Protocol for a program of research from the Aging, Community and Health Research Unit: Promoting optimal aging at home for older adults with multimorbidity

Engagement of older adults with multimorbidity as patient research partners: Lessons from a patient-oriented research program

Background

Patient "engagement" in health research broadly refers to including people with lived experience in the research process. Although previous reviews have systematically summarized approaches to engaging older adults and their caregivers in health research, there is currently little guidance on how to meaningfully engage older adults with multimorbidity as research partners.

Objectives

This paper describes the lessons learned from a patient-oriented research program, the Aging, Community and Health Research Unit (ACHRU), on how to engage older adults with multimorbidity as research partners. Over the past 7-years, over 40 older adults from across Canada have been involved in 17 ACHRU projects as patient research partners.

Methods

We developed this list of lessons learned through iterative consensus building with ACHRU researchers and patient partners. We then met to collectively identify and summarize the reported successes, challenges and lessons learned from the experience of engaging older adults with multimorbidity as research partners.

Results

ACHRU researchers reported engaging older adult partners across many phases of the research process. Five challenges and lessons learned were identified: 1) actively finding patient partners who reflect the diversity of older adults with multimorbidity, 2) developing strong working relationships with patient partners, 3) providing education and support for both patient partners and researchers, 4) using flexible approaches for engaging patients, and 5) securing adequate resources to enable meaningful engagement.

Conclusion

The lessons learned through this work may provide guidance to researchers on how to facilitate meaningful engagement of this vulnerable and understudied subgroup in the patient engagement literature.

The complexity of caregiving for community-living older adults with multiple chronic conditions: A qualitative study

Background:

Older adults with multiple chronic conditions (MCC) rely heavily on caregivers for assistance with care. However, we know little about their psychosocial experiences and their needs for support in managing MCC. The purpose of this study was to explore the experiences of caregivers of older adults living in the community with MCC.

Methods:

This qualitative study was a secondary analysis of previously collected data from caregivers in Ontario and Alberta, Canada. Participants included caregivers of older adults (65 years and older) with three or more chronic conditions. Data were collected through in-depth, semi-structured interviews. Interview transcripts were coded and analyzed using Thorne’s interpretive description approach.

Results:

Most of the 47 caregiver participants were female (76.6%), aged 65 years of age or older (61.7%), married (87.2%) and were spouses to the care recipient (68.1%). Caregivers’ experiences of caring for community-living older adults with MCC were complex and included: (a) dealing with the demands of caregiving; (b) prioritizing chronic conditions; (c) living with my own health limitations; (d) feeling socially isolated and constrained; (e) remaining committed to caring; and (f) reaping the rewards of caregiving.

Conclusions:

Healthcare providers can play key roles in supporting caregivers of older adults with MCC by providing education and support on managing MCC, actively engaging them in goal setting and care planning, and linking them to appropriate community health and social support services. Communities can create environments that support caregivers in areas such as social participation, social inclusion, and community support and health services.

What Factors Shape Self-Reported Health Among Community-Dwelling Older Adults? A Scoping Review

Self-reported health is a predictive measure of morbidity and mortality across populations. A comprehensive understanding of the factors that shape self-reported health among community-dwelling older adults, a growing population globally, is lacking. The aim of this review was to summarize the factors that are associated with self-reported health among this population and identify key areas for future research. Accordingly, we conducted a scoping review using the stage-wise framework developed by Arksey and O'Malley. We summarized 42 factors, as identified in 30 publications, and organized them into four categories. Key factors shaping self-reported health included the presence of chronic conditions and depressive symptoms. As the population of community-dwelling older adults continues to increase, there remains a need to understand how these identified factors shape self-reported health. To date, empirical research has been limited to observational and cross-sectional designs. There is a need to further explore these factors in longitudinal data.

Study protocol for a hospital-to-home transitional care intervention for older adults with multiple chronic conditions and depressive symptoms: a pragmatic effectiveness-implementation trial

BACKGROUND

Older adults (> 65 years) with multiple chronic conditions (MCC) and depressive symptoms experience frequent transitions between hospital and home. Care transitions for this population are often poorly coordinated and fragmented, resulting in increased readmission rates, adverse medical events, decreased patient satisfaction and safety, and increased caregiver burden. There is a dearth of evidence on best practices in the provision of transitional care for older adults with MCC and depressive symptoms transitioning from hospital-to-home. This paper presents a protocol for a two-armed, multi-site pragmatic effectiveness-implementation trial of Community Assets Supporting Transitions (CAST), an evidence-informed nurse-led six-month intervention that supports older adults with MCC and depressive symptoms transitioning from hospital-to-home. The Collaborative Intervention Planning Framework is being used to engage patients and other key stakeholders in the implementation and evaluation of the intervention and planning for intervention scale-up to other communities.

METHODS

Participants will be considered eligible if they are > 65 years, planned for discharged from hospital to the community in three Ontario locations, self-report at least two chronic conditions, and screen positive for depressive symptoms. A total of 216 eligible and consenting participants will be randomly assigned to the control (usual care) or intervention (CAST) arm. The intervention consists of tailored care delivery comprising in-home visits, telephone follow-up and system navigation support. The primary measure of effectiveness is mental health functioning of the older adult participant. Secondary outcomes include changes in physical functioning, depressive symptoms, anxiety, perceived social support, patient experience, and health and social service use and cost, from baseline to 6- and 12-months. Caregivers will be assessed for caregiver strain, depressive symptoms, anxiety, health-related quality of life, and health and social service use and costs. Descriptive and qualitative data from older adult and caregiver participants, and the nurse interventionists will be used to examine implementation of the intervention, how the intervention is adapted within each study region, and its potential for sustainability and scalability to other jurisdictions.

DISCUSSION

A nurse-led transitional care strategy may provide a feasible and effective means for improving health outcomes and patient/caregiver experience and reduce service use and costs in this vulnerable population.

TRIAL REGISTRATION

# NCT03157999 . Registration Date: April 4, 2017.

An integrated hospital-to-home transitional care intervention for older adults with stroke and multimorbidity: A feasibility study

BACKGROUND

Stroke is the leading cause of death and adult disability in Canada. Eighty percent of older adults (≥65 years) who have suffered a stroke will return to their homes, and 60% will require ongoing rehabilitation. The transition between hospital and home is often fragmented, leading to adverse health outcomes, hospital readmissions, and increased health-care costs. This study examined the feasibility of a 6-month integrated transitional care stroke intervention (TCSI), and explored its effects on health outcomes, patient and provider experience, and cost in 30 community-living older adults (≥55 years) with stroke and multimorbidity (≥2 chronic conditions) using outpatient stroke rehabilitation services.

METHODS

The TCSI is a 6-month intervention delivered by an interprofessional (IP) team (occupational therapist, physiotherapist, speech language pathologist, registered nurse, social worker). It involved care coordination, home visiting, and IP case conferences, supported by a web-based application. A qualitative descriptive approach was used to explore the feasibility of implementing the intervention. A prospective one-group pretest/posttest was used to evaluate the effects of the intervention on health outcomes and use and costs of health services, from baseline to 6 months.

RESULTS

Participants had an average of eight comorbid conditions. The intervention was feasible and acceptable to both older adults and providers. From baseline to 6 months, there was no statistically significant difference in health outcomes. However, there was a significant reduction in the total per person use and costs of health services.

CONCLUSIONS

This study established the feasibility of conducting a larger randomized controlled trial of this intervention.

Capacity development among academic trainees in community-based primary health care research: The Aging, Community and Health Research Unit Experience

Health care system capacity and sustainability to address the needs of an aging population are a challenge worldwide. An aging population has brought attention to the limitations associated with existing health systems, specifically the heavy emphasis on costly acute care and insufficient investments in comprehensive primary health care (PHC). Health system reform demands capacity building of academic trainees in PHC research to meet this challenge. The Aging, Community and Health Research Unit at McMaster University has purposefully employed a capacity building model for interdisciplinary trainee development. This paper will describe the processes and outcomes of the model, outlining how the provision of funding, mentorship, and a unique learning environment enables capacity building in networking, collaboration, leadership development, and knowledge mobilization among its trainees. The reciprocal advancement of the research unit through the knowledge and productivity of trainees will also be detailed.

Burden on Caregivers of Adults with Multiple Chronic Conditions: Intersectionality of Age, Gender, Education level, Employment Status, and Impact on Social Life

Intersectionality analysis is the study of overlapping or intersecting social identities. Intersecting social identities may have an impact on the perception of burden by family caregivers of older persons with multiple chronic conditions (MCC). The purpose of this study was to explore the interaction of social factors on the burden of caring for older adults with MCC. A total of 194 caregivers of older adults with MCC were recruited from Alberta and Ontario. Survey data were collected at two time points, six months apart. Additive and multiplicative models were analysed using a generalised linear model to determine the level of caregiver burden. Medium-high social interference (impact on social life) was associated with higher burden when adjusted for age, gender, education, and employment status. The overall results of the five-way interaction suggest that males in general had lower burden scores than females. Irrespective of their education and employment status, females had generally higher burden scores. These results add to the current body of literature, suggesting areas for further research to fill knowledge gaps, and promoting ideas for evidence-guided public health interventions that focus on caregivers.

Insights on multimorbidity and associated health service use and costs from three population-based studies of older adults in Ontario with diabetes, dementia and stroke

Background

Most studies that examine comorbidity and its impact on health service utilization focus on a single index-condition and are published in disease-specific journals, which limit opportunities to identify patterns across conditions/disciplines. These comparisons are further complicated by the impact of using different study designs, multimorbidity definitions and data sources. The aim of this paper is to share insights on multimorbidity and associated health services use and costs by reflecting on the common patterns across 3 parallel studies in distinct disease cohorts (diabetes, dementia, and stroke) that used the same study design and were conducted in the same health jurisdiction over the same time period.

Methods

We present findings that lend to broader Insights regarding multimorbidity based on the relationship between comorbidity and health service use and costs seen across three distinct disease cohorts. These cohorts were originally created using multiple linked administrative databases to identify community-dwelling residents of Ontario, Canada with one of diabetes, dementia, or stroke in 2008 and each was followed for health service use and associated costs.

Results

We identified 376,434 indviduals wtih diabetes, 95,399 wtih dementia, and 29,671 with stroke. Four broad insights were identified from considering the similarity in comorbidity, utilization and cost patterns across the three cohorts: 1) the most prevalent comorbidity types were hypertension and arthritis, which accounted for over 75% of comorbidity in each cohort; 2) overall utilization increased consistently with the number of comorbidities, with the vast majority of services attributed to comorbidity rather than the index conditions; 3) the biggest driver of costs for those with lower levels of comorbidity was community-based care, e.g., home care, GP visits, but at higher levels of comorbidity the driver was acute care services; 4) service-specific comorbidity and age patterns were consistent across the three cohorts.

Conclusions

Despite the differences in population demographics and prevalence of the three index conditions, there are common patterns with respect to comorbidity, utilization, and costs. These common patterns may illustrate underlying needs of people with multimorbidity that are often obscured in literature that is still single disease-focused.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4149-3) contains supplementary material, which is available to authorized users.

Feasibility and preliminary effects of an integrated hospital-to-home transitional care intervention for older adults with stroke and multimorbidity: A study protocol

BACKGROUND

Stroke is a major life-altering event and the leading cause of death and disability in Canada. Most older adults who have suffered a stroke will return home and require ongoing rehabilitation in the community. Transitioning from hospital to home is reportedly very stressful and challenging, particularly if stroke survivors have multiple chronic conditions. New interventions are needed to improve the quality of transitions from hospital to home for this vulnerable population.

OBJECTIVES

The primary objective of this study is to examine the feasibility of implementing a new 6-month transitional care intervention supported by a web-based app. The secondary objective is to explore its preliminary effects.

DESIGN

A single arm, pre/post, pragmatic feasibility study of 20-40 participants in Ontario, Canada. Participants will be community-dwelling older adults (≥55 years) with a confirmed stroke diagnosis, ≥2 co-morbid conditions, and referred to a hospital-based outpatient stroke rehabilitation centre. The 6-month transitional care intervention will be delivered by an interprofessional (IP) team and involve care coordination/system navigation, self-management education and support, home visits, telephone contacts, IP team meetings and a web-based app. Primary evaluation of the intervention will be based on feasibility outcomes (e.g. acceptability, fidelity). Preliminary intervention effects will be based on 6-month changes in health outcomes, patient experience, provider experience and cost.

CONCLUSIONS

Information on the feasibility and preliminary effects of this newly-developed intervention will be used to optimize the design and methods for a future pragmatic trial to test the effectiveness and implementation of the intervention in other contexts and settings.