Preliminary Evaluation of a Shared-Care, Primary Care-Based Interprofessional Program to Support Older Persons Living with Frailty in the Community

Background/Purpose: Comprehensive Geriatric Assessment (CGA) is an effective intervention to support older persons living with frailty. In Canada, CGA is often provided through referral to hospital-based specialized geriatric services. However, access to CGA remains limited because of human resource shortages. Shared-care models, where geriatricians work alongside primary care providers, have shown promising results.Method: The Complex Care Program (CCP) at New Vision Family Health Network in Kitchener, Ontario is supported by nurse practitioners, clinical pharmacists, family physicians, and a geriatrician. High-risk patients, identified using the standardized Assessment Urgency Algorithm or physician referral, undergo CGA using the self-report interRAI Check-Up. A mixed-methods evaluation was conducted to characterize CCP clients and assess program impact on care quality, appropriate prescribing, emergency department (ED) visits, and provider and patient experience.Results: This analysis includes 76 patients. The mean age was 81.8 years and 71% were women. Median time in the program was 1.5 years. Patients had a high burden of multimorbidity, including 47% who had dementia. Patients were taking 12.8 medications on average. Following program admission, over 50% of patients were referred to community services and 83% received geriatrician assessment. On average, one medication was deprescribed and one optimized per patient. Overall, patients required fewer primary care visits. ED visit rates fell 50% from 1.325/100 patients annually to 0.675/100 patients. The program was well-received by patients, caregivers, and family physicians.Discussion: A shared-care primary care-based program to support community-dwelling older adults living with frailty was feasible, acceptable, and associated with improved care quality, better prescribing, and fewer ED visits.Conclusion: Geriatricians can effectively support CGA through shared-care models based in primary care. Future work includes assessing program scalability to other primary care settings.

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