Working together with older adults with multiple chronic conditions and their family caregivers to promote optimal aging at home.
The Aging, Community and Health Research Unit (ACHRU) Community Partnership Program (ACHRU CPP) is a 6-month self-management intervention for older adults with diabetes and other chronic conditions and their family/friend caregivers, designed to improve Quadruple Aim outcomes: 1) population health, 2) patient/caregiver experience, 3) provider experience, and 4) cost. The research program builds on evidence of ACHRU CPP feasibility and effectiveness from our prior work and is designed with scale-up in mind
The approach is a six-month multi-faceted, evidence-informed intervention designed to integrate care across settings to improve the quality of care and health outcomes in community-living older adults (i.e., people ≥ 65 years) with diabetes and at least one other co-morbid condition, and to support their family/friend caregivers.
This intervention consists of four main components that use the expertise of health care providers from various disciplines and involves a partnership between primary care and community-based organizations:
Nurse-led care coordination and system navigation;
Home visits by certified diabetes educators (Registered Nurses and Registered Dietitians) from Primary Care linked Diabetes Education Programs;
Monthly community-based group sessions, jointly hosted by a community partner (e.g., YMCA) and a Primary Care linked Diabetes Education Program;
Monthly case conferences for the intervention team
Evidence has shown that older adults who received the ACHRU CPP in Ontario had statistically significant greater improvements in quality of life – including mental health – and self-management, and a greater reduction in depressive symptoms compared to those receiving the usual diabetes care. The intervention was well received by patients, caregivers, and service providers. These improvements were achieved at no additional cost to the system as a whole. Preliminary evidence also suggests that the ACHRU CPP will provide benefits and be cost saving when implemented at scale.
Person-centered Care for High Needs/High User Patients
Implementation of the intervention in the diverse populations of Ontario, Quebec and Prince Edward Island, where the subjects are deliberately recruited from some of the most vulnerable populations, will definitively address what works and what doesn’t work, and why. This will provide the information required to revamp existing diabetes and chronic disease management programs which must be customized to serve each unique population.
General Model for Scale-up of Interventions to achieve Province-wide Outcomes
In addition to providing evidence to scale up the ACHRU CPP, this program will test a general model for “Implementation at Scale”. In collaboration with the Diabetes Action Canada Knowledge Translation program, the scalability of their program will be assessed and new sites for implementation identified. The outcomes of this work will advance implementation science by providing practical real-world information about the steps, processes, roles and responsibilities required to take a promising intervention from a research setting to widespread adoption in Ontario, Quebec and Prince Edward Island. By bringing researchers together with patients, ministry, health service providers and community partners, the plan for implementation at scale will be refined and co-designed to meet the needs of all stakeholders who will be involved in funding, delivery or receipt.
Increase Capacity toward a Cross-Sector Learning Health System
This study is designed to serve as a mechanism to exchange cross-sector learnings. Implementation of the intervention forges collaborations through regular communications and joint training, the result being that diverse service providers learn from each other and gain knowledge about the contributions which other sectors make toward person-centred care.