Evaluating an Innovative Model of Interdisciplinary and Interagency Primary Care for Homebound Seniors

Background: Expanding on evidence-based models for home-based primary care, the Eastern York Region North Durham Ontario Health Team (Canada) launched the Seniors Home Support program in June 2021 to improve access to primary care for homebound seniors. Success of this program is in its patient-centered design, which has fueled the integration of geriatric and palliative care within a primary care service for a seamless patient experience across the continuum of care. Frail homebound seniors face a myriad of challenges to accessing traditional office-based primary care due to cognitive, physical, or social factors. Frailty, coupled with trends in increasing lifespans and chronic diseases, puts homebound seniors among the highest users of acute medical services and highly vulnerable to receiving fragmented care across health care settings. The Seniors Home Support program is a sustainable model of care that improves health care delivery and the patient and caregiver experience through one integrated team of primary care providers, nursing, allied health, and paramedics working across health sectors. Method: Using the quadruple aim, we evaluated the impact of an integrated primary care program on patient and caregiver experiences, provider satisfaction, health outcomes, and health system costs. Patient and caregiver engagement was imperative to ensure that results are meaningful. We elected using the Older Adult Experience Survey, a validated, evidence-informed tool created with older adult and caregiver co-design for specialized geriatric services. Prior to administration of this tool, we conducted informal consultations with caregivers to ensure suitability for the SHS population. Patient, caregiver, and provider surveys were administered between Aug to Dec 2023. Health outcomes were examined by estimating the number of hospital avoidance events that occurred since program inception. An extensive review of urgent care data using a standardized process and coding scheme developed by primary care and emergency care clinicians informed this process. We corroborated results of urgent care data with patient and caregiver experiences using the survey to ask if the program helped to avoid unnecessary hospital visits. Cost savings were calculated accordingly. Results and discussion: A preliminary scan reveals the following emerging themes: Responsiveness is a necessary outcome measure and highly correlates with patient and caregiver satisfaction Integrated home-based primary care prevents unnecessary hospital visits and reduces acute care service use Timely communication is pertinent to overall team functioning and positively reflected in patient, caregiver, and provider experiences This evaluation process has also highlighted key learnings such as how the quadruple aim framework can readily inform process improvement, and how continuous engagement strategies with partners (clinicians and leadership) can ensure a sustainable interagency program. Detailed analysis is planned for Jan 2024.