Co-designing a framework for integrated home care planning with older adults, family caregivers and health care providers

Abstract

Background: Older persons want to remain in their own homes as long as possible, making home care services essential for maintaining independence, completing daily activities and delaying entry into institutional care 1. While home care has the potential to improve health and well-being and reduce health care costs, provision of these services to the geriatric population is complicated by complex, multi-morbid health issues requiring care from a range of providers who work in isolation of each other. Improved integration from planning through delivery is a key priority for Canadian home care 2. Aims: This study aimed to develop an implementation framework for an integrated geriatric care planning approach in home care. Key objectives were to: a investigate current geriatric assessment practices; b collect ideas for improving person- and family-centred goal setting; and c co-design solutions for more integrated geriatric care planning with older adults, family caregivers and health care providers. Methods: This study applied a sequential transformative mixed methods design 3. Quantitative data were collected through a web-based survey that was developed with and delivered to frontline home health care nurses, occupational therapists and physiotherapists n=303. Qualitative data were collected in-person through solutions-focused key informant interviews with older adults and family caregivers n=24. Statistical and thematic analysis of the data was iterative and ongoing. Survey and interview data were brought together during the interpretation phase, where older adults, family caregivers, and health care providers n=19 were engaged in a workshop to co-design solutions for more integrated geriatric home care planning. Results: An implementation framework for integrated geriatric care planning in home care was developed. Components of the framework include: a common clinical and non-clinical information needed by everyone involved; b key touch points and actions for achieving the integrated care planning experience everyone involved wants; and c nine ideas for tools and technology to support integrated data collection, goal-setting and communication. Conclusions: Older adults, family caregivers and health care providers have both common and unique needs for sharing and receiving information to support planning care in the home. Home care planning should begin with a holistic baseline understanding of an individual person that prioritizes and applies information on personal background, goals, needs and preferences in seeking to understand individuals’ health challenges and plan for their care. Limitations: This study was conducted in a single region within Ontario, Canada. Suggestions for Future Research: Next steps for this research include additional co-design workshops in other regions, to develop prototypes of these new processes and tools for integrated geriatric care planning to be pilot tested in home care practice.