Project Overview

Background:
The Canadian health care system is challenged by growing numbers of frail elderly persons with multiple complex health problems and chronic illnesses. Primary health care is the best place within the health system to identify and coordinate care for this population, but at present is poorly equipped to do so. Strengthened primary health care for frail older persons could achieve improved patient outcomes while reducing health system costs.

Objectives:
Our project will strengthen primary health care to meet the needs of frail elderly Canadians through the design, implementation and evaluation of feasible methods and enabling technologies to: 1) quickly identify frail or at-risk patients, with appropriate follow-up assessment, 2) engage older patients and their caregivers in decision-making about their care, and 3) help older patients and caregivers navigate a complex health system.

Methods:
Our project will be informed by TVN statements on frailty screening and patient engagement, and will leverage extensive prior research, including several TVN-funded projects. Health systems may be viewed as complex adaptive systems, and we believe this needs to be reflected in health system research and evaluation. We will use accepted methods for developing and evaluating complex health system interventions (Sidani & Braden, 2011); these will allow for an iterative, user-engaged process with continual learning and system improvement, leading to a scalable model of primary health care. Primary health care teams and other health system stakeholders, including older adults and caregivers, will be actively engaged throughout the transformative project. We have identified primary health care teams in multiple Canadian centres with whom we will work to test strategies to enhance screening, patient and family engagement, shared decision making and care coordination for older frail adults. We plan a participatory approach using workshops, focus group sessions, and key informant interviews; along with quantitative measures of patient and provider experience, patient outcomes, and system performance. Testing of screening tools will follow accepted psychometric methods.

Milestones and Deliverables:

1. Tested tools, guidelines and processes for screening for frailty and risk in primary health care settings, and strategies for appropriate follow-up assessment (years 1-2);
2. Guidelines, resources and support tools to engage seniors and their caregivers in the primary health care system in decision-making about their care (years 1-2);
3. A model of system navigation and care coordination that is feasible in a primary health care setting, with care plans aligned with risk levels and patient preferences (years 2-3);
4. Enabling technologies in support of deliverables 1-3 (years 1-3); all leading to:
5. A scalable model of enhanced primary health care for frail elderly Canadians (year 3).