PROGRAM | POPULATION | DESCRIPTION | MAIN OUTCOMES |
---|---|---|---|
Integrated care | |||
• SIPA10 | Community-dwelling adults aged > 64 y (N = 1270) | Patients received comprehensive geriatric assessment from interdisciplinary teams with full clinical responsibility for delivering care through community-health and social services and the coordination of hospital and nursing home care. Patients were encouraged to continue to see their own FPs who collaborated with evidence-based management protocols. The teams had access to intensive home care, group homes, and a 24-h on-call service. Case managers followed patients through care locations, assuring continuity. FPs received $400 per SIPA patient annually to compensate for time. The SIPA staff physicians served as a backup and resource | In this RCT (SIPA group vs control group) there
SIPA was cost neutral. Community costs were 44% higher for SIPA group compared with control group users, whereas institutional costs were 22% lower |
• PRISMA11 | People aged ≥ 75 y with multiple disabilities who needed > 3 services (N = 1501) | This semi-integrated service focused on coordination. A case manager assessed and coordinated a patient’s required services and supported and directed a multidisciplinary team involved in care. Case managers could be nurses, social workers, or other health professionals. Although FPs participated in team meetings and communicated with case managers, there were issues related to FPs’ understanding and collaboration with case managers | In the fourth year of the study, the annual incidence of functional decline was lower by 137 cases per 1000 in the experimental group. Prevalence of unmet needs, satisfaction with services, and empowerment were better in the experimental group. Rates of hospitalizations and ED visits were also lower in the experimental group |
Shared care | |||
• Seniors Collaborative Care Program12 | Patients aged > 75 y in an FHT who were randomly selected to be evaluated for risk of cognitive impairment and falls (N = 25) | At-risk patients or those with clinical issues received comprehensive assessment by FHT clinicians (FPs or nurse practitioners) and were referred to other FHT clinicians (eg, social worker, pharmacist) as indicated. Care was provided at home or in clinic. A visiting geriatrician provided consultation to the team, attended case-based meetings, and saw patients when deemed appropriate by the team. Capacity building was part of the program | During this pilot project, the geriatrician was involved in 25% of cases. There were no clinical outcomes published, but there was good satisfaction from care providers, with cited improvements in wait times, crisis prevention, and teamwork |
Home-based care | |||
• Primary Integrated Interdisciplinary Elder Care at Home13 | Patients aged > 75 y enrolled in a primary care home-based practice (N = 248) | The program focused on frail patients referred for care by health professionals. Care was provided primarily by physicians or registered nurses but there was access to physiotherapists (89% saw physiotherapists at least once). On-call coverage was provided by other FPs | In this comparison study of hospital use before and after enrolment in the program, there was a 39% reduction in hospital admission rates, 37% reduction in hospital days, and 20% reduction in ED visits. Of deaths that occurred, 46.9% occurred at home. There were no data on nursing home admission rates |
• Hospital at home14 | Patients aged > 65 y in the South East Toronto Family Health Team Virtual Ward | Patients being discharged from hospital were enrolled in a virtual ward if at high risk of readmission according to LACE (length of stay, acuity of admission, comorbidities, ED visits in past 6 mo) score. Remote monitoring of vital signs was done using telehomecare equipment. Care was provided by nurses and physician’s assistants with supervision from an FP, along with conventional home-care services that were arranged as needed | Using before-and-after data, 48 patients were evaluated. CHF and COPD were primary diagnoses. Hospital admission rates decreased statistically significantly (although clinical significance was hard to ascertain). Qualitative data suggested satisfaction with care and enhanced perception of continuity for patients. Staff reported greater integration of care |
Family medicine specialty clinics | |||
• Memory clinic15 | FHT patients referred to a primary care–based memory clinic | The memory clinic was staffed by FPs, pharmacists, social workers, and registered nurses. Referrals to the memory clinic were made by FPs within the FHT. A geriatrician was available to the clinic for telephone consultation. The approach was based on a chronic disease management model | Mean wait time to see patients was 2.2 mo. For 20.5% of patients, complaints were caused by conditions other than dementia. Satisfaction ratings among patients, caregivers, and referring physicians were high. FPs reported greater comfort with managing dementia than before their involvement with the clinic |
ALC—alternate level of care, CHF—congestive heart failure, COPD—chronic obstructive pulmonary disease, ED—emergency department, FHT—family health team, PRISMA—Program of Research to Integrate Services for the Maintenance of Autonomy, RCT—randomized controlled trial, SIPA—services intégrés pour personnes âgées (System of Integrated Care for Older Persons).