Abstract
Objective To explore the barriers to and facilitators of adapting and expanding a primary care memory clinic model to integrate care of additional complex chronic geriatric conditions (heart failure, falls, chronic obstructive pulmonary disease, and frailty) into care processes with the goal of improving outcomes for seniors.
Design Mixed-methods study using quantitative (questionnaires) and qualitative (interviews) methods.
Setting Ontario.
Participants Family physicians currently working in primary care memory clinic teams and supporting geriatric specialists.
Methods Family physicians currently working in memory clinic teams (n = 29) and supporting geriatric specialists (n = 9) were recruited as survey participants. Interviews were conducted with memory clinic lead physicians (n = 16). Statistical analysis was done to assess differences between family physician ratings and geriatric specialist ratings related to the capacity for managing complex chronic geriatric conditions, the role of interprofessional collaboration within primary care, and funding and staffing to support geriatric care. Results from both study methods were compared to identify common findings.
Main findings Results indicate overall support for expanding the memory clinic model to integrate care for other complex conditions. However, the current primary care structure is challenged to support optimal management of patients with multiple comorbidities, particularly as related to limited funding and staffing resources. Structured training, interprofessional teams, and an active role of geriatric specialists within primary care were identified as important facilitators.
Conclusion The memory clinic model, as applied to other complex chronic geriatric conditions, has the potential to build capacity for high-quality primary care, improve health outcomes, promote efficient use of health care resources, and reduce health care costs.
Population aging is leading to substantial increases in rates of chronic disease.1 The most complex chronic conditions, such as cognitive impairment (CI), heart failure (HF), injurious falls, and chronic obstructive pulmonary disease (COPD), account for more than 30% of direct health care costs in Ontario2 and affect health care resource use.3–5 These conditions not only account for a disproportionate number of acute and alternate level of care hospitalization days, but also have the highest average costs per hospitalization, led by dementia and HF.6 While substantial evidence (summarized in national clinical guidelines) exists that all of these conditions can be effectively managed in isolation,7–10 their management is typically complicated by comorbidities, which have been shown to be important drivers in the use of health care services.11 In particular, use of clinics led by non–family physician specialists might result in less appropriate care of comorbid conditions outside of the specialty focus, inadequate preventive care, and higher costs, suggesting a need for greater primary care involvement in the management of these conditions.12
There is much support for initiatives in chronic disease management (CDM) at a primary care level, with emphasis on the use of evidence-based guidelines; development of strategies and protocols for integrating the use of best-practice guidelines into clinical practice; coordination of services across providers using clinical case management approaches; incorporation of self-management strategies; and inclusion of routine follow-up with patients.13–15 Various primary care CDM models exist. Patient-focused self-management programs that educate patients and provide them with self-help tools and resources to increase independence in managing and monitoring their own health have been shown to reduce use of health care services and improve quality of life and health outcomes.16,17 Team approaches, in which patients have access to multidisciplinary services for specific conditions, have demonstrated improved health outcomes.18–20 Similarly, nurse-led care models that incorporate patient education, as well as medication and symptom monitoring, have also been shown to improve health outcomes and reduce use of health services.21,22
To date, most CDM initiatives in primary care have focused on conditions such as asthma, diabetes mellitus, and depression.23 Complex chronic illness is a challenge to manage in primary care, and primary care clinics for persons with complex chronic conditions have had only limited success in improving patient outcomes and reducing use of the health care system.11,23 These results might reflect inappropriate targeting of high-intensity interventions to low- or moderate-risk patients,24 inadequate interprofessional training in CDM,12 poorly organized care processes, including limited access to allied health professionals (AHPs), and inadequate integration of other specialist input.11,12 Primary care models in which care from other specialists is well integrated have the potential to improve health outcomes; however, these models require a more collaborative approach between primary and secondary care, as well as improved organizational structures such as shared information systems.25 To successfully transform CDM in Canada, primary care capacity must be developed through a systematic reorganization of care processes, with an emphasis on training and effective interprofessional collaboration among family physicians, AHPs, and other specialists.26
Since 2006, the Centre for Family Medicine Family Health Team Memory Clinic in Kitchener, Ont, has been actively operating a primary care–based interprofessional memory clinic as described elsewhere.27–30 An accredited interprofessional training program has been developed, which to date has established 40 primary care memory clinics across Ontario and supports 475 medical practices with a patient base of more than 700 000.31,32 The collaborative interprofessional clinic teams typically consist of a family physician, 2 to 3 nurses, and a social worker, with receptionist support. Where available, some clinic teams also include a pharmacist, an occupational therapist, and representatives from local Alzheimer disease societies to facilitate access to information, education, and support for patients and caregivers.
Within this clinic, the roles of family physicians and AHPs are expanded to maximize the use of skills within their scopes of practice, with optimization of diagnostic and care processes for patients with cognitive disorders. Geriatric specialist physicians are linked with each clinic to facilitate access to consultation support. Based on the chronic care model,33 the clinic conducts evidence-based assessments that are used to develop comprehensive treatment plans and provide support to primary care providers to manage primary memory disorders independently within their practices, thereby reducing unnecessary use of specialty care providers (eg, geriatricians) for management of cognitive disorders. Patients are followed intermittently through the course of their illness. Team members work collaboratively with the primary care physician to ensure that changes in patient and caregiver needs are identified and met (eg, increases or decreases in medications and coordinating community services, and managing specific issues such as fitness to drive and responsive behaviour).
Evaluation studies of the memory clinics have demonstrated high levels of patient, family member, and referring physician satisfaction; wait time reductions for referral from between 6 and 12 months, as is typical for geriatric specialists, to an average of 1.4 months; and increased access to community support services.27,29,34 As a result, practices serviced by this model of care have been able to assume greater responsibility for the care of patients with CI, with the need for referrals to geriatric specialists reduced from approximately 80% to less than 10%.35 Chart audits by independent geriatricians have indicated the provision of high-quality care.27,29
Evidence to date would support that the primary care memory clinic model can transform the limited practice capacity of individual family practices into systematic and comprehensive interprofessional clinics for patients with CI. In this study, we explore the potential to adapt and extend the memory clinic model to integrate care for HF, COPD, falls, and frailty, assessing the extent to which chronic conditions in the elderly can be diagnosed and managed at a primary care level, and determining the required support for the expansion of the memory clinic model to address complex comorbidities. We focus on these conditions because, like CI, they are common chronic conditions in the elderly that have a profound effect on the use of health care resources.3–5 These conditions are associated with substantial morbidity and mortality, as well as impaired quality of life.36–39 Geriatric syndromes such as CI, functional decline, falls, and frailty often complicate the course of conditions such as HF and COPD, leading to worse outcomes.40,41 Moreover, these conditions often occur concurrently, increasing the complexity of diagnosis and management, as symptoms are often subtle42–44 and treatment of one condition might adversely affect other coexisting conditions.45
METHODS
Ethics approval for this study was obtained from the University of Waterloo Research Ethics Board.
Questionnaires
Two questionnaires were developed to identify physician perceptions of the management of comorbidities. One survey was distributed to family physician leads and co-leads (n = 60) of all primary care–based memory clinics in the province (n = 31) and one was distributed to geriatric specialists who provided consultation support to these clinics (n = 13). Family physicians were asked to rate their level of agreement, using a 9-point Likert scale (1 being the lowest level and 9 being the highest), with various statements related to their confidence in diagnosing and managing older patients with HF, high risk of falls, COPD, frailty, and multiple comorbidities. Using the same scale, geriatric specialists were asked to rate statements related to their confidence in the ability of family physicians to diagnose and manage similar patients. Both family physicians and geriatric specialists were also asked to rate their perceptions of the role of geriatric specialists in primary care clinics; existing funding and remuneration methods; potential effects of expanding the memory clinic model to address frailty and complex comorbidities on cost-effectiveness; wait time for assessment; and acute care use. Demographic and practice information was also collected. Invitations and reminders to complete these online surveys were distributed via e-mail. Statistical analysis was performed using SPSS, version 21.0. Analysis of variance (ANOVA) was used to determine differences in mean ratings between family physicians and geriatric specialists, testing significance (P ≤ .05).
Interviews
Individual telephone interviews were conducted in February and March 2013 with a purposeful sample of memory clinic lead physicians selected to represent a diverse range of duration in their roles and in urban and rural locations. Structured interview questions asked about the current memory clinic model, practice challenges in caring for frail complex patients, and the anticipated required resources and supports for clinic model expansion, including funding and education or training. All interviews were audio-recorded and transcribed verbatim. Content analysis to identify common themes was done using NVivo software. Transcripts were open coded to identify categories and themes. Summarized results were e-mailed to interview participants for member-checking feedback.
RESULTS
Questionnaires were completed by 29 family physicians and 9 geriatric specialists (8 geriatricians and 1 geriatric psychiatrist). Table 1 presents respondent characteristics. Interviews were completed with 16 memory clinic lead physicians; 8 were primary clinic leads and 8 were memory clinic co-lead physicians. The mean (SD) length of time in the memory clinic physician role was 2 (1.1) years and ranged from 5 months to 4.5 years.
Characteristics of questionnaire respondents
A number of themes arose from the qualitative analysis of the interviews, which were supported by quantitative data collected from the questionnaires.
Themes
Willingness of existing memory clinics to expand to include other complex conditions
Interviewed physicians perceived the memory clinic model as an important opportunity to improve care for older patients with multiple complex conditions with the caveat that sufficient resources (training, funding, staffing) be in place to support and sustain this type of care model (Table 2). Physicians acknowledged that care planning within the memory clinic often required consideration of other existing chronic conditions, ensuring that multiple patient needs were targeted, not just dementia. Formalizing this care through an expanded care model was perceived as supporting better patient management. It was generally believed that family physicians, particularly with additional training and supports, were in a good position to provide more comprehensive CDM within primary care. Consistent with this, as measured in the questionnaires, family physicians were moderately confident in their ability to diagnose and manage multiple complex conditions (Table 3). Geriatric specialists’ ratings were generally consistent with this; however, geriatric specialists had significantly lower, but still moderate, ratings of confidence in the ability of the family physicians to diagnose frailty (P = .01) and to manage 4 or more comorbidities (P = .03).
Interview participants’ quotes related to themes
Family physicians’ ratings of their confidence in their ability to diagnose and manage geriatric conditions and geriatric specialists’ ratings of their confidence in family physicians’ ability to diagnose and manage chronic conditions: Level of agreement was measured on a 9-point Likert scale, on which 1 is the lowest level and 9 is the highest level.
An expanded clinic model could potentially result in improved health outcomes and health care cost savings
Generally, it was perceived that care improvements within an expanded clinic model had the potential to improve health outcomes and reduce medication errors, hospital admissions, and falls, resulting in cost savings for the health care system. Family physicians and geriatric specialists had moderate ratings regarding the degree of potential effects of an expanded memory clinic model on cost-effectiveness and reduced use of acute care services, with family physicians having substantially higher ratings (P = .12 and P = .05, respectively) of these effects than geriatric specialists did (Table 4).
Family physicians’ and geriatric specialists’ ratings of various aspects of funding and remuneration to expand the memory clinic model and potential effects: Level of agreement was measured on a 9-point Likert scale, on which 1 is the lowest level and 9 is the highest level.
Optimal care for elderly patients with multiple medically complex conditions is enabled by providing structured training, fostering interprofessional teams, and having access to geriatric specialist consultation
Comprehensive training provided to memory clinic team members involved didactic workshops, case-based learning, and mentorship opportunities. The training was viewed as critical to building capacity to manage complex geriatric issues, as well as fostering interprofessional collaboration, in that each member of the team was viewed as providing a unique and valuable contribution to the diagnostic and care planning process. Moreover, primary care physicians in memory clinics reported that access to geriatric specialists to discuss challenging cases increased their capacity to manage complex conditions, so that an expanded clinic model would be optimally effective with greater involvement of geriatric specialists. Questionnaire results consistently reflected that both family physicians and geriatric specialists perceived effective interprofessional collaboration and capacity building as requisites for optimal care of elderly patients with multiple medically complex conditions (Table 5).
Family physicians’ and geriatric specialists’ ratings of the role of interprofessional collaboration within primary care to support geriatric care: Level of agreement was measured on a 9-point Likert scale, on which 1 is the lowest level and 9 is the highest level.
The current structure of primary care does not allow for the optimal management of comorbidities
Physicians identified the amount of time it takes to assess and manage patients with comorbidities, particularly with adequate follow-up and monitoring, and the limited resources to do so as substantial challenges to the provision of CDM in primary care (Table 2).
Limited funding and staffing are barriers to an expanded clinic model
Many physicians expressed that it was difficult to remove themselves and other staff members from their regular practices to operate the memory clinic, noting that more time and staffing would be required for an expanded clinic, with substantial budget implications. Funding was broadly seen as a barrier to specialized clinics operating within primary care. Remuneration for clinic work was perceived as inadequate, as existing primary care fee-for-service funding models do not adequately account for the time needed to optimally manage HF, falls, and COPD. Although many of the physicians interviewed were willing to assume some financial loss in exchange for the high satisfaction of working within this expanded care model, they also noted that this loss would not be sustainable in the long term. Questionnaire data confirmed these funding concerns (Table 4).
DISCUSSION
The results of this study demonstrate an overall willingness of existing memory clinics to integrate care for other chronic medical conditions. However, substantial barriers to expanding this care model were also identified.
Previous studies support approaches to managing complex conditions in primary care that are integrated, comprehensive, and sustained over time,14,46–48 and that manage comorbidities rather than a single disease, with consultation support from non–family physician specialists.49 Yet many Canadian seniors with chronic diseases receive suboptimal care.2 In the face of the critical shortage of geriatric specialists in Canada and limited health care resources,50,51 there is an urgent need for new care models to better manage seniors with multiple complex chronic conditions. In this study, physicians believed that the memory clinic care model was likely applicable to managing HF, COPD, falls, and frailty. Of importance, physicians recognized the potential for improved health outcomes and health care cost savings. Like dementia, these particular chronic conditions account for the highest numbers of acute and alternate level of care hospitalization days in Canada.3,5,6 The integration of these conditions into existing memory clinic care processes has the potential to expand capacity to better manage seniors with complex chronic conditions through more systematic, comprehensive, and effective collaborations among family physicians, AHPs, and geriatric specialists.
It has been suggested that, in ideal models of CDM, most patients with chronic disease can be adequately managed with low- to moderate-intensity interventions, with 5% to 10% requiring high-intensity interventions.24 The memory clinic model exemplifies these principles by stratifying patients according to risk of poor outcomes and tailoring the intensity of management accordingly, with demonstrated referral rates of less than 10% to geriatric specialists and most care appropriately provided within primary care practice.27,29 Within this care model, patients benefit from the varied expertise of those contributing to the care plan and the collaboration among care providers integrated within the primary care practice. Allied health professional assessments are conducted concurrently with those of physicians; and results and recommendations are shared among providers immediately and directly, as opposed to care models in which AHP and physician assessments are conducted at different times, which might limit and delay information sharing. Integration of AHPs and geriatric specialists into primary care enables “person-focused care” in which care is accessible, comprehensive, coordinated, and continuous.52 A team-based case management approach allows these clinics to act as hubs in which patients are connected to a variety of health care providers and community services with concurrent assessment and information sharing. This not only more accurately identifies the medical and psychosocial needs of the patient-caregiver dyad, but also allows a much more coordinated and holistic care plan.
This study identified specific barriers to integrating care for other chronic conditions into the existing memory clinic model. In particular, funding to support the time and staff necessary to assess and manage multiple complex medical conditions remains a key challenge. With complex multiple comorbidities affecting aging Canadians being an important driver of health system costs, it is critical for provincial health care funding agencies to reinvest in a fundamental redesign of the structure of primary care, with appropriate remuneration and opportunities for capacity building.
In this study, family physicians had greater confidence in their ability to manage multiple complex comorbid conditions than geriatric specialists had in family physicians’ ability to manage these conditions. The reasons for this discrepancy in perceptions is unclear. Less than half of the family physicians reported residency training exposure to CI, HF, COPD, fails, and frailty. Although more family physicians had exposure to these conditions in continuing medical education activities, there is likely room for greater capacity building. Similarly, geriatric specialists reported limited exposure to continuing medical education on HF and COPD. Embedding geriatric specialists in primary care settings to see patients alongside interdisciplinary team members, with opportunities to provide both “in the moment” and formal teaching, as well as mentorship and relationship building, has the potential to facilitate true collaboration and improve care.53,54
Limitations
The sample selected for this study might not be representative of all memory clinic members and geriatric specialists. Although the sample sizes are small, the sample is purposive in that it represents a diverse selection of participants.
Conclusion
This study demonstrated the potential for expansion of the memory clinic model to address HF, falls, COPD, and frailty. If the identified challenges can be addressed, the model has the potential to transform care processes, improve care for seniors with multiple chronic conditions, improve health outcomes, promote efficient use of health care resources, and reduce health care costs.
Acknowledgments
This study was funded as an Applied Health Research Question for 2012 to 2013 through the Primary Health Care System Program, the System Integration and Innovation Research Network, and the Ontario Ministry of Health and Long-Term Care.
Notes
EDITOR’S KEY POINTS
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There is an urgent need for system improvements within primary care to enable optimal care of seniors with multiple chronic conditions.
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Both family physicians and geriatric specialists believed that effective interprofessional collaboration and capacity building were required for optimal care of seniors with complex comorbidities.
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Funding and remuneration were identified as barriers to integrating care for seniors with multiple chronic conditions within an existing primary care model. Redesigning the existing primary care system to support structured training to form interprofessional primary care teams and increase access to integrated geriatric specialist support might improve the management of complex multiple comorbidities affecting the elderly and reduce health system costs.
POINTS DE REPÈRE DU RÉDACTEUR
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Il est urgent d’améliorer le système des soins primaires pour permettre un traitement optimal des aînés souffrant de multiples conditions chroniques.
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Selon les médecins de famille et les gériatres, une collaboration interprofessionnelle efficace et une amélioration des compétences sont nécessaires pour traiter de façon optimale les personnes âgées présentant plusieurs maladies chroniques.
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Le financement et la rémunération ont été identifiés comme des obstacles à l’intégration des soins des aînés souffrant de multiples conditions chroniques dans le contexte actuel des soins primaires. Si on réorganisait le système des soins primaires en encourageant la formation d’équipes interprofessionnelles et en augmentant la possibilité d’un soutien de la part des gériatres, on pourrait améliorer le traitement des personnes âgées souffrant de multiples conditions chroniques et ainsi réduire les coûts pour le système de santé.
Footnotes
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This article has been peer reviewed.
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Cet article a fait l’objet d’une révision par des pairs.
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Contributors
Drs Lee, Heckman, McKelvie, and Jong contributed to the study concept and design; data analysis, review, and interpretation; and final manuscript preparation and approval. Ms D’Elia contributed to the study concept and design; data collection, analysis, review, and interpretation; and final manuscript preparation and approval. Ms Hillier contributed to data analysis and interpretation, and final manuscript preparation and approval.
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Competing interests
None declared
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