Integrated Care for Older Adults Living with Complexity: Elements of Design

The May 2021 blog post written by Provincial Geriatrics Leadership Ontario. 

Older adults have been identified by many Ontario Health Teams (OHTs) as a priority population of focus.

After identification, where to next in terms of population health management?

While OHTs grapple with understanding and scoping their older adult populations (we have created a resource for segmenting the older adult population and another with estimates of frailty by census division that can help), questions about implementation and care models loom large. Thus, the time is right for evidence-informed, practical guidance that describes how to deliver integrated systems of care for older adults.

What is the best way to care for older adults living with complex and chronic health and social needs?

Provincial Geriatrics Leadership Ontario (PGLO) sought to answer this question based on available evidence and translate evidence into resources that OHTs and specialized geriatric service (SGS) providers could use to develop and improve services for older adults. As the provincial body that coordinates perspectives in clinical geriatrics services (including care of the elderly family medicine, geriatric psychiatry, geriatric medicine, and interprofessional geriatric teams), PGLO reviewed and synthesized frameworks and models of integrated care for older adults to identify the best approaches to design and implementation.

Thirteen design elements were identified and published in a scoping review. These design elements can be applied at the micro (practice), meso (team), and macro (system) levels to guide the development of integrated care for older adults living with complex health and social needs. As a reflection of our multi-disciplinary membership and commitment to support health service design across the continuum of care, the 13 design elements can be applied to all care settings and regardless of geography. They can assist health system planners, policy makers, health leaders, and clinicians in their work to deliver better care for older adults living with complexity.

 We know that implementation is not sustainable without evaluation, though. In order to build on our design work, PGLO launched a second phase of our integrated care project – the Indicators for Integrated Older Persons’ Care in Ontario Initiative.

Despite the many indicators currently collected, and the many more that hold potential for valuable measurement, there is currently no consensus regarding which indicators should be used (e.g. we found 1900 in our first scan), how data should be collected, and how results ought to be reported relevant to older persons’ care.

Over the course of Spring/Summer 2021, we will provide a comprehensive set of indictors and associated tools that can be used to evaluate the systems of care for older persons, consistent with the 13 design elements of integrated care for older persons living with complex and chronic health and social care needs. For updates on this project and other PGLO initiatives, please visit our website and sign up for our monthly newsletter.