Developing an Integrated System of Care for Frail Seniors

Heckman, George A.; Hillier, Loretta M.; Manderson, Brooke; McKinnon-Wilson, Jane; Santi, Selena M.; Stolee, Paul

doi:10.1016/j.hcmf.2013.09.003

Cited by 25 publications

(41 citation statements)

References 26 publications

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“…Complicated specialist access and referrals was a theme common to all participants, but rural patients and caregivers focused on the difficulty of mid-day out-of-town appointments, while urban participants spoke more about lengthy referral wait times. Overall, these findings are consistent with current literature that has identified both poor system integration [ 14 , 17 , 19 , 30 - 32 ] and access, particularly access to specialists, as barriers to health care in Canada [ 30 , 31 , 33 - 36 ]. We note, however, that the Health Council of Canada [ 32 ] found that access to primary care was actually higher for persons with chronic illness when compared to members of the general population, perhaps indicating that health care providers are prioritizing these patients with higher needs.…”

Section: Discussionsupporting

confidence: 90%

“…Community-based primary health care (CBPHC) is intended to provide first-contact health services to ensure continuity of care, ease of movement across the system, and improved system integration [ 3 ]. However, Canada’s health care system is characterized by fragmentation of services [ 4 , 14 ], with deficits in transitional care and coordination [ 15 - 20 ], and limited efforts to engage or support patients to manage their conditions [ 21 ]. Fragmentation of the health care system is particularly challenging for older adults [ 14 ].…”

Section: Introductionmentioning

confidence: 99%

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Community-based primary health care for older adults: a qualitative study of the perceptions of clients, caregivers and health care providers

et al. 2015

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BackgroundOlder persons are often poorly served by existing models of community-based primary health care (CBPHC). We sought input from clients, informal caregivers, and health care providers on recommendations for system improvements.MethodsFocus group interviews were held with clients, informal caregivers, and health care providers in mid-sized urban and rural communities in Ontario. Data were analyzed using a combination of directed and emergent coding. Results were shared with participants during a series of feedback sessions.ResultsAn extensive list of barriers, facilitators, and recommended health system improvements was generated. Barriers included poor system integration and limited access to services. Identified facilitators were person and family-focused care, self-management resources, and successful collaborative practice. Recommended system improvements included expanding and integrating care teams, supports for system navigation, and development of standardized information systems and care pathways.ConclusionsOlder adults still experience frustrating obstacles when trying to access CBPHC. Identified barriers and facilitators of improved system integration aligned well with current literature and Wagner’s Chronic Care Model. Additional work is needed to implement the recommended improvements and to discern their impact on patient and system outcomes.Electronic supplementary materialThe online version of this article (doi:10.1186/s12877-015-0052-x) contains supplementary material, which is available to authorized users.

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Section: Discussionsupporting

confidence: 90%

Section: Introductionmentioning

confidence: 99%

Community-based primary health care for older adults: a qualitative study of the perceptions of clients, caregivers and health care providers

et al. 2015

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“…(50) Understanding and overcoming system barriers to dementia care integration is an urgent priority. An approach whereby clear roles are negotiated among dementia stakeholders can provide sufficient flexibility to meet regional needs (especially in rural areas where access to specialists is more limited), foster more effective collaboration and accountability, and thus facilitate the delivery and measurement of care quality for dementia.…”

Section: Discussionmentioning

confidence: 99%

Quality of Dementia Care in the Community: Identifying Key Quality Assurance Components

et al. 2016

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BackgroundPrimary care-based memory clinics (PCMCs) have been established in several jurisdictions to improve the care for persons with Alzheimer’s disease and related dementias. We sought to identify key quality indicators (QIs), quality improvement mechanisms, and potential barriers and facilitators to the establishment of a quality assurance framework for PCMCs.MethodsWe employed a Delphi approach to obtain consensus from PCMC clinicians and specialist physicians on QIs and quality improvement mechanisms. Thirty-eight candidate QIs and 19 potential quality improvement mechanisms were presented to participants in two rounds of electronic Delphi surveys. Written comments were collected and descriptively analyzed.ResultsThe response rate for the first and second rounds were 21.3% (n = 179) and 12.8% (n = 88), respectively. The majority of respondents were physicians. Fourteen QIs remained after the consensus process. Ten quality improvement mechanisms were selected with those characterized by specialist integration, such as case discussions and mentorships, being ranked highly. Written comments revealed three major themes related to potential barriers and facilitators to quality assurance: 1) perceived importance, 2) collaboration and role clarity, and 3) implementation process.ConclusionWe successfully utilized a consultative process among primary and specialty providers to identify core QIs and quality improvement mechanisms for PCMCs. Identified quality improvement mechanisms highlight desire for multi-modal education. System integration and closer integration between PCMCs and specialists were emphasized as essential for the provision of high-quality dementia care in community settings.

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“…However, poorly executed transitions, inconsistencies in assessments among practitioners, and interventions that are often poorly tailored to meet the person's needs and expressed goals, available resources and health care settings may result in frail older adults being put at risk of adverse outcomes. 1 Indeed, poor transitions can lead to deleterious consequences such as medical errors and loss of critical health information, premature transfers from home care to nursing homes, unnecessary transfers to hospital emergency departments and inadequate end-of-life care planning.…”

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confidence: 99%

Regional variations of care in home care and long-term care: a retrospective cohort study

Hébert

Morinville

Costa

et al. 2019

cmajo

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Developing an Integrated System of Care for Frail Seniors

Abstract: A consultation process was undertaken with healthcare providers in the Waterloo Wellington region of southern Ontario to assess current system strengths, challenges and gaps in providing care to frail seniors. The findings were used to implement strategies for improving system integration.

Cited by 25 publications

References 26 publications

Community-based primary health care for older adults: a qualitative study of the perceptions of clients, caregivers and health care providers

Community-based primary health care for older adults: a qualitative study of the perceptions of clients, caregivers and health care providers

Quality of Dementia Care in the Community: Identifying Key Quality Assurance Components

Regional variations of care in home care and long-term care: a retrospective cohort study

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