Co-design of an integrated home-based primary care model for older adults living with frailty in Ontario, Canada
Authors: Garasia Sophiya , Badesha Harleen , Mitra Aruna , Cheung Joyce 
Published: January 2024

Background: The demand for home care is predicted to increase with increasing senior population and the aging-at-home phenomenon. Countries world-wide are preparing for this growing demand by making changes to their health care and social care systems. This change is much needed given that, globally, evidence shows that seniors are experiencing fragmented care particularly when they are living with frailty. To address this problem, the Central West Ontario Health Team in Canada is creating an integrated home-based primary care model for individuals 65+ who are living with frailty. At the ICIC23 Conference, I plan to share our research findings, design of the program, learnings from every phase of our co-design and change management approach, and findings from the evaluation of the pilot program.

Methods: The program is being co-designed (using Experienced Based Co-Design) in collaboration with patients, caregivers, primary care, hospitals, the municipality, mental health organizations, social workers, home and community care, and other community groups. To date, the co-design team has worked together in partnership to share experiences, segment the population, conduct an environmental scan of documents, and conduct quantitative and qualitative research. First, the team performed descriptive data analysis of hospitalization and community data, and then, three separate focus groups were held with local organizations, service providers, and patients and caregivers (n=60). The data that emerged from the focus groups was then thematically analyzed. The co-design team is now finalizing the program as it is set to be piloted in January 2023, at which point, the program will be evaluated (on measures such as emergency department (ED) diversion and patient experience), updated, and scaled up appropriately.

Results: Research showed that 80% of Alternate-Level-of-Care days in the Region are among those who are 65+. A cohort of the older adult population are also high users of the ED who are being discharged home each time. Reported reasons for high ED use include isolation, confusion about the health care system, caregiver burnout, and not receiving proper care in the community in a timely manner. Our research also identified frail older adults to be particularly vulnerable. The program I will describe in the presentation will aim to address these issues. It is novel to Ontario, Canada, and will consist of a screening process to identify “at risk” older adults presenting to the ED, a comprehensive assessment, and ongoing access to an intraprofessional team (consisting of physicians, nurses, physiotherapists, nutritionists, pharmacists, and mental health professionals) that will work together on a shared care plan for each patient. All the tools are being adapted to meet a multi-faceted definition of frailty as well as local needs given that the Central West Region is one of the most ethnically diverse regions in the province. By co-designing, the aim is to implement an integrated program that matches the preferences of patients and their family-members and caregivers.

Discussion: The learnings will be helpful to the many groups world-wide who are also planning on creating integrated co-designed primary-care based programs for diverse older adults experiencing frailty.