Effect of an innovative model of complexity care on family caregiver experience: Qualitative study in family practice.

OBJECTIVE: To investigate the experiences of family caregivers who participated in an innovative model of interprofessional team-based care specifically designed for elderly patients with complex care needs. DESIGN: Qualitative study. SETTING: Large academic family practice in Toronto, Ont. PARTICIPANTS: Family caregivers of elderly patients who had attended the IMPACT (Interprofessional Model of Practice for Aging and Complex Treatments) clinic (N = 13). METHODS: Individual semistructured interviews, which were conducted face-to-face, audiorecorded, transcribed verbatim, and analyzed using the constant comparative method. MAIN FINDINGS: Family caregivers who attended the IMPACT clinic believed it enhanced caregiver experience and capacity. Caregivers experienced increased validation and engagement with the treatment team. Feelings of isolation were reduced, resulting in increased confidence and greater feelings of empowerment in their caregiver role. CONCLUSION: While the needs and value of caregivers are increasingly acknowledged, health care teams continue to struggle with how to relate to and engage with family caregivers-how best to support them and work with them in the context of their family members' care. Interprofessional teams who adopt the IMPACT model-providing synchronous, real-time interventions that include the caregiver-can facilitate increased caregiver capacity, confidence, and empowerment.

Experience of Care as a Critical Component of Health System Performance Measurement: Recommendations for Moving Forward.

People's experiences can provide critical guidance on how to better meet their quality of life and care needs and deploy resources more appropriately. To maximize the utility of experience data and to advance the current debate, we present four recommendations: (1) measuring experiences outside the healthcare system can provide insight into what needs to change within the healthcare system; (2) focusing on patient experience is necessary but insufficient, (family) caregiver insights and experiences require attention and can provide insight into the needs of the patient; (3) moving from "one time/single sector" measurement of experience to iterative, ongoing measurement across sectors better reflects the true lived experience of patients (especially those with complex care needs) and their caregivers; and (4) embedding measurement within engagement-capable environments that adequately resource patients, caregivers, and providers to work together is required to move from collection to meaningful change. Applying these recommendations requires a longer-term vision, shifting from provider-centred to person-centred models of care, and a deep understanding of the structural, cultural, and normative barriers to measuring care experiences.

From Volumes to Valued Experiences: Measurement and the Challenge before Us.

We are grateful for the thoughtful discussion and ideas put forth in this issue on the measurement of healthcare experiences. Our colleagues, who span multiple jurisdictions across Canada and internationally, agree that we need to do a better job at engaging patients and families in their care and measuring their experiences across health services and sectors. In this response paper, we reflect on three core content areas that were identified across the eight papers in this issue: the role of context and engagement-capable environments; approaches to improve the measurement of experience and acting on results; and challenges that must be attended to in our quest to make our healthcare systems work better.

Perceived risk factors of health decline: a qualitative study of hospitalized patients with multimorbidity.

BACKGROUND: Effectively preventing and managing chronic illness are key goals for health systems worldwide. A growing number of people are living longer with multiple chronic illnesses, accompanied by a high degree of treatment burden and heavy use of health care resources. People with multimorbidity typically have to manage their care needs for a number of years, and from this experience may offer valuable perspectives on factors that influenced their health outcome. PURPOSE: The purpose of this study was to explore factors that may serve as tipping points into poor health from the perspective of hospitalized patients with multimorbidity. PARTICIPANTS AND METHODS: Patient interview data were analyzed from 43 hospitalized patients with multimorbidities who indicated that something could have been done to either avoid or slow down their health decline. The study used qualitative description as the analytic method to generate themes from a specific question collected through one-on-one interviews. Two reviewers independently analyzed and thematically coded the data and reached consensus on the final themes after a series of meetings. RESULTS: According to patient accounts, factors at the personal level (eg, personal behaviors), provider level (eg, late diagnoses), and health care system level (eg, poor care transitions) contributed to their health decline. CONCLUSION: This paper focuses on prevention in the context of multimorbidity. While some respondents indicated personal behaviors that impacted health, many pointed to factors outside themselves (providers and the broader health system). The orientation of health care systems, historically designed to support acute and episodic care and not multimorbidity, places patients, at least in some cases, at additional risk of decline. The patient accounts suggest that the notion of prevention should evolve throughout the course of illness. A successful health system would embrace this notion and see the goal as forestalling not only mortality (as achieved for the most part in high socioeconomic nations) but morbidity as well. High rates of multimorbidity and health system challenges suggest that we have not yet achieved this latter aim.

Medical characteristics of the oldest old: retrospective chart review of patients aged 85+ in an academic primary care centre.

BACKGROUND: The population aged 85 + - the "oldest old" - is now the fastest growing age segment in Canada. Although existing research demonstrates high health services utilization and medication burden in this population, little clinically derived evidence is available to guide care. This is a descriptive study in a primary care context seeking to describe the most common health conditions and medications used in the "oldest old". METHODS: We conducted a retrospective chart review of all family practice patients aged 85+ (N = 564; 209 males, 355 females) at Sunnybrook Health Sciences Centre in Toronto, Canada. Electronic medical records were reviewed for all current chronic conditions and medication prescriptions, and then stratified by sex and age subgroup (85-89, 90-94, 95+) for descriptive analysis. RESULTS: On average, patients experienced 6.4 concurrent chronic conditions and took 6.8 medications. Most conditions were related to cardiovascular (79%) and bone health (65%). Hypertension (65%) was the most common condition. Bone-related conditions (e.g. osteoarthritis, osteoporosis) and hypothyroidism predominantly affected women, while coronary artery disease and type 2 diabetes were more prevalent in men. The top two prescribed medications were atorvastatin (33%) and aspirin 81 mg (33%). Males were more likely to be prescribed lipid-lowering medications, while females were more likely to receive osteoporosis therapy. Patients received less lipid-lowering therapy with increasing age. CONCLUSIONS: Multimorbidity and polypharmacy are highly prevalent in patients in the 85+ age group. The most common clinical conditions are related to cardiovascular and bone health, and the most commonly prescribed medications are directed towards risk factors for these illnesses. In the absence of data to guide clinical decision-making, this study provides a first look at the common health concerns and medication profiles in this population and reveals trends that give rise to reflections on how clinical care for these patients can be improved.

Canadian national surveys on pandemic influenza preparations: pre-pandemic and peri-pandemic findings.

BACKGROUND: Prior to the 2009 H1N1 Influenza pandemic, public health authorities in Canada and elsewhere prepared for the future outbreak, partly guided by an ethical framework developed within the Canadian Program of Research on Ethics in a Pandemic (CanPREP). We developed a telephone-based survey based on that framework, which was delivered across Canada in late 2008. In June, 2009, the WHO declared pandemic Phase 6 status and from the subsequent October (2009) until May 2010, the CanPREP team fielded a second (revised) survey, collecting another 1,000 opinions from Canadians during a period of pre-pandemic anticipation and peri-pandemic experience. METHODS: Surveys were administered by telephone with random sampling achieved via random digit dialing. Eligible participants were adults, 18 years or older, with per province stratification approximating provincial percentages of national population. Descriptive results were tabulated and logistic regression analyses used to assess whether demographic factors were significantly associated with outcomes, and to identify divergences (between the pre-pandemic and intra-pandemic surveys). RESULTS: N = 1,029 interviews were completed from 1,986 households, yielding a gross response rate of 52% (AAPOR Standard Definition 3). Over 90% of subjects indicated the most important goal of pandemic influenza preparations was saving lives, with 41% indicating that saving lives solely in Canada was the highest priority and 50% indicating saving lives globally was the highest priority. About 90% of respondents supported the obligation of health care workers to report to work and face influenza pandemic risks excepting those with serious health conditions which that increased risks. Strong majorities favoured stocking adequate protective antiviral dosages for all Canadians (92%) and, if effective, influenza vaccinations (95%). Over 70% agreed Canada should provide international assistance to poorer countries for pandemic preparation, even if resources for Canadians were reduced. CONCLUSIONS: Results suggest Canadians trust public health officials to make difficult decisions, providing emphasis is maintained on reciprocity and respect for individual rights. Canadians also support international obligations to help poorer countries and associated efforts to save lives outside the country, even if intra-national efforts are reduced.

The IMPACT clinic: innovative model of interprofessional primary care for elderly patients with complex health care needs.

PROBLEM ADDRESSED: The growing number of elderly patients with multiple chronic conditions presents an urgent challenge in primary care. Current practice models are not well suited to addressing the complex health care needs of this patient population. OBJECTIVE OF PROGRAM: The primary objective of the IMPACT (Interprofessional Model of Practice for Aging and Complex Treatments) clinic was to design and evaluate a new interprofessional model of care for community-dwelling seniors with complex health care needs. A secondary objective was to explore the potential of this new model as an interprofessional training opportunity. PROGRAM DESCRIPTION: The IMPACT clinic is an innovative new model of interprofessional primary care for elderly patients with complex health care needs. The comprehensive team comprises family physicians, a community nurse, a pharmacist, a physiotherapist, an occupational therapist, a dietitian, and a community social worker. The model is designed to accommodate trainees from each discipline. Patient appointments are 1.5 to 2 hours in length, during which time a diverse range of medical, functional, and psychosocial issues are investigated by the full interprofessional team. CONCLUSION: The IMPACT model is congruent with ongoing policy initiatives in primary care reform and enhanced community-based care for seniors. The clinic has been pilot-tested in 1 family practice unit and modeled at 3 other sites with positive feedback from patients and families, clinicians, and trainees. Evaluation data indicate that interprofessional primary care models hold great promise for the growing challenge of managing complex chronic disease.

Still dizzy after all these years: a 90-year-old woman with a 54-year history of dizziness.

This report presents the case of a 90-year-old female with a 54-year history of dizziness, which has been exhaustively investigated. Over the years, the patient made 59 visits to her family doctor and 18 visits to various specialists, as well as emergency department visits and hospitalisations. In detailing the exhaustive investigations and referrals that the patient has undergone over many years (with inconclusive results), this case illustrates the myriad challenges in diagnosing and treating chronic dizziness in the older. The authors suggest that, in complex cases characterised by multimorbidity and polypharmacy, a function-oriented approach is indicated. In place of the conventional 'diagnose and treat' model, a functional approach to ongoing care emphasises the symptom management, improvement of function and quality of life. To optimise patient outcomes, an interprofessional team approach is preferred.

The assessment and treatment of a complex geriatric patient by an interprofessional primary care team.

Mr K is an 89-year-old married man with a number of comorbid conditions and multiple recent falls. He was referred to the IMPACT clinic (Interprofessional Model of Practice for Aging and Complex Treatments) as his primary care physician was concerned about his declining health and the growing care giver burden on his wife. Mr K's condition was deteriorating while the complexity of his case was increasing; therefore, an in-depth team assessment was sought to determine the best management plan and to assess his capacity to remain at home (his expressed preference). The IMPACT team met with Mr K and his wife for a 2 h interprofessional assessment. A comprehensive care plan was developed including specific recommendations for implementing change. After the visit to the IMPACT clinic, Mr K's care was returned to his regular family physician.

Measuring change in health status of older adults at the population level: the transition probability model.

BACKGROUND: The current demographic transition will lead to increasing demands on health services. However, debate exists as to the role age plays relative to co-morbidity in terms of health services utilization. While age has been identified as a critical factor in health services utilization, health services utilization is not simply an outcome of ill health, nor is it an inevitable outcome of aging. Most data on health service utilization studies assess utilization at one point in time, and does not examine transitions in health service utilization. We sought to measure health services utilization and to investigate patterns in the transition of levels of utilization and outcomes associated with different levels of utilization. METHODS: We conducted a population-based retrospective cohort study of all Ontario residents aged 65+ eligible for public healthcare coverage from January 1998-December 2006. The main outcome measure was total number of utilization events. The total is computed by summing, on a per annum basis, the number of family physician visits, specialist visits, Emergency Department visits, drug claims, lab claims, X-rays, CT scans, MRI scans, and inpatient admissions. Three categories of utilization were created: low, moderate, and high. RESULTS: There is heterogeneity in health services utilization across the late lifespan. Utilization increased consistently in the 9-year study period. The probability of remaining at the high utilization category when the person was in the high category the previous year was more than 0.70 for both males and females and for all age groups. Overall healthcare utilization increases more rapidly among the high users compared to the low users. There was negligible probability for moving from high to low utilization category. Probability of death increased exponentially as age increased. Older adults in the low utilization category had the lowest probability of death. The number of male nonagenarians increased more rapidly than female nonagenarians. CONCLUSION: There are measurable and identifiable differences in the patterns of health services utilization among older adults. This data will permit clinicians and policy makers to tailor interventions appropriate to the risk class of patients.

From pharmaco-therapy to pharmaco-prevention: trends in prescribing to older adults in Ontario, Canada, 1997-2006.

BACKGROUND: The developed world is undergoing a demographic transition with greater numbers of older adults and higher rates of chronic disease. Most elder care is now provided by primary care physicians, who prescribe the majority of medications taken by these patients. Despite these significant trends, little is known about population-level prescribing patterns to primary care patients aged 65+. METHODS: We conducted a population-based retrospective cohort study to examine 10-year prescribing trends among family physicians providing care to patients aged 65+ in Ontario, Canada. RESULTS: Both crude number of prescription claims and prescription rates (i.e., claims per person) increased dramatically over the 10-year study period. The greatest change was in prescribing patterns for females aged 85+. Dramatic increases were observed in the prescribing of preventive medications, such as those to prevent osteoporosis (+2,347%) and lipid-lowering agents (+697%). And lastly, the number of unique classes of medications prescribed to older persons has increased, with the proportion of older patients prescribed more than 10 classes of medications almost tripling during the study period. CONCLUSIONS: Prescribing to older adults by family physicians increased substantially during the study period. This raises important concerns regarding quality of care, patient safety, and cost sustainability. It is evident that further research is urgently needed on the health outcomes (both beneficial and harmful) associated with these dramatic increases in prescribing rates.

A population-based cohort study of ambulatory care service utilization among older adults.

RATIONALE, AIMS AND OBJECTIVES: Age-related effects on ambulatory care service utilization are not well understood. We aim to measure the utilization patterns of ambulatory health care services (i.e. family physician visits, specialist physician visits and emergency room visits) in the late life course (65 years and older). METHODS: A population-based retrospective cohort study was conducted for the period 1 April 2005 to 31 March 2006. All Ontario, Canada, residents aged 65+ and eligible for government health insurance were included in the analysis. RESULTS: This population-based cohort study demonstrates considerable increase in utilization rates and variability of ambulatory services as age increases. Variations in utilization were observed by gender as overall women were more likely to consult a family physician, and men more likely to visit specialists and the emergency room. A small group of high users, constituting 5.5% of the total population, accounted for 18.7% of total ambulatory visits. Finally, we report socio-economic status (SES) based disparity for specialist services in which high users were more likely to have higher SES. CONCLUSIONS: There is increasing utilization and variability in ambulatory service utilization with increase in age. Further research is required to explain the gender and SES differences reported in this study.

Primary care physicians' attitudes towards cognitive screening: findings from a national postal survey.

OBJECTIVE: The objectives of this paper are: (a) to determine Canadian family physicians' attitudes towards cognitive screening, (b) to identify what cognitive screening tools are being used, (c) to investigate how they rate these tools' effectiveness and (d) to identify the attributes of an ideal cognitive screening tool for the primary care setting. METHOD: Postal survey questionnaire of a random sample of 249 practicing members of the College of Family Physicians of Canada. RESULTS: Response rate was 52%. The majority of physicians 'Agreed' or 'Strongly Agreed' that cognitive impairment assessment is important in primary care (89%), and 'Disagreed' or 'Strongly Disagreed' that it should be left to specialists (92%). However, 35% were undecided when asked if assessment in primary care would lead to better outcomes. The most frequently used assessment tools were Mini-Mental Status Exam (MMSE), Clock Drawing, Delayed Word Recall, Standardized MMSE and Alternating Sequences, but were mainly rated as only 'Good' in terms of perceived effectiveness. Validity/accuracy was identified as the top attribute of an ideal screening tool. Female physicians were more likely to have a positive attitude towards cognitive assessment. Younger physicians, those in group practices, or those with either

Public perceptions of quarantine: community-based telephone survey following an infectious disease outbreak.

BACKGROUND: The use of restrictive measures such as quarantine draws into sharp relief the dynamic interplay between the individual rights of the citizen on the one hand and the collective rights of the community on the other. Concerns regarding infectious disease outbreaks (SARS, pandemic influenza) have intensified the need to understand public perceptions of quarantine and other social distancing measures. METHODS: We conducted a telephone survey of the general population in the Greater Toronto Area in Ontario, Canada. Computer-assisted telephone interviewing (CATI) technology was used. A final sample of 500 individuals was achieved through standard random-digit dialing. RESULTS: Our data indicate strong public support for the use of quarantine when required and for serious legal sanctions against those who fail to comply. This support is contingent both on the implementation of legal safeguards to protect against inappropriate use and on the provision of psychosocial supports for those affected. CONCLUSION: To engender strong public support for quarantine and other restrictive measures, government officials and public health policy-makers would do well to implement a comprehensive system of supports and safeguards, to educate and inform frontline public health workers, and to engage the public at large in an open dialogue on the ethical use of restrictive measures during infectious disease outbreaks.

Trends in health services utilization, medication use, and health conditions among older adults: a 2-year retrospective chart review in a primary care practice.

BACKGROUND: Population aging poses significant challenges to primary care providers and healthcare policy makers. Primary care reform can alleviate the pressures, but these initiatives require clinical benchmarks and evidence regarding utilization patterns. The objectives of this study is to measure older patients' use of health services, number of health conditions, and use of medications at the level of a primary care practice, and to investigate age- and gender-related utilization trends. METHODS: A cross-sectional chart audit over a 2-year study period was conducted in the academic family practice clinic of Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada. All patients 65 years and older (n = 2450) were included. Main outcome measures included the number of family physician visits, specialist visits, emergency room visits, surgical admissions, diagnostic test days, inpatient hospital admissions, health conditions, and medications. RESULTS: Older patients (80-84 and 85+ age-group) had significantly more family physician visits (average of 4.4 visits per person per year), emergency room visits (average of 0.22 ER visits per year per patient), diagnostic days (average of 5.1 test days per person per year), health conditions (average of 7.7 per patient), and medications average of 8.2 medications per person). Gender differences were also observed: females had significantly more family physician visits and number of medications, while men had more specialist visits, emergency room visits, and surgical admissions. There were no gender differences for inpatient hospital admissions and number of health conditions. With the exception of the 85+ age group, we found greater intra-group variability with advancing age. CONCLUSION: The data present a map of greater interaction with and dependency on the health care system with advancing age. The magnitudes are substantial and indicate high demands on patients and families, on professional health care providers, and on the health care system itself. There is the need to create and evaluate innovative models of care of multiple chronic conditions in the late life course.