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Multilevel approach to Patient and Family Centered Care for Elderly Islanders

  • kelseyphelan3
  • Jul 3, 2022
  • 7 min read

Updated: Jul 30, 2022



The multilevel model of care that caught my interest and applied to my population was ‘A New Model of care for PEI’(Health PEI, 2009). PEI is a very small place with limited resources. Similar to many rural areas in the larger provinces. We have an aging population that is expected to keep growing, as seen in the chart below. We need to prioritize proper care for our aging Islanders. One of the key parts is ensuring that the care is patient and family centered care. PFCC dates back to health care post World war II.(Rawson, 2016). Teaching the patient to care for themselves and having their families present to aid in the care makes a world of difference. Patients have more positive outcomes when family support is available which leads to shorter hospital stays and lower health care costs.


The framework for that future vision of care has 4 main levels that center on the patient's care. The 4 levels are: people, processes, information and technology(graphic below). People need to know their roles and apply their skills where they have the biggest impact. As discussed in previous forums, we have a shortage of registered nurses across Canada. We can make a change to the roles by bringing licensed practical nurses and resident care workers to take on certain tasks. This can free up some nurses for home care teams to care for elderly people in their homes.With this team in place the patients should get better and more efficient care. It can be difficult to change people's roles and takes time and effort to ensure those changes take place. A well thought out framework and evidence based sources help people realize this is for the greater good of the patients.





They ‘identified a number of processes that need to be changed if any new model is going to be effective including: integrated plans of care, discharge planning, medication administration, patient navigation, care coordination within the team, care management. Standardization of these processes across PEI is viewed as a critical issue. The need to involve patients and their families more directly in their own care was also seen as an important principle for the new model’ (Health PEI, 2009). Streamlining these processes makes better use of time and resources that can be used elsewhere.


‘Information is currently viewed as a serious “disenabler” of integrated care delivery. Information flow is described as fragmented both within and across sectors along the continuum’ (Health PEI,2009). I have first hand experience with this. We have several different electronic systems used for patient information. You have to access a couple different systems to obtain all of the information needed to care for a patient. The government is still working on simplifying this and creating an Island wide electronic medical record system.


We need access to low and high tech equipment. Low tech being wheelchairs, stretchers, blood pressure cuffs, etc. High tech is the information systems(ie Electronic Medical Record) and MRI machines, etc. Without the proper technology a system can not be efficient or provide the best care for patients and their families.


The model they are working from focuses on community care, long term care and hospital/acute care. They want to enable people, most commonly the elderly to care for themselves so they can stay in their own homes for longer. We have a great sense of community in our small province, which supports this model. Care from family and friends enables this to happen. By using tools like interRAI we can assess the patients needs, strengths, and preferences. It focuses on the patient's functional ability and quality of life. ‘The early stages of implementation are characterised by the need to address issues like resistance to change, unfamiliarity with new assessment procedures and clinical terminology, limited computer literacy, introduction of data submission standards and reorganisation of business processes to eliminate redundant or unnecessary documentation’(Hirdes,2006). As Hirdes says, these new tools are often met with resistance. People can be very uncomfortable and intimidated by change. We need to see the potential in the system. The home care plan can be customized to meet the needs of each patient. I have included a video describing how keeping islanders their homes is our goal.



Service processes need to be streamlined for easy access. One way to do this is to create multi-disciplinary teams called medical neighbourhoods (Jenkins, 2022) with access to electronic medical records. The basic idea is ‘The "home'' is the family doctor, who will coordinate each patient's care, and the "neighbourhood" is an integrated team of other health-care providers, which could include nurse practitioners, diabetes nurse educators, and dietitians among others. The person's overall medical care will be documented and communicated through an electronic health record’ (Bruce, 2021). There are similar models in New Brunswick and Nova Scotia. Ontario also has collaborative care models. In Ontario, ‘there is widespread concern in the popular media that population ageing will have catastrophic financial consequences, it is generally felt that population ageing has played a minor role in rising health expenditures in Canada [2], and it will be possible to cope with the costs of caring for future cohorts of the elderly if we manage the health care system appropriately’(Hirdes, 2006).The initial costs are more expensive but it helps address the determinants of health sooner so patients are healthier in the long run which saves money.


‘The future financing of healthcare and social services in Canada. These discussions are of particular relevance to Canadian elders both because the growth in their numbers is often perceived as one of the contributors to the need for change and because they have a major stake in the outcome’ (Beland,1995). The current healthcare system has many financial challenges ahead, one of those being our aging population. As shown in the graph below healthcare costs increase drastically as we age but the taxes for that group decrease. Can our current healthcare system keep up as the financial demands increase? That is why we need new models to address these issues sooner to save money long term.



Another useful tool used to care for our aging Islanders is Telemedicine.Use of telemedicine decreases the amount of travel needed to access services not available on the Island. Travel that can be stressful and difficult for many of our elderly patients.

People will still need to travel for procedures but follow up can be done from the comfort of their home.Telemedicine allows families near and far to join in on the care of their loved one.


There is some overlap between the process and information. If we streamline the process then the information can be more accessible. Another task is making information accessible for our aging population. That can be a daunting task especially for elderly people. PEI has a Prince Edward Island Seniors’ Guide. Some of the topics include: active living activities, financial help, health, housing, and life long learning to list a few. All of which provide care in different capacities. There is also a 1-800 number for people who prefer that method of communication. PEI Seniors’ Guide is an excellent resource for many elderly islanders and their families.


Another program is Caring for older adults in the community and at home (COACH). ‘The COACH team provides direct patient care at home to predict, prevent or proactively manage health crises, and decrease the need for emergency services or admission to hospital. Outcomes of the COACH pilot program included a 66 percent decrease in inpatient admissions, a 33 percent decrease in emergency department visits and a 50 percent decrease in primary care visits (average appointments per month). The program enabled savings of $1.41 million’(Healthcare Excellence Canada, 2022). These programs can change the way we spend healthcare our dollars.


We also have a Geriatric program. ‘If you are an older adult with complex health needs, you may be referred by your family doctor for a geriatric assessment. The Geriatric Program’s interdisciplinary team provides specialized care and support to families that can help address health issues affecting the frail elderly’(Health PEI,2020). All of these programs provide information for elderly patients and their families to ensure they have the best care and quality of life.


The four levels of the framework work in conjunction to form the model. Without advancements in technology we wouldn’t have the EMR system, interRAI, or telemedicine. By using those tools we gain easier access to information. This streamlines the process and allows the caregivers to center the care on the patients and their families. By addressing health determinants sooner while people are in their homes we can make better use of healthcare dollars. All of this helps the model reach its goal of having patient and family centered care that is high quality and sustainable. This multifaceted model will adapt as needs change and new tools and processes develop.


References


Beland,F., Shapiro,E. (1995). Editorial: Policy Issues in Care for the Elderly in Canada.

Canadian Journal on Aging, 14(2), 153-158. file:///Users/kelsey/Downloads/editorial-

policy-issues-in-care-for-the-elderly-in-canada.pdf


Bruce,Steve.(2021,February 24). P.E.I. to launch new health-care model in 3 communities.


Canadian Foundation of Healthcare Improvement. (2018, April 25). Prince Edward Island tells

families, “You’re welcome to stay.” https://www.cfhi-fcass.ca/about/news-and-


Healthcare Excellence Canada. (2022). Caring for Older Adults in the Community and at

Health PEI. (2020,June 9). Geriatric Program.


Health PEI (2020,April 9). Home Care Program - Government of Prince Edward Island.


Health PEI. (2018). Patient and Family Centered Care Newsletter.


Health PEI. (2009). A New Model of Care for PEI :Building a Plan to Improve Care Delivery


Health PEI (2009). Prince Edward Island Seniors’ Guide.


Hirdes, J,P.(2006, July 01). Addressing the health needs of frail elderly people: Ontario’s

experience with an integrated health information system. Age and Ageing, 35(4), 329-


Jenkins, Alison. (2022, May 12). Collaboration key to better health care in P.E.I. Saltwire.


PEI introduced interRAI for home care. (2022, May 25). Canadian Healthcare Technology.


Rawson,J,V., Moretz,J. (2016,December). Patient- and Family-centered Care: A Primer.

Journal of the American College of Radiology, 13(12), 1544-


Zeidenberg,Jerry. (2021,March 29). PEI to create ‘medical neighborhoods’ using new EMR.

Canadian Healthcare Technology.https://www.canhealth.com/2021/03/29/pei-to-


 
 
 

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