Using technology to support frail patients in the community

Discussing frailty with our loved ones as we age is not something most people are comfortable with.  

Neither is discussing our wishes for care during an inevitable health crisis, which is increasingly likely as a person’s level of frailty increases.

Primary Health Care and the Palliative and Therapeutic Harmonization (PATH) clinic (part of the Division of Geriatrics, Nova Scotia Health Authority) have developed a web-based tool for family physicians that is currently in a pilot phase to support the assessment and care of patients who are frail.

Frailty refers to an accumulation of health issues that often occur with aging.  As individuals age health issues can accumulate and when this occurs the result can be declining function, impaired mobility, cognitive impairments and unmanageable symptoms. 

“I might see an older patient who seems to be doing fairly well, but in fact has a few health issues that makes them vulnerable and frail,” says Dr. Iona Wile, family physician, Hants Community Hospital, Windsor.  “Completing this frailty assessment helps to quickly determine their level of frailty, and this tool identifies several concerns we should talk about with our frail seniors, such as what would this patient do if they experience a health crisis, such as a stroke for example.”

“How would they and their families manage in that situation?  Who would be their substitute decision maker? Many seniors don’t talk about advanced directives with their family, and my role is to encourage these discussions with my patients.”

Frailty refers to the accumulation of health issues that often occurs with aging.  

“It’s a predictor of risk for poor health outcomes as a person ages, including increased need for home support resources, increased health care use, and eventually, death,” says Dr. Rick Gibson, Department of Family Practice Chief, Central Zone, Nova Scotia Health Authority.

“With Nova Scotia’s aging population, there are probably thousands of citizens who are currently frail in the Halifax, Eastern Shore and West Hants communities, and tens of thousands who will become frail over the next few years.”

Over the past two years, Primary Health Care and the Department of Family Practice have been identifying and implement activities to strengthen health care for the frail elderly with the intent to reduce the incidence of adverse events for patients.  

This frailty portal created with two of the PATH clinic’s geriatricians is one example of an initiative that is underway, and that is part of the organization’s broader frailty strategy.

“I wanted to be a part of trying out the frailty portal as the concept is perfect to support primary care providers to screen for frailty and cognitive impairment in an efficient way,” says Dr. Wile.  

“It’s fairly quick and easy to use, at my finger tips, and once I started using it, now I use it all the time.”

“As an example, when I do a consult for falls in an elderly patient, I also do a cognitive and functional assessment and include that information in the portal.”

“Once it generates a frailty level, in follow-up care for this patient, any health care provider who uses the frailty portal will be able to adjust the scores in cognition and function as the person ages and experiences changes in their health. The care plan is reviewed as needed.”

A person’s frailty level is determined by using a nine-point scale, from thriving and normal aging, through vulnerable and moderately frail, to severely frail and terminally ill.

Each level in the frailty portal has suggested evidence-based care guidelines that a family physician or nurse practitioner can use as a tailored resource in their overall care plan to support patients in their practice who are frail.

“I do an average of four assessments each week using the frailty portal; it takes about 15 minutes,” says Dr. Wile.  

“I use the information provided from the assessment to put a care plan together for the patient.  This includes informing the patient and their family about planning for the future, discussing advanced directives and concepts such as enduring power of attorney, having a substitute decision maker, and what they might do in a health crisis.”

“We have a conversation about health knowledge and attitude, what co-morbidities mean in terms of choices in health care for their future.”

Once the phase two pilot testing of the frailty portal is complete, it is expected to be available for use in family practices in the Halifax, Windsor and Eastern Shore in fall of 2015.