From perpetual pilots to sustainable transformation: Scaling up geriatric care.

With an ageing population, there is an increasing need to focus on the care of older adults, particularly those who are more medically complex. Frail older adults are more likely to require care from multiple providers across multiple settings. It is well recognized that the current Canadian healthcare system is not well-designed for this complex population.

The Integrated Care Team: A primary care based-approach to support older adults with complex health needs.

Many older adults have complex needs and experience high rates of acute care use and institutionalization. Comprehensive Geriatric Assessment (CGA) is a specialized multidimensional interprofessional intervention to prevent such outcomes, but access to CGA in the community is limited. The Integrated Care Team (ICT) is a proactive case-finding intervention to support older adults with complex needs in primary care.

Integrated care for adults with chronic musculoskeletal disorders: a scoping review protocol.

Objective: The objective of this scoping review is to describe the current evidence exploring integrated care for people with chronic musculoskeletal disorders.

Introduction: The integrated model of care is an emerging approach to delivering person-centered care. Integrated care supports the management of people with major chronic health conditions; however, the evidence behind its use to support people with chronic musculoskeletal disorders is scant.

Codesigned standardised referral form: simplifying the complexity.

Background: Referring providers are often critiqued for writing poor-quality referrals. This study characterised clinical referral guidelines and forms to understand which data consultant providers require. These data were then used to codesign an evidence-based, high-quality referral form.

From Compliance to Care: Qualitative Findings from a Survey of Essential Caregivers in Ontario Long-Term Care Homes.

Background: The COVID-19 pandemic highlighted the importance of the care provided by family members and close friends to older people living in long-term care (LTC) homes. Our implementation science team helped three Ontario LTC homes to implement an intervention to allow family members to enter the homes during pandemic lockdowns.

Objective: We used a variety of methods to support the implementation, and this paper reports results from an Ontario-wide survey intended to help us understand the nature of the care provided by family caregivers.

Virtual care during COVID-19: The perspectives of older adults and their healthcare providers in a cardiac rehabilitation setting.

The present study aimed to explore the perspectives of older adults and health providers on cardiac rehabilitation care provided virtually during COVID-19. A qualitative exploratory methodology was used. Semi-structured interviews were conducted with 15 older adults and 6 healthcare providers.

Transitional Care from Hospital to Cardiac Rehabilitation During COVID-19: The Perspectives of Older Adults and Their Healthcare Providers.

Transitional care to cardiac rehabilitation during the pandemic was a complex process for older adults, with additional challenges for decision-making and participation. This study aimed to explore the perspectives of older adults and health providers on transitional care from the hospital to cardiac rehabilitation, focusing on patient participation in decision-making. A qualitative exploratory design was used.

Policy and practices in primary care that supported the provision and receipt of care for older persons during the COVID-19 pandemic: a qualitative case study in three Canadian provinces.

Background: The effects of the COVID-19 pandemic on older adults were felt throughout the health care system, from intensive care units through to long-term care homes. Although much attention has been paid to hospitals and long-term care homes throughout the pandemic, less attention has been paid to the impact on primary care clinics, which had to rapidly change their approach to deliver timely and effective care to older adult patients. This study examines how primary care clinics, in three Canadian provinces, cared for their older adult patients during the pandemic, while also navigating the rapidly changing health policy landscape.

Feasibility of Goal Attainment Scaling as a patient-reported outcome measure for older patients in primary care.

Background: Goal Attainment Scaling (GAS) is an outcome measure that reflects the perspectives and experiences of patients, consistent with patient-centred care approaches and with the aims of patient-reported outcome measures (PROMs). GAS has been used in a variety of clinical settings, including in geriatric care, but research on its feasibility in primary care practice has been limited. The time required to complete GAS is a barrier to its use by busy primary care clinicians.

Developing an in-depth understanding of patient and caregiver engagement across care transitions from hospital: protocol for a qualitative study exploring experiences in Canada.

Introduction: Patient and caregiver engagement is critical, and often compromised, at points of transition between care settings, which are more common, and more challenging, for patients with complex medical problems. The consequences of poor care transitions are well-documented, both for patients and caregivers, and for the healthcare system. With an ageing population, there is greater need to focus on care transition experiences of older adults, who are often more medically complex, and more likely to require care from multiple providers across settings.

Development, successes, and potential pitfalls of multidisciplinary chronic disease management clinics in a family health team: a qualitative study.

Background: The creation of Family Health Teams in Ontario was intended to reconfigure primary care services to better meet the needs of an aging population, an increasing proportion of which is affected by frailty and multimorbidity. However, evaluations of family health teams have yielded mixed results.

Methods: We conducted interviews with 22 health professionals affiliated or working with a well-established family health team in Southwest Ontario to understand how it approached the development of interprofessional chronic disease management programs, including successes and areas for improvement.

Designing systems for the care we need: A transformation journey in Southwestern Ontario.

Primary care is considered the foundation of any health system. In Ontario, Canada Bills 41 and 74 introduced in 2016 and 2019, respectively, aimed to move towards a primary care-focused and sustainable integrated care approach designed around the needs of local populations. These bills collectively set the stage for integrated care and population health management in Ontario, with Ontario Health Teams (OHTs) introduced as a model of integrated care delivery systems.

Potential Factors Influencing Adoption of a Primary Care Pathway to Prevent Functional Decline in Older Adults.

Introduction: To help recognize and care for community-dwelling older adults living with frailty, we plan to implement a primary care pathway consisting of frailty screening, shared decision-making to select a preventive intervention, and facilitated referral to community-based services. In this study, we examined the potential factors influencing adoption of this pathway.

Methods: In this qualitative, descriptive study, we conducted semi-structured interviews and focus groups with patients aged 70 years and older, health professionals (HPs), and managers from four primary care practices in the province of Quebec, representatives of community-based services and geriatric clinics located near the practices.

A Community of Practice on Environmental Design for Long-Term Care Residents with Dementia.

The use of communities of practice (CoP) to support the application of knowledge in improved geriatric care practice is not widely understood. This case study's aim was to gain a deeper understanding of the knowledge-to-action (KTA) processes of a CoP focused on environmental design, to improve how persons with dementia find their way around in long-term care (LTC) homes. Qualitative data were collected (key informant interviews, observations, and document review), and analysed using emergent coding.

Responding to COVID-19 with integrative health and sheltering models for persons experiencing homelessness in Southern Ontario, Canada: protocol for a qualitative study exploring implementation and sustainability.

Introduction: COVID-19 has disproportionately impacted persons experiencing homelessness in Canada, who are at an increased risk of infection and severe outcomes. In response to the pandemic, several regions have adopted programmes that aim to address the intersecting nature of health and social challenges faced by persons facing homelessness. These programmes adopted during the pandemic may contribute to broader health and social impacts beyond limiting COVID-19 transmission, but the processes involved in developing and implementing these types of programmes and their sustainability after the pandemic are unknown.

"I Hope That the People Caring for Me Know About Me": Exploring Person-Centred Care and the Quality of Dementia Care.

Background: Person-centred care is at the core of high-quality dementia care but people living with dementia are often excluded from quality improvement efforts. We sought to explore person-centred care and quality of care from the perspectives of persons living with dementia in the community and their care partners.

Methods: We used a qualitative descriptive approach with in-person, semi-structured interviews with 17 participants (9 persons living with dementia and 8 care partners) from Ontario, Canada.

Lessons and Reflections From an Extended Co-design Process Developing an mHealth App With and for Older Adults: Multiphase, Mixed Methods Study.

Background: There are many mobile health (mHealth) apps for older adult patients, but research has found that broadly speaking, mHealth still fails to meet the specific needs of older adult users. Others have highlighted the need to embed users in the mHealth design process in a fulsome and meaningful way. Co-design has been widely used in the development of mHealth apps and involves stakeholders in each phase of the design and development process.

Understanding racialised older adults' experiences of the Canadian healthcare system, and codesigning solutions: protocol for a qualitative study in nine languages.

Introduction: Racialised immigrant older adults (RIOAs) in Canada have poorer self-rated health and are more likely to report chronic conditions, while they concurrently experience well-documented challenges in navigating and accessing the healthcare system. There is strong evidence that patient and caregiver engagement in their healthcare leads to improved management of chronic disease and better health outcomes. International research suggests that engagement has the potential to reduce health disparities and improve quality of care.

Developing a Regional Strategy for Older Adults Living With Frailty: Recommendations From Patients, Family Caregivers and Health Care Providers.

Introduction: Health care organizations are increasingly recognizing the need to integrate the health care system to better care for older adults. We partnered with a local health centre to inform the development of a for Southwestern Ontario, Canada.

Methodology: Interviews were conducted with 12 older adults (65+, with chronic conditions) and family caregivers.

Co-Designing Together through Crisis: Development of a Virtual Care Guidance Document to Support Providers, Older Adults, and Caregivers.

COVID-19 has had a disproportionate and devastating impact on older adults. As health care resources suddenly shifted to emergency response planning, many health and community support services were cancelled, postponed, or shifted to virtual care. This rapid transformation of geriatric care resulted in an immediate need for practical guidance on decision making, planning and delivery of virtual care for older adults and caregivers.

Guidance to (Re)integrate Caregivers as Essential Care Partners Into the LTC Setting: A Rapid Review.

Objectives: This rapid review aimed to identify the strategies used to (re)integrate essential caregivers (ECs) into the LTC setting, particularly pertaining to principles of equity, diversity, and inclusion. In addition, this rapid review aimed to identify the strategies used during prior infectious disease threats, when similar blanket visitor restrictions were implemented in LTC homes. The review was part of a larger effort to support LTC homes in Ontario.

A SHARP Response: Developing COVID-19 Research Aims in Partnership with the Seniors Helping as Research Partners (SHARP) Group.

COVID-19 has disproportionally impacted older adults, and has highlighted many issues, including extreme deficiencies in Canadian long-term care homes and gaps in home and community care services for older adults. In recent years, there has been a push towards better patient and family engagement in health system research, and with the onset of the pandemic, engaging older adults in research and policy planning is more important than ever. In this article, we describe the Seniors Helping as Research Partners (SHARP) approach to engagement with older adults as an example of how partnerships that engage older adults in the development of research aims and processes can help to ensure that future research meets the needs of older adults.

A national intervention to support frail older adults in primary care: a protocol for an adapted implementation framework.

Background: Older Canadians are high users of health care services, however the health care system is not well-designed to meet the complex needs of many older adults. Older persons often look to their primary care practitioners to assess their needs and coordinate their care. The intervention seeks to improve primary care for older persons living with frailty and will be implemented in six primary care clinics in three Canadian provinces.

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

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.

Transitional Care Experiences of Patients with Hip Fracture Across Different Health Care Settings.

Background: Transitions of care often result in fragmented care, leading to unmet patient needs and poor satisfaction with care, especially in patients with multiple chronic conditions. This project aimed to understand how experiences of patients with hip fracture, caregivers, and healthcare providers differ across different points of transition.

Methods: A secondary analysis of 103 qualitative, semi-structured interviews was conducted using emergent coding techniques, to gain an understanding of how transitional care experiences may differ across varying settings of care.