Implementing a Risk Screening Tool in Primary Care for Older Frail Adults
This project allowed the project team to work with three Ontario primary health care practices to implement and test an approach to assess and manage older adults. They monitored patient and provider experiences.
Possible Research Results
Anticipated findings: We will operationalize, implement and test strategies to enable primary care in Ontario. We will use very brief tools to screen all older adults in the primary care practice, and identify those who are at greater risk of developing problems. Those at higher risk can then be evaluated in greater depth, and connected with appropriate health care services as soon as possible.
Impact of findings: Our study will generate knowledge of the level of risk and need of older adults in community-based primary care, and how individualized care planning and assignment aligns with level of risk. This research has the potential to develop a more appropriate and effective health system response for frail, older persons. This research will yield a multi-faceted strategy for frailty screening in primary care through improved assessment, management of chronic disease in older persons, and will provide us a rich understanding of how to implement this strategy in other jurisdictions. This screening method will ensure frail patients are receiving appropriate services, at the right time, and are engaged in the decisions around which services to access. Immediate impacts will include greater skills and resources for self-management and system navigation; greater patient, caregiver and provider satisfaction through improved patient-centered care; and more efficient and effective access to community resources and specialists.
About the Project
Population aging has led to greater numbers of seniors, many of whom suffer from multiple ongoing health problems. Unfortunately, the health care system is currently designed to deal with single, sudden and usually curable problems. Providing care to older frail persons is challenging due to comorbidities, multiple providers, multiple care settings, long wait times, inefficient referral processes and insufficient transitional care across settings. As a result, many of these frail seniors have no other choice than to visit crowded hospital emergency departments. One way to respond to these pressures is to improve the ability of Canada’s primary health care providers to deliver care to older frail people.
Very brief tools were used to screen all seniors in the primary care practice, and identify those who are at greater risk of developing problems. Those at higher risk were then evaluated in greater depth, and connected with appropriate health care services as soon as possible. Our highly qualified team worked with these care practices to develop and evaluate a model of care to accomplish these tasks.
The model was refined and our results were shared with older adults, care providers, health care managers and policymakers.
Project Team
Principal Investigators:
Paul Stolee, PhD, MSc, MPA, BA — University of Waterloo
George Heckman, MD, MSc, FRCP(C) — University of Waterloo
Knowledge Users and Partners:
Primary care teams in Ontario
Project Contact: Dr. Paul Stolee — stolee@waterloo.ca
FRA 2015-B-19
Key words: older adults; risk screening; primary care; care coordination
Rationale: Our prior research, literature reviews, and extensive stakeholder consultations have identified a number of priorities for improving PHC (i.e. consistent processes to identify and assess older persons and create individual care plans aligned with risk levels). We will work with three Ontario PHC practices to implement and test a model of care based on these priorities.
Hypothesis: PHC is the best place within the health system to provide and coordinate care for frail seniors using our new model of care.
Objectives: Enable PHC teams to achieve an aim of coordinated care for older frail patients. For example, by working with PHC and community stakeholders to operationalize and implement a model of locally adapted strategies to enhance care for older adults with chronic conditions through efficient risk assessment and appropriate linkages to community resources.
Research plan: We will use very brief tools to screen (e.g., interRAI Assessment Urgency Algorithm) all seniors in PHC practice, and identify those who are at high risk of developing problems. Those at high risk can then be evaluated in greater depth, and quickly connected with community or specialist health care services.
CFN Webinar (July 12, 2017): Implementing a Risk Screening Tool in Primary Care for Older Frail Adults