Implementing the ‘Frailty Portal’ in Community Primary Care Practice: Evaluating feasibility, effects and expansion needs
The ‘Frailty Portal’ was developed to aid in the identification, screening and care planning for frail patients. The web-based portal includes an electronic version of the Frailty Assessment for Care Planning Tool, practical evidence-based visit goals to support individualized care plan development and a toolkit of available, integrated supportive resources.
About the Project
In this community-based study we proposed to assess the implementation feasibility and impact of the ‘Frailty Portal’ in the identification, raising awareness of, care planning and delivery of appropriate care for the frail in community primary care practice. Primary Healthcare (PHC) providers regularly encounter frail persons in their daily clinical work. However, routine identification and measurement of frailty is not part of primary care standard practice and there is a general lack of awareness about, and consistency in approach to, frailty.
Deliverables of the project included: (1) knowledge about factors potentially influencing the feasibility of implementing the ‘Frailty Portal’ in PHC and reasons why; (2) an assessment of whether the Frailty Portal initiative activities had an impact on targeted immediate outcomes among providers, patients and caregivers; and (3) the identification of core components necessary for successful scale-up.
These deliverables will aid in the planning and delivery of optimal, timely and relevant care for the frail in the community which over the long-term, is expected to include a reduction in service duplication, improved continuity, coordination of care, reduced wait time for provider and appropriate community services and greater confidence in the care patients receive by healthcare providers and the degree to which family/caregivers can provide.
Paige Moorhouse, MD, MPH, FRCPC — Nova Scotia Health Authority
Fred Burge, MD, MSc, FCFP — Dalhousie University
Tara Sampalli, PhD, MASc — Nova Scotia Health Authority
Melissa Andrew, MD, PhD, MSc, FRCPC — Nova Scotia Health Authority
Lisa Bedford, BA, CHRM, MPA — Nova Scotia Health Authority
Minnie Downey, BA, MA, CHE — Fraser Health Authority
Lynn Edwards, BScN, PDT, MHSA — Nova Scotia Health Authority
Antonina Garm, RN, MA, MN, GNC(C) — Fraser Health Authority
Rick Gibson, MD — Nova Scotia Health Authority
Laurie Mallery, MD, FRCPC — Nova Scotia Health Authority
Deidre Taylor, BBA, BPR — Nova Scotia Health Authority
Grace Warner, PhD — Nova Scotia Health Authority
Knowledge Users and Partners:
Fraser Health Authority
Nova Scotia Health Authority
Project Contact: Paige Moorhouse — firstname.lastname@example.org
Moorhouse, P., Mallery, L., McNally, M., Ellen, R., Moffatt, H. Frailty: It’s Time to Give Family Caregivers a Real Seat at the Table. J Fam Med. 2016; 3(5): 1067.
Moorhouse, P. (September 27-29, 2015). Routine measurement of frailty in clinical practice: Progress in community and acute care. 3rd Annual TVN Conference Improving Care for Frail Elderly Canadians. Toronto, ON.
Moorhouse, P., Gibson, R., Muckler, M., Bedford, L. (June 15, 2015). The Frailty Strategy – Towards a consistent approach to frailty through engagement, technology and innovative practice. National Leadership Conference. Charlotteown, PEI.
- One hundred percent of providers who participated in this study agreed that frailty was an important issue for their practice and that improving timely care for their patients was a high priority.
- A high percentage of those surveyed acknowledged that having the portal in their EMRs would improve use of the tool and having practice support and access to community resources as key enablers to improve care.
- Provider confidence levels seem to significantly improve in two key areas post-study: ability to assess and have conversations with their clients about frailty.
Why was this study was needed?
Routine identification of frailty in Primary Care (PC) offers opportunities for targeted preventive care that can reduce health system costs. The implementation of innovative strategies within primary care (PC) practice face unique challenges due to the community context of PC practice and the diverse needs of patients and their families. To successfully integrate an online frailty tool into everyday routines of PC providers it should be linked to PC practice electronic medical records; and initially implement the tool in practices with a higher readiness such as those with a large proportion of older patients and practices with team members who can share administrative and assessment responsibilities for administering the tool. We aimed to increase provider confidence in early identification and assessments of frailty through education and training using an online Frailty Portal.
Suggestions on how administrators or policy makers could use the findings:
- Ensure time and resources are provided to help practitioners integrate innovations into their everyday practices and recognize that sustainable change takes time.
- PC providers considered care for their frail patient a priority, but indicated the time required to identify, assess and develop care plans translated into a lost opportunity to see additional patients. Administrators and decision makers can help cultivate a PC practice culture that values the need to screen for and address frailty and promote it as part of best practices in PC.
- Initially target PC practices with more geriatric populations and those using a collaborative care team model.
Brief comment on type of study in lay terms:
- We aimed to identify 1) the barriers and facilitators influencing the use of an online frailty tool among community PC providers and, 2) the major components required for successful spread of the tool to more PC providers.
- We conducted surveys and interviews among participating PC providers and key stakeholders.
- Primary outcomes were barriers and facilitators to using the Frailty Portal, as well as elements necessary for successful implementation
- All primary care (PC) providers considered improving care for their patients living with frailty a high priority. All PC providers considered the Frailty Portal a better way to identify and assess frailty patients. Nevertheless, uptake was low and many PC providers perceived the cost of using the Frailty Portal resulted in less opportunity to see other patients.
- Barriers to uptake were centered around the tool’s usability and accessibility, time and practice organization (including reimbursement), and training following assessment.
- To successfully integrate the Frailty Portal into everyday routines of PC providers multiple barriers need to be addressed.
- At the regional level, it should be linked to practice electronic medical records (EMR).
- At the practice level, it would be best to initially implement the tool among practices with a higher proportion of older patients and those practices with multidisciplinary team members who can share administrative and assessment responsibilities.
- Although all providers felt frailty was an important concept in PC practice and desired to improve care for their frail patients, only 7 of 14 participating providers completed at least one assessment. Barriers to use included its usability and accessibility, time and practice organization, training, and steps following assessment.
Why was this study needed?
Routine identification of frailty in Primary Care (PC) offers opportunities for targeted preventive care. This study identified barriers that need to be addressed to integrate frailty assessment into the everyday routines of primary care practices.
Brief overview of the methodology:
- This study assessed the implementation feasibility and impact of the Frailty Portal, a web-based tool developed to aid providers in community PC practice in the identification of, and response to frailty.
- Objectives were to: 1) identify barriers and facilitators influencing the Frailty Portal’s use in community PC practice, 2) assess the immediate impact of the Frailty Portal on frail patients, their caregivers and PC providers and, 3) identify core components for successful scaling up of the initiative to the broader PC community.
- The study involved PC providers, key stakeholders, and patients and/or their caregivers in Nova Scotia.
- A convergent mixed method approach was used. Quantitative (provider; patient and/or caregiver surveys) and qualitative data (provider; stakeholder interviews) were collected concurrently over a 9-month period.
Potential impact of findings on clinical practice/patient care and how this impact might be measured:
- Having access to a tool such as the Frailty Portal can aid PC providers in their consideration of whether a patient’s multiple health issues are associated with normal aging or frailty.
- Despite the relatively short implementation period, the immediate impact of Frailty Portal use resulted in greater confidence in provider comprehensive understanding of frailty, ability to assess levels of frailty and discussing frailty with their patients.
- Future implementation and evaluation over a longer period following attention to amenable barriers.
- Many providers are reluctant to use the term frail with their patients. Continued use of the Frailty Portal may help shift this hesitation among providers and their patients. An investigation using qualitative methods may help shed light on this issue and means of addressing it and assessment of change.
Remaining knowledge/research gaps:
- There is a need to cultivate a PC practice culture that values the need to screen for and address frailty and consider it part of best practices in PC. This would include supportive resources to do so.
- Future research is encouraged to identify how best to facilitate changes in PC practices to address frailty.