Approval for this study was obtained from the Research Ethics Board of the Hamilton Health Sciences Faculty of Health Sciences.
For the pilot study, seniors older than 75 years of age at SFHC were randomly assigned numbers using a random number generator to be contacted by telephone to evaluate their risk of cognitive impairment and falling. summarizes telephone-screening results.
Table 1 Telephone screening questions to identify seniors at risk:
Of 163 calls, contact was established with 114 seniors and 76 completed the telephone screen; of the 51 identified as at risk, 31 accepted the appointment for further review and 25 attended for (more ...)
Seniors identified as at risk by telephone screening were invited for further assessment. Screening continued until 25 seniors were evaluated. summarizes their demographic characteristics, wait times, and nutrition, cognitive, and depression scores.14–17
Characteristics of patients screened by telephone and recruited for the pilot phase:
N = 25 (7 men and 18 women).
, showing time spent by SCCP members with direct and indirect pilot patient care, demonstrates the prominent role of the NP and the focused role of the geriatrician.
Time spent by patients and SCCP practitioners with direct and indirect care during the pilot phase
Interviews were conducted to obtain opinions about the successes and limitations of the program. All pilot patients were invited to provide feedback approximately 2 weeks after the intervention. Six patients or caregivers consented to interviews. All 5 NPs and all 5 FPs attached to pilot study patients consented to interviews. A combination of Likert ratings and open-ended questions were used to determine satisfaction with the program. Interviews and open-ended responses were audiotaped, transcribed, and evaluated for thematic content. Patients, NPs, and physicians who provided feedback were highly satisfied with the program overall and agreed it was worthwhile for seniors ().
Satisfaction of pilot study patients, NPs, RPNs, and FPs with the SCCP
Participants identified several common themes that made the program workable or that were benefits of involvement. For practitioners, the ease of access facilitated by short wait times and the flexibility to have services in patients’ homes were important. They also identified fast and effective communication among team members as contributing to program success. Several respondents commented on the benefits of multidisciplinary contributions that provided information and support from multiple perspectives.
One of the most important factors identified was the preventive nature of the program, which in some cases included identification and elimination of home fire and falling hazards, food procurement problems, and caregiver exhaustion. Practitioners reported that identification of problems and potential hazards allowed the team to put plans in place quickly to prevent crises. As a result, it is possible that patients might have been able to be maintained at home rather than going into an institution, although this was not measured. Nurses and FPs appreciated the opportunities for SFHC learners, who are involved in all stages of care, to learn about a growing segment of the population for their future work.
Although seniors expressed satisfaction with the program and found it worthwhile (based on Likert ratings), responses to open-ended questions indicated that they did not have sufficient recollection of the program to provide detailed commentary.
Respondents reported confusion with defining roles and responsibilities between SCCP practitioners and the patient’s main care team (eg, who responds to telephone calls from patients and caregivers). Roles and expectations are now clarified during initial team meetings.
Patients are no longer recruited by telephone, as this case-finding method is inefficient. The FPs and other allied providers at the SFHC now identify which seniors they require assistance with and refer them for any issue. Seniors are no longer screened for pilot-study inclusion criteria (risk of falling and cognitive impairment). Since completion of the pilot project, approximately 4 patients per month are now referred and reviewed. summarizes the characteristics of these referred patients, which are similar to those of pilot study patients in terms of age and cognitive scores.14–17
The pilot study is too limited to make further comparisons between seniors identified by telephone screening and those referred to the program. The average wait time for referred patients is 32 days. As illustrated in ,14–17
these patients are at high risk of medication complications and cognitive impairment, and are primarily referred for “cognition concerns” (51%) and “multimorbidity” (41%).
Characteristics of referred patients reviewed by the SCCP since completion of the pilot phase:
N = 67 (25 men and 42 women).