Models of primary care for frail patients

Integrated care

Health delivery systems have been developed to care for acute health problems or patients with single medical diagnoses. This has resulted in services that are fragmented and difficult for those with multiple comorbidities to navigate. Integration of services is often proposed as a remedy to these shortcomings; however, what does integrated care mean? Service integration is the process of combining social and health service needs to care for a defined population of older patients. In integrated systems, the financial, administrative, and clinical management are aligned with the interdisciplinary team providing care.⁸ For example, hospital services trying to discharge an older patient might not need to request services from a home-care organization that has completely separate management, budget, staff, and priorities. The intent is that pooling resources from multiple systems and creating clinical services that are linked and coordinated with resources will lead to more seamless care and better match needs with services.^9–11

The System of Integrated Care for Older Persons (known as SIPA, French acronym for services intégrés pour personnes âgées), a program in Quebec, provides an example of these concepts. This program enrolled frail seniors in a team-based community care program.¹⁰ After enrolment, patients received a comprehensive geriatric assessment and the team used a number of care protocols in collaboration with the primary care provider. Case managers addressed chronic and evolving acute issues in collaboration once again with the FP and coordinated access to on-call coverage, in-home supports, and even short stays in a group home. Case managers also played a role in transitions to and from hospital. Family physicians remained the primary providers of medical care and were funded via their usual model (most commonly fee for service) but also via an annual payment of $400 per patient per year to compensate for time spent with team communication. A SIPA physician acted as a resource to the team and the FPs.

In a well designed randomized controlled trial of more than 1200 participants over 22 months, SIPA was found to be cost neutral (total community costs were 44% higher, but institutional costs were 22% lower).¹⁰ Outcomes such as quality of life and function were not studied, but SIPA patients had substantially lower alternate level of care rates and there was a trend toward increasing satisfaction with care (more so among caregivers than among participants). There was no difference in rates of hospitalization or emergency department visits. Incentives for active participation and challenges mobilizing resources within and outside of the SIPA team were believed to be factors in the moderate outcomes.

Another example from Quebec is the PRISMA (Program of Research to Integrate Services for the Maintenance of Autonomy) model,¹¹ which relies on highly coordinated services between separately funded organizations and providers. The SIPA and PRISMA programs are summarized in Table 1.^10–15 Overall, the promise of integrated care is offset by challenges in reorganizing complicated systems into integrated ones, as well as by the muted benefits seen in randomized controlled trials.

Shared care

Shared care refers to close collaboration between an external consultant and an FP, with the consultant being more embedded in primary care than in a traditional specialist model. The shared care concept in Canadian primary care is best known in the realm of mental health. Roles and activities of both the FP and the psychiatrist are defined, coordinated, and complementary.¹⁶ The link between family medicine and psychiatry in shared care formally dates back to 1996 when a task force was struck with the CFPC and the Canadian Psychiatric Association. In geriatric care, the opportunities for a shared approach could be with geriatric medicine or geriatric psychiatry services.

Primary health reform has opened up options for a shared care approach in primary care, but there remain few studies on shared care in geriatrics. Access to sessional fees, interdisciplinary care, and alternate funding arrangements has allowed efforts to integrate specialized geriatric services (medical and psychiatric) or to involve geriatricians or geriatric psychiatrists. A 2012 article published by Canadian Family Physician provides an example of shared care with a geriatrician in an Ontario family health team.¹² Moore et al did not include clinical outcomes in their study, but American studies might have relevance to shared care in Canada.

In 2012, the US Department of Veterans Affairs published evidence briefs on geriatric services.¹⁷ When interpreting American literature, it is relevant to remember that both FPs and internists can call themselves geriatricians once they finish training and examinations. In Canada, only internists are called geriatricians and they have different backgrounds and roles than some geriatricians in American models. In American outpatient services, there is evidence for greater benefit when geriatricians provide direct patient care rather than providing input to team conferences or to specific clinicians. Geriatricians working in teams or as consultants have been shown to improve function, reduce use of health services, and delay move to nursing homes.¹⁸ There is limited research on geriatricians as primary care providers; studies have found improvements in medication management but no improvements in mortality with geriatric involvement.¹⁹ In Canada, geriatricians do not provide primary care and there are no studies of care (shared or otherwise) provided by FPs with enhanced skills in care of the elderly.

Other health disciplines can work with primary care physicians in shared care for frail seniors. Ideally these services are embedded within the Patient’s Medical Home, as described by the CFPC, which presents a large advantage for seniors given their familiarity with their FPs and their FPs’ practice locations.²⁰ Advance practice nurses might focus on specific chronic diseases such as diabetes, heart failure, or chronic obstructive pulmonary disease.

Palliative care services might be developed using the shared care approach in which the FP maintains responsibility for issues not related to the terminal diagnosis.²¹ The Palliative and Therapeutic Harmonization program in Nova Scotia is of relevance to primary care of very frail seniors. This service provides consultation to primary care to review goals of care for patients with multiple comorbidities and frailty, and makes recommendations about targets for care and prescribes medications to match function and prognosis.²² This model could be developed as shared care within a primary care group; the role does not need to be performed by a geriatrician and could be done by an FP, with or without additional training in care of the elderly.

Home-based care

Interest in home visits for elderly patients is being revitalized by practitioners’ awareness of their relevance in keeping frail seniors at home and by provincial governments’ promotion via funding or policy.²³ The value of home visits is well recognized, but models have been developed that go beyond the traditional home visit by the family doctor. Two main family medicine roles are providing ongoing care to home-bound seniors and providing care for acute or subacute illness (the hospital-at-home approach). There are several published examples of interprofessional teams for elder care, such as the Toronto House Call program (as seen in the documentary House Calls).^24–26 Home-based care might be provided by a physician as part of a focused or comprehensive practice; in Ontario, an alternate funding program has helped make this an option for full- or part-time practice.

The hospital-at-home concept focuses on keeping patients at home during an acute illness by optimizing home supports without hospital admission. A hospital at-home or virtual ward program has been tried in Canada.^14,27 Patients who would traditionally have been admitted to hospital for illnesses such as pneumonia and delirium are cared for at home with enhanced home support services and physician visits. With this model, the primary care physician is not always the most responsible physician for care.²⁸ However, we think many FPs would be able to provide care for common illnesses seen with geriatric patients and could function as the most responsible physician at home in many cases. Rapid response teams for newly discharged patients are more common; their effect on transitions back to family medicine care is not clear.²⁹

Family medicine specialty clinics

Family physicians sometimes see patients who are referred from outside their own practices for consultation about specific issues such as dementia, Parkinson disease, and incontinence. An example of this model is the family medicine memory clinic developed in Ontario, where patients are seen by FPs for comprehensive assessment and management of dementia.³⁰ There are now more than 50 memory clinics in primary care settings. Evaluations have shown accurate diagnosis with good patient and physician satisfaction and low rates of re-referral to geriatricians or neurologists (8%).¹⁵ No clinical outcomes are available, but an audit tool based on Canadian dementia guidelines might provide more evaluation in future.

Human resources and training

Geriatricians are experts in caring for frail seniors; however, there will never be enough geriatricians to provide care to even a small majority of these patients. Family physicians need to be comfortable and capable of providing care to frail seniors in any care setting. For this reason it is crucial that core family medicine residents receive training in the care of frail seniors and are comfortable dealing with patients with multiple comorbidities and with seeing patients at home. Practising FPs should also optimize their knowledge and skills given the demographic imperative experienced in most practices. There are barriers that prevent FPs from providing care outside of traditional comprehensive practices. Governments and health policy planners need to reduce these obstacles.

What is the role of FPs with enhanced skills in care of the elderly? This group could play an important role in many of the models described here, given their training and skills and their grounding in the principles of family medicine. Fee-for-service models and primary care reform have not always helped physicians who have care of the elderly training put their skills to best use. A survey done in 2005 found that most of the physicians with care of the elderly training still provided comprehensive care; they were also likely to work in long-term care facilities.³¹ A substantial proportion of the surveyed physicians had focused practices with specialized geriatrics programs. There has been little study or evaluation of the role of physicians with this form of training in home-based or shared care models.