Speaker
Description
Background
Older adults with complex care needs often face challenges navigating fragmented health and social services, resulting in unmet needs, caregiver burden, and inequitable access to care. Within a Toronto Family Practice Elder Care Program (ECP), providers identified gaps in awareness and coordination of community supports. Guided by the RNAO Person- and Family-Centred Care Best Practice Guideline, this quality improvement initiative adapted evidence-based recommendations to improve accessibility, patient engagement, and care coordination. A provider survey (N=9) identified limited social support as the greatest barrier to quality senior care.
Aim
To increase uptake of community resources by 80% among seniors enrolled in the ECP by September 2024 using standardized, person-centred navigation strategies.
Methods
Using Plan–Do–Study–Act (PDSA) cycles, an interprofessional team co-designed interventions tailored to seniors’ needs. PDSA Cycle 1 developed a standardized, culturally sensitive community resource directory in collaboration with the Family Practice Patient and Family Advisory Committee. PDSA Cycle 2 evaluated resource delivery methods, including written handouts, website access, and verbal instruction. Outcome measures tracked service uptake, while balancing measures assessed patient and provider satisfaction.
Results/Outcomes
At baseline, 83% of seniors entered the ECP without community supports. Following implementation, 78% of seniors who received written handouts accessed at least one recommended service, compared with 8% of those receiving online-only resources. Patients reported increased confidence in navigating services and greater satisfaction with care coordination. Providers reported improved efficiency and consistency in addressing social determinants of health.
Lessons Learned & Implications for Practice
Adapting the RNAO Person- and Family-Centred Care Best Practice Guideline to a primary care setting improved equitable access to community supports. Written resources proved substantially more effective than online-only approaches for seniors with limited digital literacy. This low-cost, scalable intervention offers a practical model for strengthening person- and family-centred care and improving access to community services for older adults.
What RNAO BPG or tool/toolkit is your abstract related to?
Person and Family Centered Care
Author(s) Credentials and Title
Registered Nurse, Master of Nursing - Advanced Practice Nurse
| Organization Name | Women's College Hospital |
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