Let's change the lens on seniors' care

Our daring idea for health care in Alberta

June 7, 2017

Sheny Khera, MD, CCFP (COE), FCFP, MPH (left) and Marjan Abbasi, MD, CCFP, CAC (COE) (right)

Contributed by: Sheny Khera, MD, CCFP (COE), FCFP, MPH (left) and Marjan Abbasi, MD, CCFP, CAC (COE) (right)

The proportion of Canadians 65 years and over is growing more rapidly than any other age group. According to Statistics Canada data from 2005, seniors will account for 22.8% of the Canadian population by 2031. Frailty and chronic complex conditions, both more common in seniors, have emerged as drivers of high health care utilization, such as emergency visits and hospital admissions. Social costs, such as dependency and caregiver burden are also increasing. As a result, seniors’ care is a priority for our current health care system, and this necessitates health reorganization and innovative models of care delivery to meet growing needs.1

Successful transformation of care requires a change in the current lens on seniors’ health. First we need to be mindful that the majority of Canadian seniors are in good health, financially secure, well housed and safe. They are active and key contributors to society by paid or volunteer activities. Secondly, given that individuals are living longer, they are more likely to be living with complex comorbidities and the current health system has not kept up with this demographic shift. While care has long been in the hospital (which worked when health issues were predominantly acute in nature such as infections and injuries), current needs and trends necessitate a more community-centric, proactive care model that embraces prevention, upstream health promotion and chronic disease management in an aging population.

Achieving an integrated model of seniors’ care requires collaborative efforts supported by policy and funding to ensure that the right blend of supports and services are provided in the right place at the right time. Evidence shows that integrated care systems that coordinate care and promote continuity are associated with better patient experiences, improved quality of care and improved efficiency of health and social services.2

Here are some steps toward an integrated model of seniors’ care that can be achieved right now.3

Walk the journey of care as experienced by seniors and caregivers

Explore the gaps and opportunities in care from prevention through to end-of-life. Involve seniors and caregivers in service redesign, especially at transitions/interfaces across the continuum of care. Solicit important values and priorities from people.

Network with other organizations to collectively commit to health system change

Engage in conversations on shared overarching vision of seniors’ care, develop key standards of care across the continuum and share funds to achieve common outcomes. These key outcome measures should include outcomes that matter to patients and should define the performance indicators of services provided.

Design components of care for seniors along the spectrum of care needs

Think in terms of care needs for seniors who are:

  • Fit and aging well (health promotion)
  • Vulnerable (self-management, physical/mental/social supports)
  • Living with frailty (primary health care teams working with seniors and caregivers in care and support planning/navigational support)
  • Needing end-of-life care (coordinated palliative care services, early discussions of care goals)

Share experiences and lessons learned from local innovative leaders/services/strategies for collective benefit

Several Alberta initiatives in primary care are underway creating fertile ground for innovations in care delivery, such as primary care network evolution and strategic clinical networks. These can aid the collaboration between primary care physicians, specialists, inter-professional teams, patients and family/caregivers. We can learn from the transformations in the acute care and community care circles, such as elder-friendly units, enhanced geriatric skills of health care workers and outreach community care services for seniors and caregivers.

Changing the seniors’ care system may seem overwhelming, but it can be done. And it can be started right now. No single best-integrated system exists. The system needs to arise out of the local context and be a collaborative effort between local catalysts of change, patients and families, care providers and stakeholders both from bottom-up and top-down approaches. These efforts in designing a value-based, person-centered, integrated model of care that aims to understand and meet the needs of seniors and care providers will improve the health care system for all of us.

References available upon request.

The Alberta Medical Association stands as an advocate for its physician members, providing leadership & support for their role in the provision of quality health care.