Transforming primary care for older Canadians living with frailty: mixed methods study protocol for a complex primary care intervention

Paul Stolee, Jacobi Elliott, Anik Mc Giguere, Sara Mallinson, Kenneth Rockwood, Joanie Sims Gould, Ross Baker, Veronique Boscart, Catherine Burns, Kerry Byrne, Judith Carson, Richard J Cook, Andrew P Costa, Justine Giosa, Kelly Grindrod, Mohammad Hajizadeh, Heather M Hanson, Stephanie Hastings, George Heckman, Jayna Holroyd-Leduc, Wanrudee Isaranuwatchai, Ayse Kuspinar, Samantha Meyer, Josephine McMurray, Phyllis Puchyr, Peter Puchyr, Olga Theou, Holly Witteman, Paul Stolee, Jacobi Elliott, Anik Mc Giguere, Sara Mallinson, Kenneth Rockwood, Joanie Sims Gould, Ross Baker, Veronique Boscart, Catherine Burns, Kerry Byrne, Judith Carson, Richard J Cook, Andrew P Costa, Justine Giosa, Kelly Grindrod, Mohammad Hajizadeh, Heather M Hanson, Stephanie Hastings, George Heckman, Jayna Holroyd-Leduc, Wanrudee Isaranuwatchai, Ayse Kuspinar, Samantha Meyer, Josephine McMurray, Phyllis Puchyr, Peter Puchyr, Olga Theou, Holly Witteman

Abstract

Introduction: Older Canadians living with frailty are high users of healthcare services; however, the healthcare system is not well designed to meet the complex needs of many older adults. Older persons look to their primary care practitioners to assess their needs and coordinate their care. They may need care from a variety of providers and services, but often this care is not well coordinated. Older adults and their family caregivers are the experts in their own needs and preferences, but often do not have a chance to participate fully in treatment decisions or care planning. As a result, older adults may have health problems that are not properly assessed, managed or treated, resulting in poorer health outcomes and higher economic and social costs. We will be implementing enhanced primary healthcare approaches for older patients, including risk screening, patient engagement and shared decision making and care coordination. These interventions will be tailored to the needs and circumstances of the primary care study sites. In this article, we describe our study protocol for implementing and testing these approaches.

Methods and analysis: Nine primary care sites in three Canadian provinces will participate in a multi-phase mixed methods study. In phase 1, baseline information will be collected through questionnaires and interviews with patients and healthcare providers (HCPs). In phase 2, HCPs and patients will be consulted to tailor the evidence-based interventions to site-specific needs and circumstances. In phase 3, sites will implement the tailored care model. Evaluation of the care model will include measures of patient and provider experience, a quality of life measure, qualitative interviews and economic evaluation.

Ethics and dissemination: This study has received ethics clearance from the host academic institutions: University of Calgary (REB17-0617), University of Waterloo (ORE#22446) and Université Laval (#MP-13-2019-1500 and 2017-2018-12-MP). Results will be disseminated through traditional means, including peer-reviewed publications and conferences and through an extensive network of knowledge user partners.

Trial registration number: NCT03442426;Pre-results.

Keywords: geriatric medicine; health services administration & management; primary care.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Timeline and overview.

References

    1. Statistics Canada . Canada’s population estimates: age and sex, 2015. Available: [Accessed 18 May 2020].
    1. Canadian Institute for Health Information . Has the share of health spending on seniors changed? Ottawa, on, 2018. Available: [Accessed 18 May 2020].
    1. Slade S, Shrichand A, DiMillo S. Health care for an aging population: a study of how physicians care for seniors in Canada. The Royal College of Physicians and Surgeons of Canada, 2019.
    1. Canadian Medical Association . The state of seniors healthcare in Canada. Ottawa: CMA, 2016.
    1. Andrew MK, Dupuis-Blanchard S, Maxwell C, et al. . Social and societal implications of frailty, including impact on Canadian healthcare systems. J Frailty Aging 2018;7:217–23. 10.14283/jfa.2018.30
    1. Clegg A, Young J, Iliffe S. Frailty in elderly people. The Lancet 2013;381:752–62.
    1. Nicholson C, Gordon AL, Tinker A. Changing the way “we” view and talk about frailty…. Age Ageing 2017;46:349–51. 10.1093/ageing/afw224
    1. Lorig KR, Sobel DS, Stewart AL, et al. . Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care 1999;37:5–14. 10.1097/00005650-199901000-00003
    1. Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within organization for economic cooperation and development (OECD) countries, 1970-1998. Health Serv Res 2003;38:831–65. 10.1111/1475-6773.00149
    1. McLeod J, McMurray J, Walker JD, et al. . Care transitions for older patients with musculoskeletal disorders: continuity from the providers' perspective. Int J Integr Care 2011;11:e014. 10.5334/ijic.555
    1. Registered Nurses’ Association of Ontario. . Primary solutions for primary care: maximizing and expanding the role of the primary care nurse in Ontario primary care nurse Task force report, 2012. Available:
    1. The Change Foundation . Who is the puzzle maker? Patient/caregiver perspectives on navigating health services in Ontario, 2008. Available:
    1. The Change Foundation . Loud and Clear: Seniors and caregivers speak out about navigating Ontario’s healthcare system. Toronto, ON, 2012. Available:
    1. Toscan J, Mairs K, Hinton S, et al. . Integrated transitional care: patient, informal caregiver and health care provider perspectives on care transitions for older persons with hip fracture. Int J Integr Care 2012;12:e13. 10.5334/ijic.797
    1. Canadian Institute for Health Information . How Canada compares: results from the Commonwealth Fund’s 2017 international health policy survey of seniors. Ottawa: CIHI, 2018.
    1. Ploeg J, Matthew-Maich N, Fraser K, et al. . Managing multiple chronic conditions in the community: a Canadian qualitative study of the experiences of older adults, family caregivers and healthcare providers. BMC Geriatr 2017;17:40. 10.1186/s12877-017-0431-6
    1. McMurray J, Stolee P, Hicks E, et al. . The role of documentation and inter-provider information exchange in care continuity for older hip fracture patients. Stud Health Technol Inform 2013;192:1197.
    1. Forster AJ, Auger C, ISTOP ADE Investigators . Using information technology to improve the monitoring of outpatient prescribing. JAMA Intern Med 2013;173:382–4. 10.1001/jamainternmed.2013.2002
    1. Moore C, Wisnivesky J, Williams S, et al. . Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med 2003;18:646–51. 10.1046/j.1525-1497.2003.20722.x
    1. Kripalani S, LeFevre F, Phillips CO, et al. . Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007;297:831–41. 10.1001/jama.297.8.831
    1. National Physician Survey (NPS) . Ottawa: the College of family physicians of Canada (CFPC), Canadian Medical Association (CMA), the Royal College of physicians and surgeons of Canada (RCPSC) 2011.
    1. McCarthy D, Ryan J, Klein S. Models of care for high-need, high-cost patients: an evidence synthesis. Commonwealth fund publications, 2015. Available:
    1. Lee L, Heckman G, Molnar FJ. Frailty: identifying elderly patients at high risk of poor outcomes. Can Fam Physician 2015;61:227–31.
    1. Lacas A, Rockwood K. Frailty in primary care: a review of its conceptualization and implications for practice. BMC Med 2012;10:4. 10.1186/1741-7015-10-4
    1. Lee L, Patel T, Hillier LM, et al. . Frailty screening and case-finding for complex chronic conditions in older adults in primary care. Geriatrics 2018;3:39. 10.3390/geriatrics3030039
    1. Chen CY, Gan P, How CH. Approach to frailty in the elderly in primary care and the community. Singapore Med J 2018;59:240–5. 10.11622/smedj.2018052
    1. Sutorius FL, Hoogendijk EO, Prins BAH, et al. . Comparison of 10 single and stepped methods to identify frail older persons in primary care: diagnostic and prognostic accuracy. BMC Fam Pract 2016;17:102. 10.1186/s12875-016-0487-y
    1. Ball T. Disruptive Innovation: Patient/Family-Focused Care [Internet]. Essays, 2010. Available:
    1. Institute of Medicine (US) Committee on Quality of Health Care in America . Crossing the quality chasm: a new health system for the 21st century. Washington: National Academy Press, 2001.
    1. World Health Organization . What are integrated people-centred health services? 2020. Available: [Accessed 16 May 2020].
    1. Barry MJ, Edgman-Levitan S. Shared decision making--pinnacle of patient-centered care. N Engl J Med 2012;366:780–1. 10.1056/NEJMp1109283
    1. Schillinger D, Handley M, Wang F, et al. . Effects of self-management support on structure, process, and outcomes among vulnerable patients with diabetes: a three-arm practical clinical trial. Diabetes Care 2009;32:559–66. 10.2337/dc08-0787
    1. Sims-Gould J, Byrne K, Hicks E, et al. . Examining "success" in post-hip fracture care transitions: a strengths-based approach. J Interprof Care 2012;26:205–11. 10.3109/13561820.2011.645090
    1. Cramm JM, Nieboer AP. The chronic care model: Congruency and predictors among patients with cardiovascular diseases and chronic obstructive pulmonary disease in the Netherlands. BMC Health Serv Res 2012;12:242. 10.1186/1472-6963-12-242
    1. Cramm JM, Nieboer AP. Development and validation of the older patient assessment of chronic illness care (O-PACIC) scale after hospitalization. Soc Indic Res 2014;116:959–69.
    1. Davis K, Schoenbaum SC, Audet AM. A 2020 vision of patient‐centered primary care. J Gen Inter Med 2005;20:953–7.
    1. Rosenthal TC. The medical home: growing evidence to support a new approach to primary care. J Am Board Fam Med 2008;21:427–40. 10.3122/jabfm.2008.05.070287
    1. Giguère AM, Labrecque M, Légaré F, et al. . Feasibility of a randomized controlled trial to evaluate the impact of decision boxes on shared decision-making processes. BMC Med Inform Decis Mak 2015;15:13. 10.1186/s12911-015-0134-x
    1. O'Loughlin J, Renaud L, Richard L, et al. . Correlates of the sustainability of community-based heart health promotion interventions. Prev Med 1998;27:702–12. 10.1006/pmed.1998.0348
    1. Sevin C, Moore G, Shepherd J. Transforming care teams to provide the best possible Patient‐Centered, collaborative care. J Ambul Care Manag 2009;32:24–31.
    1. Stolee P, Elliott J, McNeil H, et al. . Choosing healthcare options by involving Canada's elderly: a protocol for the choice realist synthesis project on engaging older persons in healthcare decision-making. BMJ Open 2015;5:e008190. 10.1136/bmjopen-2015-008190
    1. Ferguson T. e-patients: how they can help us heal healthcare, 2007. Available:
    1. Elliott J, McNeil H, Ashbourne J, et al. . Engaging older adults in health care decision-making: a realist synthesis. Patient 2016;9:383–93. 10.1007/s40271-016-0168-x
    1. Stille CJ, Jerant A, Bell D, et al. . Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice. Ann Intern Med 2005;142:700–9. 10.7326/0003-4819-142-8-200504190-00038
    1. Elliott J, Stolee P, Boscart V, et al. . Coordinating care for older adults in primary care settings: understanding the current context. BMC Fam Pract 2018;19:137. 10.1186/s12875-018-0821-7
    1. Bates DW. Health information technology and care coordination: the next big opportunity for informatics? Yearb Med Inform 2015;10:11–14. 10.15265/IY-2015-020
    1. Tai-Seale M, Downing NL, Jones VG, et al. . Technology-enabled consumer engagement: promising practices at four health care delivery organizations. Health Aff 2019;38:383–90. 10.1377/hlthaff.2018.05027
    1. Clark D, Dean G, Bolton S, et al. . Bench to bedside: the technology adoption pathway in healthcare. Health Technol 2020;10:537–45. 10.1007/s12553-019-00370-z
    1. Kim TK, Choi M. Older adults' willingness to share their personal and health information when adopting healthcare technology and services. Int J Med Inform 2019;126:86–94. 10.1016/j.ijmedinf.2019.03.010
    1. Bodenheimer T. Coordinating care--a perilous journey through the health care system. N Engl J Med 2008;358:1064–71. 10.1056/NEJMhpr0706165
    1. Sixsmith A. Technology and the Challenge of Aging. In: Sixsmith A, Gutman G, eds. Technologies for active aging. International perspectives on aging, 2013.
    1. Hirdes JP. Addressing the health needs of frail elderly people: Ontario's experience with an integrated health information system. Age Ageing 2006;35:329–31. 10.1093/ageing/afl036
    1. Bilodeau G, Witteman H, Légaré F, et al. . Reducing complexity of patient decision AIDS for community-based older adults with dementia and their caregivers: multiple case study of decision boxes. BMJ Open 2019;9:e027727. 10.1136/bmjopen-2018-027727
    1. Bogza L, Patry-Lebeau C, Farmanova E. Design of a web-based decision aid to support explicit values clarification and informed decision making of older adults with mild cognitive impairment and their healthcare providers. JMIR 2020.
    1. Harris AD, McGregor JC, Perencevich EN. The use and interpretation of quasi-experimental studies in medical informatics. J Amer Med Inform Assoc 20016;13:16–23.
    1. Jüni P, Altman DG. Egger M. assessing the quality of controlled clinical trials. BMJ 2001;323:42–6.
    1. Cook TD, Campbell DT. Quasi-experimentation: design and analysis issues for field settings Houghton Mifflin. Boston, MA, 1979.
    1. Bracht GH, Glass GV. The external validity of experiments. Am Educ Res J 1968:437–74.
    1. Sidani S, Braden CJ. Design, evaluation, and translation of nursing interventions. John Wiley & Sons, 2011.
    1. Damschroder LJ, Aron DC, Keith RE, et al. . Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009;4:50. 10.1186/1748-5908-4-50
    1. Glasgow RE, Whitesides H, Nelson CC, et al. . Use of the patient assessment of chronic illness care (PACIC) with diabetic patients: relationship to patient characteristics, receipt of care, and self-management. Diabetes Care 2005;28:2655–61. 10.2337/diacare.28.11.2655
    1. Schmittdiel J, Mosen DM, Glasgow RE, et al. . Patient assessment of chronic illness care (PACIC) and improved patient-centered outcomes for chronic conditions. J Gen Intern Med 2008;23:77–80. 10.1007/s11606-007-0452-5
    1. Herdman M, Gudex C, Lloyd A, et al. . Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res 2011;20:1727–36. 10.1007/s11136-011-9903-x
    1. Xie F, Pullenayegum E, Gaebel K. Canadian EQ-5D-5L valuation Study Group. A time Trade-off-derived value set of the EQ-5D-5L for Canada. Med Care 2016;54:98–105.
    1. van Reenen M, Janssen B. EQ-5D-5L user guide. basic information on how to use the EQ-5D-5L instrument. Rotterdam, the Netherlands: EuroQOL Research Foundation, 2015.
    1. Kiresuk TJ, Sherman RE. Goal attainment scaling: a general method for evaluating comprehensive community mental health programs. Community Ment Health J 1968;4:443–53. 10.1007/BF01530764
    1. Kiresuk TJ, Smith A, Cardillo JE. Goal attainment scaling: applications, theory, and measurement. Psychology Press, 2014.
    1. Stolee P, Rockwood K, Fox RA, et al. . The use of goal attainment scaling in a geriatric care setting. J Am Geriatr Soc 1992;40:574–8. 10.1111/j.1532-5415.1992.tb02105.x
    1. Canadian Institute for Health Information . Pan-Canadian primary health care survey questions and tools, 2013. Available:
    1. Hoch JS, Rockx MA, Krahn AD. Using the net benefit regression framework to construct cost-effectiveness acceptability curves: an example using data from a trial of external loop recorders versus Holter monitoring for ambulatory monitoring of "community acquired" syncope. BMC Health Serv Res 2006;6:68. 10.1186/1472-6963-6-68
    1. Sloan JA, Cella D, Hays RD. Clinical significance of patient-reported questionnaire data: another step toward consensus. J Clin Epidemiol 2005;58:1217–9. 10.1016/j.jclinepi.2005.07.009
    1. Guest G, MacQueen KM. Handbook for team-based qualitative research. Rowman Altamira, 2008.
    1. Lofland J. Analyzing social settings: a guide to qualitative observation and analysis. 4th edn. Belmont, CA: Wadsworth Publishing, 2006.
    1. Morse JM. Critical analysis of strategies for determining rigor in qualitative inquiry. Qual Health Res 2015;25:1212–22. 10.1177/1049732315588501
    1. Creswell JW. Qualitative inquiry and research design: choosing among five approaches. Sage, 2013.
    1. Ritchie J, Lewis J. Qualitative research practice: a guide for social science students and researchers. Sage, 2003.
    1. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007;19:349–57. 10.1093/intqhc/mzm042
    1. Government of Canada . Unleashing innovation: Excellent healthcare for Canada - executive summary, 2015. Available:

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren