Through this process, it was possible to define the features of an intervention in elderly care that met the professionals' and managers' expectations. Indeed, the stepwise approach comprised three steps, each of which led to specific results. In the first step of the pre-intervention study, we gathered data on practices, perceived issues, and broad expectations of healthcare professionals and managers. Participants shared the same perceptions regarding current practices and issues in elderly care. This step revealed the processes that lead to adverse outcomes and that needed to be improved through the intervention.
The second step involved multidisciplinary focus groups, which were held to define the characteristics of a customized intervention. Overall, the investigators' role in iterative data collection and focus group facilitation helped participants define the key objectives of the intervention. These key features were identified at the clinical, structural, and process levels.
Current practices and perceived issues in elderly care
Main challenges
While caring for older persons in good health or with a single chronic problem seemed relatively straightforward to the participants, all participants mentioned the difficulties they encountered caring for 'their' very frail older persons with complex and multidimensional chronic conditions:
PCP D: 'Managing care for older people is complicated and time-consuming when they have a lot of problems. It's emotionally draining, it exposes your shortcomings.'
PCPs were identified as the key clinicians for frail elderly persons. PCPs felt responsible for their patients, and other participants confirmed this essential role, highlighting the loyalty felt by patients towards their PCPs:
PCP R: ' [As] the patient's family physician, I'm in a key position.
Home-care worker H: The woman felt close to this physician who didn't examine her. I told her to change, but she felt close to him. She trusted him.'
Inadequate needs assessment process within primary care
The participants agreed that the needs assessment process was not centered on common geriatric syndromes, but rather on acute medical problems. PCPs recognized that they were concentrating on the patients' complaints and the assessment of acute medical needs:
PCP C: 'We check to see if the problem is medical, but helping them and all that – we don't know how. There are geriatrics assessment sheets and forms, but we don't use them.'
Moreover, the assessment process did not employ a multidisciplinary approach. When other professionals (nurses, social workers, et al.) were involved, they performed their own needs assessments, which were not usually communicated to PCPs, creating incongruence between medical, functional, and social needs assessments:
Community-based nurse N: 'I'm quite aware when someone has difficulty breathing, when there's a change in their condition. I don't contact their physician directly, but I'll speak to the patient's wife about it.'
Inadequate coordination of primary care services
In practice, no one was responsible for coordinating services. PCPs often tried to play this role, but they did not have enough time and sufficient knowledge of existing services. Coordination problems were identified by all the participants, such as poor knowledge of each others' roles and poor communication and collaboration, particularly between social and health services:
Community-based social worker H: 'A woman with dementia was living with her daughter who could no longer handle all the responsibility. I would hope that [the PCP] would remember that home care services are available.'
Moreover, fee-for-service remuneration of PCPs and some other healthcare professionals was seen as one of the barriers to coordination, since the time they spent coordinating tasks was not compensated:
Community-based health service manager one: 'We need to know each other better. I'm glad I'm finally getting to see people in this meeting who I have only known by name.'
Community-based social service manager three: 'While the [PCP] is coordinating, he isn't with the patient, so he won't be paid (...). We can't get him to attend our meetings.'
Inadequate coordination of primary and secondary care
All participants found that inadequate coordination between primary and secondary care led to poor continuity of care. Hospital-based professionals acknowledged their poor knowledge of community-based services and the pressure to transfer patients quickly, which led to poor service planning at discharge and a lack of communication with community-based services:
Emergency physician B: 'We [hospital physicians] feel pressure over the length of hospital stays, and it results in not having the time to organize hospital discharges.'
Geriatrician H: 'The problem is that everyone works quite independently. When a patient returns home, sometimes it's just organized on the fly. We don't always know who was involved before the hospitalization.'
PCPs felt that access to hospital-based specialists, including geriatricians, was too complicated when they needed a consultation. Moreover, because PCPs were not routinely notified about patient discharges and decisions made during the hospitalization, it was difficult for them to make appropriate decisions after discharge:
PCP D: 'From time to time, we don't know what to do. (...) We don't know what occurred during the hospitalization... The hospital has no idea how we work. They've changed medications at the hospital, and we don't know why.'
Perceived consequences for patients and families
All participants felt that because of the problems identified, the overall needs of older persons were not being recognized or met in a timely manner, leading to 'crisis' situations. Consequently, while PCPs knew that an emergency room visit is an adverse experience for older patients (eg, long waits, use of restraints), they were still using it inappropriately (eg, falls, overextended families) because it was the only way for them to gain access to a geriatric assessment:
PCP A: 'After you've made four or five calls to the hospital and had no success or your request has been refused, you give up. We send them to the emergency room; at least we can be sure that they'll get a hospital bed.'
Moreover, transitions between settings were performed with insufficient exchange of information between clinicians. When the patients were discharged, their PCPs were not fully debriefed by the hospital, raising the risk of inappropriate care that would lead to a new crisis situation and a return to the emergency room. Hospital physicians were not clearly informed about the medical condition leading to the hospitalization, and they lacked information needed to make appropriate decisions. Poor coordination of care was therefore generating a vicious circle of emergency room visits and hospitalizations.
Finally, families were left too often with a significant burden. They tried to compensate for the lack of communication and coordination, but felt overwhelmed. When patients did not have family members to perform these coordination tasks, healthcare professionals had to consider institutionalization, even if the elderly patient wanted to be cared for at home:
Hospital social worker M: 'Most of the time, it's the service that gives the information to the family on how to complete the hospital discharge and apply for home services.'
Hospital nurse J: 'Before discharge, you need to determine if the family is ready to manage patient care. If the family is unavailable, if they work or live abroad, it won't work. So we look for an institutional placement.'
Defining characteristics of the intervention
The participants defined a proposal for change that included the objectives of the intervention and the key features needed to attain these objectives. More specifically, two main intervention objectives were deemed essential by all participants: improving quality of care for very frail older persons and preventing unnecessary hospital and emergency room use and unwanted institutionalizations:
PCP D: 'This is why our approach needs to change, so that we can provide better care and organize the care needed to keep patients in their homes.'
In order to meet these objectives, participants requested, first, that the intervention rely on multidisciplinary primary care and that the PCP remain the main medical practitioner. Participants felt that primary care should be strengthened by introducing an ongoing formal case-management process. This would include a multidimensional geriatric needs assessment, the development and implementation of care plans, coordination of services, and follow-up. This process would be supported by a multidisciplinary team of health professionals, with case managers collaborating closely with PCPs:
PCP S: 'If the case manager could take care of social problems and home care, that could help avoid hospitalizations, particularly if they can provide a rapid response (...).'
Second, participants requested the integration of primary and specialized care. Coordination between primary and specialized care needed to be improved through better service planning and better communication of relevant information at hospital discharge. Case managers would participate in the transition from hospital-based to community-based services. Moreover, PCPs expected to be informed of the care provided and decisions made during hospital stays. They wanted improved access to scientific evidence through the introduction of evidence-based protocols. In addition, they expected collaborative practices with geriatricians through the introduction of community-based geriatricians working as consultants, but they wanted to remain responsible for medical decision-making. PCPs would also be allowed to recommend direct hospital admissions rather than send their patients to emergency services:
PCP B: 'Easier access in order to hospitalize directly, without going through emergency. It's a question of trust with family physicians.'
Finally, the participants did not want any changes made to existing funding mechanisms for hospitals and community-based services:
Funding authority administrator two: 'The professionals are different, but so is the funding. And we aren't ready to combine budgets.'