Project Overview

Context: Aging is heterogeneous: many seniors remain independent while others are frail, experiencing a rising burden of illness and disability, risk of poor health outcomes and premature death. Clinical trials have established that multifaceted interventions can improve outcomes for frail seniors. However, widespread implementation of interventions has been limited by inefficient targeting of "at-risk" patients, healthcare system fragmentation and a lack of information on patient needs and preferences.
Hypothesis: Tailored, evidence-based interventions based on standardized assessments of needs and preferences in high risk patient groups will improve patient/family centered outcomes. 4
Objectives: Leveraging evidenced-based interRAI decision-making tools widely-implemented across Canada, we propose a transformative program for frail seniors across the continuum of home care, long-term care (LTC), and acute care.
The specific objectives are to:

1. Identify unstable home care clients and implement interventions such as a detailed care plan including advanced care planning. We expect to improve health related-quality of life and reduce avoidable emergency department (ED) visits.
2. Target unstable residents of LTC facilities with enhanced Advance Care Planning (ACP) to improve the concordance between what individuals want when they become acutely ill, and what they receive. We expect this will also improve appropriateness of decisions regarding transfers to acute care institutions.
3. Target older patients at risk of iatrogenic complications admitted to ED with senior-friendly care planning and delivery, to reduce length-of-stay and premature admissions to LTC facilities.

Methods:
Over the next 3 years, we will conduct a multi-phased mixed-methods evaluation (quantitative observational, qualitative, and pragmatic experimental evaluations) of these three linked implementation projects. Each project has been piloted and supported by local decision makers. We will adopt a systems approach for the creation of proactive and common models of assessment and care that respond to risk of adverse outcomes in frail older persons in home care, LTC, and acute care settings. We will establish a pan-Canadian collaboration of knowledge users and researchers from many settings to ensure that inter-jurisdictional differences are considered and integrated into all evaluations. In addition, we will develop all of the ACP modules and interventions will be developed with Dr. John You and his team (TVN Transformative Grant 2015 proposal). The three linked projects along the continuum of care will: 1) expand the use of an evidence-informed chronic cardiorespiratory management home care program developed and pilot tested in Ontario; 2) introduce best-practice ACP and care interventions in LTC facilities; 3) expand the pilot deployment of interRAI instruments in 10 acute care sites (TVN SIG 2014) designed to identify high-risk seniors in acute care (interRAI ED and AC) in order to target specific interventions.

Impact:
Using a common framework and language, we hope to ensure that high risk elderly persons will be appropriately identified in order that we may offer personalized care plans across many settings - home care, LTC, acute care. The three large scale projects in this research program will serve as an important precedent for co-innovation with knowledge users and pave the way towards greater health system integration for frail seniors.