for older Canadians living with frailty Paul Stolee, PhD School of - - PowerPoint PPT Presentation

Transforming primary care for older Canadians living with frailty

Paul Stolee, PhD

School 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 Sessions 127 Interviews 4 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 Interviews 34 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
• ften 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
• lder 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 frameworks

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?

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

• f 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 Capitale Nationale

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

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 3 4 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