Implementing and Evaluating a Model of Care Coordination in Primary Care for Older Adults using a Co-Design Approach
Notice bibliographique
Résumé
Background: Older Canadians with chronic diseases are the biggest users of the health care system. Primary health care (PHC) could play a central, coordinating role in assessing and managing older adults, but at present lacks specific strategies to fulfil this role. Priorities for enhanced care coordination in PHC include: 1) consistent processes to identify and assess older persons and create individual care plans aligned with risk levels; 2) improved care coordination and system navigation; 3) improved access to appropriate services; and 4) improved patient and caregiver engagement (Heckman et al., 2013; World Health Organization, 2008; Wagner, 2000; Goodwin et al., 2013).Aims: This study aims to understand how a model of risk-stratified care coordination for older adults can be developed and implemented in primary care. Information gathered will provide an in-depth understanding of: (1) the local context a region in Ontario, Canada (2) what referral pathways can link older patients to services appropriate for their level of risk, and (3) providers, patients and caregivers experiences to understand how the model could be modified and what factors are important for implementation in future primary care sites.Methods: This study used mixed methods, within a developmental evaluation approach (Patton, 2011). Ongoing focus group (n=6) and key informant interviews were conducted with patients (n=15), families (n=4), and primary care and community care providers (n=15) in three locations (rural and urban) in Ontario, Canada. Data were coded using a line by line, emergent approach. Risk-screening data (n=600) and service utilization were also collected and analyzed at the study sites.Results: A model of care coordination was developed through engagement of patients, families, and health care providers. Components of the model include: a) consistent screening (interRAI Assessment Urgency Algorithm) and referral processes; b) coordination of care through individualized care plans; and c) patient and caregiver engagement in decision-making. Implementation resulted in patient and provider awareness of resources for self-management, stronger linkages between PHC teams and community resources; improved patient and caregiver experiences and engagement in decision-making.Conclusions: A model of care coordination was developed and implemented in primary care through an ongoing, iterative process with older adults, caregivers, and health care providers.This process resulted in key principles necessary for improving care coordination in primary care for older adults and their caregivers.Limitations: This project was conducted in one Ontario region. Strategies may need to be tailored to the specific needs and resources of other communities.Suggestions for Future Research: The next phases of our work will involve implementing and evaluating this model in primary care sites that are not team-based settings.
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,001 | 0,000 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,000 | 0,000 |
| Bibliométrie | 0,000 | 0,000 |
| Études des sciences et des technologies | 0,000 | 0,000 |
| Communication savante | 0,000 | 0,000 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,000 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,000 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule tête enseignante, pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».