Better tArgetting, Better outcomes for frail ELderly patients (BABEL)

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 home care and long-term care (LTC).

Possible Research Results

Anticipated findingsWe expect to produce evidence to support the development and targeting and design chronic disease management care across Canada based on a common understanding of clients’ needs and the necessary resources to meet those needs.

Impact of findingsKnowledge on the chronic disease management needs and resources available to home care agencies will allows us to implement a feasible intervention with our home care partners, as well as assure the viability of the intervention across Canada. Provincial governments and regional health authorities can use the findings to invest in or reorganize community programs to help vulnerable older adults avoid unnecessary ED visits and hospital admissions. The actions taken based on the findings will help generate supportive chronic disease management services so that older adults in the community can maintain their independence and engagement.

About the Project

We all age differently. Many seniors remain independent while others become frail, experiencing more and more health issues, progressive disability, complications of care and premature death. Evidence suggests that multifaceted interventions can improve outcomes for frail seniors. However, implementation of effective system wide interventions has been limited by inefficient targeting of “at-risk” patients, healthcare system fragmentation and a lack of information on patient needs and preferences.

We are proposing a series of targeted interventions for frail seniors across the continuum of home care and LTC. Over the next three years, we will conduct a multi-phased mixed-methods evaluation (quantitative observational, qualitative and pragmatic experimental evaluations) of three linked implementation projects. Each project is evidence-informed, based on tested implementation strategies, and supported by local decision makers. We will implement our interventions on existing common models of assessment and care that respond to risk of adverse outcomes in frail older persons in home care and LTC. We will continue our efforts to 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.

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. Each project in our program is scalable because they make use of adapted and available evidence-informed interventions, standardized widely used risk assessments and secondary data. In the future, other comparable projects could easily be implemented using our approach.

For more details on the project rationale, hypothesis, objectives and research plan, click here.

Project Team

Principal Investigators:

Paul Hébert, MD — Centre de recherche du Centre Hospitalier de l’université de Montréal (CHUM)

Andrew Costa, PhD, BSc (Hons.) — McMaster University

Allan Garland, MD, MA, BS — University of Manitoba

George Heckman, MD, MSc, FRCP(C) — University of Waterloo

John Hirdes, PhD — University of Waterloo

Co-Investigators:

Veronique Boscart, RN, MScN, MEd, PhD — Conestoga College

Susan Bronskill, PhD, MSc — Institute for Clinical Evaluative Sciences

James Downar, MD, CM, MHSc, FRCPC — University of Toronto

David Feeny, PhD, MA, BA — McMaster University

Michelle Grinman, MD, FRCPC, MPH — University of Calgary

Heather Keller, PhD, RD, FDC — University of Waterloo

Linda Lee, MD, MCISc(FM), CCFP, FCFP — McMaster University

Robert McKelvie, MD, PhD, MSc, BSc, FRCPC — McMaster University

Lori Mitchell, PhD — Winnipeg Regional Health Authority

Patrick Quail, MB — University of Calgary

Clare Ramsey, MD, FRCPC — University of Manitoba

Machelle Wilchesky, MSc, PhD – McGill University

Project Contact: Paul Hébert — paul.hebert.chum@ssss.gouv.qc.ca

TG 2015-15-P

Rationale

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 home care and long-term care (LTC).

Principal Investigators

Paul Hébert, MD — Centre de recherche du Centre Hospitalier de l’université de Montréal (CHUM)

Andrew Costa, PhD, BSc (Hons.) — McMaster University

Allan Garland, MD, MA, BS — University of Manitoba

George Heckman, MD, MSc, FRCP(C) — University of Waterloo

John Hirdes, PhD — University of Waterloo

Rationale: It is critical to have a firm grasp of the care needs of home care clients and the resources available to home care agencies across Canada (urban, rural, remote, etc.) in order to adapt the DIVERT intervention for each jurisdiction.

Hypothesis: Based on previous experience, we hypothesize that the chronic disease needs of home care clients will be very similar across jurisdictions, but that the chronic disease management resources will vary considerably in quality and quantity.

Objectives: To describe the: (1) chronic disease profile of home care clients in each study jurisdiction and (2) the supportive chronic disease management resources available to home care agencies across Canada.

Research plan: (1) Chronic disease profiles – we will conduct a retrospective cohort study using existing clinical and administrative data from our home care partners (Island Health, Winnipeg Region and Ontario CCACs). We will analyze assessment and other databases to profile clients across DIVERT categories. This will provide data needed to adapt the DIVERT intervention in each setting. (2) Scan of resources – We will conduct an environmental scan across publicly funded home care bodies in Canada on the use and availability of chronic disease management resources including: nursing, pharmacy, primary care support, allied health, self-care management resources, specialist support, advanced care/care goal planning, etc. Results will help determine which chronic disease management strategies are feasible across jurisdictions.

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