both peer-reviewed and grey literature. Results The search generated 15,683 articles, with 562 focusing on healthcare research and planning. The review lead to the development of a framework to engage older adults and their caregivers in healthcare research and planning. The 5 stages environment, plan, establish, build, and transition are accompanied with example context, mechanism, and outcomes to guide the use of this framework. Conclusion We have identified a framework that promotes meaningful engagement of older adults and their caregivers. We are continuing to collaborate with our community partners to further develop and evaluate engagement strategies that align with the presented framework.This work was supported by a Knowledge Synthesis Grant from the Technology Evaluation for the Elderly Network (TVN), grant # KS2013-08, which is funded by the Government of Canada’s Networks of Centres of Excellence (NCE) Program

Choosing Healthcare Options by Involving Canada's Elderly: a protocol for the CHOICE realist synthesis project on engaging older persons in healthcare decision-making

Introduction: While patient and citizen engagement has been recognised as a crucial element in healthcare reform, limited attention has been paid to how best to engage seniors-the fastest growing segment of the population and the largest users of the healthcare system. To improve the healthcare services for this population, seniors and their families need to be engaged as active partners in healthcare decision-making, research and planning. This synthesis aims to understand the underlying context and mechanisms needed to achieve meaningful engagement of older adults in healthcare decision-making, research and planning. Methods and analysis: The CHOICE Knowledge Synthesis Project: Choosing Healthcare Options by Involving Canada's Elderly aims to address this issue by synthesising current knowledge on patient, family, and caregiver engagement. A realist synthesis will support us to learn from other patient and citizen engagement initiatives, from previous research, and from seniors, families and caregivers themselves. The synthesis will guide development or adaptation of a framework, leading to the development of best practice guidelines and recommendations for engagement of older people and their families and caregivers in clinical decision-making, healthcare delivery, planning and research. Ethics and dissemination: The components of this protocol involving consultation with patients or caregivers have received ethics clearance from the University of Waterloo, Office of Research Ethics (ORE# 19094). After completion of the project, we will amalgamate the information collected into a knowledge synthesis report which will include best practice guidelines and recommendations for patient, family and caregiver engagement in clinical and health system planning and research contexts. Results: Will be further disseminated to citizens, clinicians, researchers and policymakers with the help of our partners.Technology Evaluation in the Elderly Network (TVN, grant # KS2013-08), which is funded by the Government of Canada's Networks of Centres of Excellence (NCE) Progra