Interprofessional and integrated care of the elderly in a family health team

Program description

The Seniors Collaborative Care Program (SCCP) began as a pilot program at the Stonechurch Family Health Centre (SFHC) in 2008 and continues to operate. The SFHC is part of the McMaster FHT of the Department of Family Medicine at McMaster University in Hamilton, Ont. The SFHC serves 15 204 patients including 737 seniors older than 75 years of age. The composition of the McMaster FHT has been described elsewhere.¹⁰ Each SCCP core team consists of 1 nurse practitioner (NP) (who dedicates 0.35 full-time equivalent [FTE] hours to the team), 1 FP (0.10 FTE), and 1 registered practical nurse (RPN) (0.05 FTE). Additional SCCP members include a pharmacist, a social worker, a dietitian, and a visiting geriatrician.

The goals of the SCCP were to improve the quality, efficiency, and coordination of care for frail elderly patients living in the community, and to enhance geriatric and interprofessional skills for SFHC practitioners and learners. The objectives of the pilot project were to determine the feasibility of the new model to learn what would work and what resources would be required, and to understand team roles and the integration of a geriatrician.

The pilot study was conducted between November 2008 and May 2009. A case-finding strategy was used to identify seniors at risk of cognitive impairment or falling. These conditions were chosen to identify patients who could most benefit from multidisciplinary approaches to care. The pilot program emphasized providing care in the homes of housebound seniors, which is a less prominent aspect of usual care at the SFHC.

Approximately 6 new patients per month were evaluated during the pilot study. Patients were seen within 5 weeks of initial contact, which compares favourably with the 6-month delay for nonurgent referrals to geriatricians in our region.¹¹

Initially each patient was seen by the RPN and the FP or the team NP. The RPN screened for depression, nutrition, and medication risks to involve appropriate SCCP professionals with care. The FP or NP then provided a more comprehensive assessment, including identification of patient and caregiver goals and preferences. These assessments were done sequentially at the same visit at the SFHC or, for housebound patients, in their homes. Standardized assessments for falls and cognition were conducted, based on Quality Indicators for the Management and Prevention of Falls¹² and the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia.¹³

When identified needs exceeded the scope of the FP, NP, or RPN, other SCCP members were accessed. For example, when medication risks were identified, a request for pharmacist assessment was made. For diagnostic clarification or advice with challenging management strategies, a visiting geriatrician was involved. The geriatrician attended regular monthly, case-based team meetings with the SCCP team and other SFHC learners and practitioners involved with care. The geriatrician provided consultation to the team and direct care as deemed necessary by the team. As with initial assessments, visits with any provider, including the geriatrician, could occur at the SFHC or in the patient’s home. Team plans were communicated and implemented, and follow-up arrangements were negotiated among the SCCP, the patient’s main care team, community care providers, caregivers, and patients. Figure 1^14–17 shows patient flow through the pilot SCCP.

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Figure 1

Care path for pilot study patients

NP—nurse practitioner, RD—registered dietitian, RPN—registered practical nurse, SW—social worker.

This model offers numerous advantages. Coordinating care is easier because it remains within the patient’s family practice. It is facilitated by fast, effective communication among SCCP members and the patient’s main practitioners through internal electronic messaging embedded within the patient’s Web-based electronic medical record (EMR). Shared medication profiles contribute to prescribing safety and rational treatment. Teamwork is enhanced by bringing SCCP members together for case-based team meetings with access to EMRs, promoting uninhibited interactions and shared assignment of care plans.

Another advantage is educational. The expertise of the geriatrician builds capacity within the team. When FPs have exhausted all their own resources, it is important that they receive team support quickly and easily. It is an ideal learning forum for SFHC practitioners, residents, and other health professional students. Team-based case meetings provide educational opportunities, emphasizing approaches to the “geriatric giants” of dementia, delirium, falls, incontinence, and polypharmacy as they converge with common chronic or degenerative conditions. Group problem solving stimulates creative and expanded options for patients and families, and provides an opportunity to appreciate each profession’s scope of practice. Learning opportunities are bi-directional. The geriatrician learns about the challenges facing primary care practitioners when caring for frail elderly patients.

Evaluation

Approval for this study was obtained from the Research Ethics Board of the Hamilton Health Sciences Faculty of Health Sciences.

For the pilot study, seniors older than 75 years of age at SFHC were randomly assigned numbers using a random number generator to be contacted by telephone to evaluate their risk of cognitive impairment and falling. Table 1 summarizes telephone-screening results.

Seniors identified as at risk by telephone screening were invited for further assessment. Screening continued until 25 seniors were evaluated. Table 2 summarizes their demographic characteristics, wait times, and nutrition, cognitive, and depression scores.^14–17

Table 3, showing time spent by SCCP members with direct and indirect pilot patient care, demonstrates the prominent role of the NP and the focused role of the geriatrician.

Interviews were conducted to obtain opinions about the successes and limitations of the program. All pilot patients were invited to provide feedback approximately 2 weeks after the intervention. Six patients or caregivers consented to interviews. All 5 NPs and all 5 FPs attached to pilot study patients consented to interviews. A combination of Likert ratings and open-ended questions were used to determine satisfaction with the program. Interviews and open-ended responses were audiotaped, transcribed, and evaluated for thematic content. Patients, NPs, and physicians who provided feedback were highly satisfied with the program overall and agreed it was worthwhile for seniors (Table 4).

Participants identified several common themes that made the program workable or that were benefits of involvement. For practitioners, the ease of access facilitated by short wait times and the flexibility to have services in patients’ homes were important. They also identified fast and effective communication among team members as contributing to program success. Several respondents commented on the benefits of multidisciplinary contributions that provided information and support from multiple perspectives.

One of the most important factors identified was the preventive nature of the program, which in some cases included identification and elimination of home fire and falling hazards, food procurement problems, and caregiver exhaustion. Practitioners reported that identification of problems and potential hazards allowed the team to put plans in place quickly to prevent crises. As a result, it is possible that patients might have been able to be maintained at home rather than going into an institution, although this was not measured. Nurses and FPs appreciated the opportunities for SFHC learners, who are involved in all stages of care, to learn about a growing segment of the population for their future work.

Although seniors expressed satisfaction with the program and found it worthwhile (based on Likert ratings), responses to open-ended questions indicated that they did not have sufficient recollection of the program to provide detailed commentary.

Respondents reported confusion with defining roles and responsibilities between SCCP practitioners and the patient’s main care team (eg, who responds to telephone calls from patients and caregivers). Roles and expectations are now clarified during initial team meetings.

Patients are no longer recruited by telephone, as this case-finding method is inefficient. The FPs and other allied providers at the SFHC now identify which seniors they require assistance with and refer them for any issue. Seniors are no longer screened for pilot-study inclusion criteria (risk of falling and cognitive impairment). Since completion of the pilot project, approximately 4 patients per month are now referred and reviewed. Table 5 summarizes the characteristics of these referred patients, which are similar to those of pilot study patients in terms of age and cognitive scores.^14–17 The pilot study is too limited to make further comparisons between seniors identified by telephone screening and those referred to the program. The average wait time for referred patients is 32 days. As illustrated in Table 5,^14–17 these patients are at high risk of medication complications and cognitive impairment, and are primarily referred for “cognition concerns” (51%) and “multimorbidity” (41%).