Our 2017-2022 Strategic Plan includes four strategic priorities, based on a comprehensive consultation process with key partners and stakeholders:
1. Foster matching care to values
Many older Canadians living with frailty who may have a limited life expectancy often receive invasive and uncomfortable procedures that may lessen quality of life even though the duration of life may be mildly extended. There is evidence that Canadians receive invasive and highly aggressive care in spite of their wishes. The values and preferences of Canadians are poorly captured in the health system leading to minimal data on congruence between health care received, preference and outcomes such as quality of life. The health care system needs to align with Canadians’ values so that the system is focused on providing appropriate interventions that maximize person-centred outcomes and quality of life. Of particular importance is the need to provide opportunities for individuals in late life, and nearing end of life to be able to choose their preferred place to live. Specifically, CFN will:
- Continue to implement the CFN ethical framework for care of older Canadians living with frailty and in support of their family/friend caregivers to provide a foundation for the creation, dissemination and implementation of health care evidence.
- Ensure that every older Canadians living with frailty with a life limiting diagnosis or chronic illness has an advance care plan (ACP).
- Foster improved inter-professional collaboration for those working with older Canadians living with frailty.
- Enable living and dying in the person’s preferred environment.
- Create a health and social care culture that is elder friendly and which translates to compassionate, person-centered care during late life.
2. Empower, engage and support patients and their families/caregivers
Older Canadians living with frailty, their families and informal caregivers often feel under-informed and ill-equipped when dealing with their complex health care needs. The health care system and support services are often difficult to navigate. Care decisions, particularly in times of acute illness, or at end of life, can be difficult and overwhelming, leaving frail elders and families feeling helpless and confused. The complexity of these issues require decisions and care at a level which many families and caregivers feel they are unable to provide. Older Canadians living with frailty individuals and their families and caregivers require support, but they also need to be empowered and engaged in planning for their care. Specifically, CFN will:
- Support strategies for citizen engagement in all aspects of the Network research. This includes the implementation of an active and engaged citizen engagement committee plus having older Canadians living with frailty or caregiver representation on all CFN management committees.
- Develop and evaluate tools for care planning and shared decision making.
- Develop interventions to improve communication between health care providers and older Canadians living with frailty citizens, families and caregivers.
- Increase the recognition of the importance of and support for family and friend caregivers.
3. Improve clinical outcomes
As a population, the older Canadians living with frailty characteristically are of an advanced age and have multiple chronic health care conditions. Individuals with these characteristics are often excluded from studies designed for treating single conditions resulting in the lack of evidence specifically applicable to this patient population. As a result, treatments or technologies may be over-utilized or under-utilized since evidence gleaned from individuals who are younger, not in late life or who have single system disease may be generalized to this group. In addition, the measures for the evaluation of success in this age group may be different than in younger or healthier groups. Particularly important is the measurement of patient directed/reported outcomes, patient reported experiences, and measure of functional status. Specifically, CFN will:
- Increase the recognition and understanding of frailty and late life
- Increase evidence-informed practice to normalize, improve or maintain function in the older Canadians living with frailty.
- Develop and encourage appropriate use of health care evidence for treatment including end-of-life care.
- Promote quality indicators for care of the older Canadian living with frailty at the individual, institutional and system level.
- Ensure that for the older Canadians living with frailty, hospitalization is avoided where possible; where it is not possible, acute care is elder-friendly and accompanied by post-acute, restorative and rehabilitative care.
- Conduct research that informs reallocation of resources consistent with achieving a higher quality of care.
4. Improve care across the continuum
The care needs of the older Canadian living with frailty are complex and often require collaboration among different health professionals, community organizations and institutions. The current health care system has a strong focus on solving singular health issues in isolation. In addition, institutions, organizations and care providers tend to work in silos making transitions of care a cause of adverse events, particularly in the older Canadians living with frailty population. Older adults living with frailty often do not have easy access to the breadth of specialized knowledge needed for clinical decisions, nor the continuity of services when moving between different care settings. Specifically, CFN will:
- Promote the implementation of evidence-informed practices around systems of care.
- Develop evidence to enable processes of care between health care settings to be seamless.
- Develop interventions to improve communication among health care providers across different settings of care.
- Evaluate methods to improve the effectiveness of patient and system navigation.