cares: delaying frailty through stakeholder engagement and technology
TRANSCRIPT
Breakout Session E5:
The Golden Years-Exceptional Care for Seniors
March 3, 2017, 9:45-10:45am
Community Actions & Resources Empowering
Seniors (CARES)
Delaying Frailty through Stakeholder Engagement &
Technology
Disclosure
Nothing to disclose
Pre-frail seniors are becoming frail
unnecessarily
Imagine a world where we all Age Well & Die Fit
Ministry of Health. Setting Priorities for the B.C. Health System. 2014. Available at:
http://www.health.gov.bc.ca/library/publications/year/2014/Setting-priorities-BC-Health-Feb14.pdf
Aim / Context
Periodic comprehensive geriatric assessments (CGA) are associated with better health outcomes for the pre-frail senior (Beswick et al., 2008).
Augment health assessments to enhance seniors natural protective factors with wellness planning and health coaching (Wang et al., 2014, Vackerberg et al., 2016).
Health protective factors can reduce deficit accumulation (Wang, C., 2014).
Primary care providers are ideally situated to incorporate proactive and best practices in their daily clinical work (Lacas et al., 2012).
To proactively delay frailty in pre-frail seniors:
CARES Model
Target Population - Inclusion Criteria
Persons 65 - 85 years (and by exception): • Living at home or in assisted living within catchment community with a Rockwood
Clinical Frailty Scale score between 3 (Managing Well) to 5 (Mildly Frail)
• Emerging chronic health issue or other risk factor for frailty
Upstream Proactive Primary Health Care Intervention
E-CGA-FI
Health
Assessments
Health
Coaching
Wellness
Summary/
Community
Referral
Seniors age well
Risk for frailty
decreases
Reduce acute &
ED utilization
Enhance provider
satisfaction /
experience
Quadruple Aim
Active Case
Finding for
Pre-Frail
Seniors
What is the Self-Management Health Coach program?
• It is a three month telephone program that supports participants to identify health goals and develop a plan to manage their health conditions.
• A coach works with participants one-to-one through weekly telephone support.
Who developed the program?
• The program was developed by the University of Victoria, Institute on Aging & Lifelong Health.
• It is considered a best practice program in self-management.
What does it cost to participate?
• It is FREE to participants.
• The program is funded by the Ministry of Health and delivered through Self-Management BC; a Patients as Partners Initiative administered by the University of Victoria.
Why we choose to partner with Self-Management BC?
• Provides evidence based programs that demonstrate improvements in health.
• Links health assessments with community based programs that enhance participants “protective factors”.
Why Spread CARES?
Technology as Spread Enabler
Assumptions
The e-CGA-FI will be widely
accepted as the standard for clinical
frailty assessment
Primary care providers are well
positioned to screen for frailty
Primary care providers will use the
e-CGA-FI to measure frailty index
through ongoing periodic
assessments
Upstream assessment and assistance
with motivation will lead to more
active lifestyles for seniors
e-CGA-FI enables assessment of
frailty at point of care
Increased geriatric competency in
primary care providers (frailty
and dementia education)
Better understanding that frailty
is preventable by both seniors
and primary care providers
Frailty assessment is best
completed in a team based
setting
Must have partnerships:
Co-development and collaboration
with Divisions of Family Practice
Self Management BC
CFHI national collaboration
Academic partnerships
Health Authority is change
enabler
Challenges
Adoption of e-CGA-FI as standard frailty assessment tool
Physicians want a shorter frailty assessment tool
Costs to develop e-CGA-FI in all vendor EMRs
Keeping funders/stakeholders engaged
Time to plan strategically (national & international)
Thank
you!
QUESTIONS
Presenter Contact Information
Dr. Grace Park Regional Medical Director, Home Health, Fraser Health
Annette Garm Project Director, CARES, Fraser Health