SIIReN - System Integration & Innovation Research Network

Primary Health Care System

Applied Health Research Questions

Building Capacity for Care for Seniors: Expanding a Unique Model of Integrated Interprofessional Care to Manage Complex Chronic Diseases in Primary Care Practice
Linda Lee, George Heckman, Robert McKelvie, and Philip Jong
Knowledge User: Bruce Lauckner

There are currently 31 inter-professional Memory Clinics (MCs) in Ontario, led by family doctors and supported by interdisciplinary health care professionals (including geriatric specialists). Team members working within the current MCs reorganize care processes using standardized assessments, making optimal use of inter-professional care through structured collaboration, and focus on integrated patient-centered care. The objective of this study is to assess the factors related to adapting and extending the current MC model to integrate care provision for multiple complex conditions, including Heart Failure, falls and Chronic Obstructive Pulmonary Disease, with the goal of improving patient outcomes and increasing the efficiency of health care utilization. The study design included surveys (n=36) and structured telephone interviews (n=16) with MC physician leads and supporting physician specialists. Surveys results provided descriptive statistics and qualitative data was coded to identify key themes. Preliminary results indicate high satisfaction rates with the current MC model and overall support for expanding the model to integrate care for other complex conditions. Funding and staffing resources were reported as key barriers to facilitating integration, including limited remuneration for physician leads and supporting specialists. Facilitators included structured training, a successful team approach and access to supporting specialists. Study results will inform the specific design, implementation process, and pilot testing of an expanded MC care model.

Key Messages:
Summarized responses to the study research questions:

  • Overall physicians felt positively about integrating more care to the memory clinic model, as long as the necessary resources were in place. Concerns over adequate funding and resources to expand the model were commonly reported.

  • Physicians noted that many patients in the memory clinic had multiple complex conditions and stated numerous challenges in caring for frail older patients. The challenge most often mentioned was the amount of time required to assess and manage frail patients and the limited resources available to do so. Treating multiple comorbidities requires intensive investigation and support. There was widespread concern over polypharmacy risks, particularly for those living alone who could experience side effects or deterioration without help.  In addition to the memory clinic model itself, the most noted facilitators to caring for frail patients were accesses to community services and coordination with community care.

  • The most commonly reported benefit to expanding care in the memory clinic model was better care coordination.  Physicians felt that better complex care would lead to better health outcomes including fewer medication errors, reduced hospital admissions, falls and confusion. Reduced consultation times and wait periods were also stated as potential benefits, as well as corresponding cost savings within the health care system.

  • Participants stated the key facilitators to the integration of care provision for HF, falls, and COPD into existing MCs to be applied training and greater resources. Resource needs included easy access to diagnostic testing, consultations with physician specialists and pharmacists, increased infrastructure and adequate staff. Funding for adequate staff and competing scheduling demands were noted as key barriers to sustainable integrated care.

Back to Applied Health Research Questions