Collaborative Nurse Practitioner And Physician Primary Health Care Service
Provision For At-Risk Seniors In Fort St. John, B.C.
Diella Schatz
Nursing Diploma, Lethbridge Community College, 1990
B.N., University ofLethbridge, 1993

Project Proposal Submitted In Partial Fulfillment Of
The Requirements For The Degree Of
Master Of Science
In

Nursing
(Family Nurse Practitioner)

v W ...RS! 8.,. OF NORYHEftN
BRITISH COLUMB
LIBRARY
Prince Georg@, BC

The University of Northern British Columbia
September 2008
© Diella Schatz, 2008

11

Abstract
Collaborative nurse practitioner and physician primary health care service provision has the
potential to improve access, ensure quality, and promote cost effective primary health care
and case management for frail elders. Through a critical appraisal of research, this paper will
seek to explore outcomes regarding the provision of collaborative nurse practitioner and
physician community based primary health care service for the frail elderly. The research
substantiates that collaborative nurse practitioner and physician health care service provision
to at-risk seniors, reduces emergency department utilization, reduces admissions to hospitals
and nursing homes and maintains or improves functional capacity. Three integrated health
care service delivery models will be discussed, critiqued, and woven into these research
findings to serve as a framework to sift these research findings into practice. Finally,
recommendations based on this research will be proposed for integration into the Northern
Health Authority Integrated Health Network for At-Risk Seniors in Fort St. John, B.C. for
application of these research findings in practice.

lll

Table of Contents

Abstract

11

Table of Contents

Ill

List of Tables

v

Acknowledgments

VI

Section I
Introduction
Background

1
2

~~

Collaborative Practice
Primary Health Care Service Planning for At-Risk Seniors in British Columbia
Primary Health Care Service Planning for At-Risk Seniors in Fort St. John, B.C.
Statement of the Problem
Purpose of the Project
Significance of the Project
Summary
Section II
Appraisal of Evidence
Introduction
Sources and Search Process
Literature Review and Analysis
Emergency Department Utilization
Hospital Admissions
Nursing Home Admissions
Health Status/Functional Capacity
Discussion
Synthesis of the Research for Emergency Department Utilization
Synthesis of the Research for Hospital Admissions
Synthesis of the Research for Nursing Home Admissions
Synthesis of the Research for Health Status/Functional Capacity
Overview of Proposed Health Service Delivery Models
SIPA Model
PRISMA Model
MHCP Model
Synthesis of Evidence Based Research with Models of Integrated
Health Care
Consumer/Client Focus
Coordination and Integration
Flexibility and Efficiency
Access

2

3
5
7
8
9
9
10
11
11
11
13
13
15
21
26
29
30
31
33
34
35
36
37
38
40
40
41
42
44

Table of Contents
Discussion
Summary

lV

45

47

Section III
Limitations, Implications for Practice, and Research and Concluding Recommendations
Introduction
Limitations and Assumptions
Implications for Nurse Practitioner Practice
Implications for Future Research
Recommendations
Conclusion

48
48
48
49
50
51
53

References

54

Appendix A

58

v
List of Tables
Appendix A - Synthesis Table of Evidence Based Research Articles

58

Vl

Acknowledgements
I would like to extend a very heartfelt thank you to Dr. Martha MacLeod for providing
me with much guidance and encouragement to see this project through after many drafts to
meet the requirements for this paper. Special thanks to Rod Schellenberg, Project Manager
for the Northern Health Authority Integrated Health Network for At-Risk Seniors, and Mary
Augustine, Care North Coordinator (Fort St. John), for taking time out of their busy
schedules to provide me with the background information in which to pursue this project.
Thank you also to Tom Macleod for your encouragement during one of my many calls for
assistance to Martha Macleod and for sharing information regarding the Northern Health
Geriatric Outreach Service.
Thank you to the many special elderly patients in Fort St. John, British Columbia and
the surrounding area that I have had the privilege to encounter in my journey as a nurse.
Their pioneering spirits that opened up the north inspire me with passion to practice as a
pioneer nurse practitioner in the north. May the trials and tribulations that lay ahead of me
make me as strong and passionate as the pioneer trails of the north that you all have
encountered.
I would like to extend a very special thank you to my dad, Benny, my mom Diana,
and my brother Trevor. I could not have pursued my dream to become a nurse practitioner
without my dad's financial support and I could not have kept blazing this trail without
stopping a time or two to look to my mom and brother to set me back on the trail again when
I felt I had lost my way. I would also like to extend a very special thank you to Adrian for
your friendship and support and for all of your technical expertise as I complained time and
time again how much I dislike computers.
Finally, I would like to extend a very special thank you to my son Joshua. You are the
light of my life and the inspiration for me to keep forging ahead to teach you that hard work
and determination will allow you to pursue your passions and dreams. Your patience and
understanding regarding my most infamous mom line these past two years of "just wait a
minute until I finish this sentence" are truly appreciated. And I thank God for lending you to
me for just a short while as you are growing up so very quickly.

Collaborative Nurse Practitioner and Physician Primary Health Care Service
Provision for At-Risk Seniors in Fort St. John, B.C.
Introduction
Projections regarding Canada' s aging population, in combination with budget
constraints and subsequent major reforms in health care systems, have placed increasing
pressure on primary care and continuing care networks . Particular emphasis has been
directed towards frail elders, as frailty is a strong predictor of negative outcomes, including
new disabilities, institutionalization, and mortality (Iersel & Olde Rickert, 2006). "Care for
the frail elderly is characterized by fragmentation, lack of overall accountability and
responsibility" resulting in "costly and inappropriate use of acute care hospitals and longterm care institutions" (Bergman, et. al., 1997). Prevention, early identification, and timely
management of elder care issues have the potential to impact positively on the present and
future burden of health care services by maintaining or improving the health status of aged
and aging persons. Northern Health Authority' s Integrated Health Network (IHN) for AtRisk Seniors in British Columbia is a primary health care initiative focused on improving
care for at-risk seniors living in community settings (Northern Health, 2008). The aim of the
IHN is to improve care for frail elders through a coordinated, multidisciplinary, proactive
approach (Northern Health, 2007b).
Collaborative practice amongst nurse practitioners and primary health care physicians
has the potential to improve access, ensure quality, and promote cost effective primary care
and individual case management to frail elders (Cestari & Currier, 2001). "The combined
knowledge of physicians and nurse practitioners has resulted in multidimensional teams in
which each professional contributes unique skills to provide comprehensive health care and

2
produce improved outcomes for patients" (Bickford, n.d., para. 5). Through a critical
appraisal of evidence, this paper will seek to explore outcomes regarding primary health care
service provision to the frail elderly, provided collaboratively through nurse practitioner and
physician services. This appraisal of evidence will be explored in terms of four key outcome
measures: decreased emergency department utilization, admissions to hospital, admissions to
long term care institutions, and maintenance of functional capacity. Four emergent
implementation themes were extracted from this research evidence as strategies for success
and will be discussed. An analysis of three integrated health care service delivery models
will be discussed, critiqued, and integrated into the research findings to serve as a framework,
through which to improve continuity and increase efficiency of community based health care
services for frail elders. These research findings will be applied to the Northern Health
Authority Integrated Health Network for At-Risk Seniors. Themes emanating from this
project are proposed to guide future discussions regarding health care service provision for
frail elders in Fort St. John, B.C.

Background
Frailty
The investigation ofjrailty as a concept is an emerging field of research at an early
stage of inquiry (Walston, et al., 2006). Frailty is a term that is frequently utilized and
variably defined (Rockwood, 2005a) with a "lack of consensus about its meaning and use,
and no clear conceptual guidelines for identifying and describing older adults as frail"
(Markle-Reid & Browne, 2003, p. 58). It is imperative that the term frail be operationalized
to identify clinically recognizable degrees of frailty, and to establish criteria to describe older
adults as frail in order to appropriately determine what frailty is and to consequently perform

3
measurements regarding the receipt ofhealth care services (Rockwood, 2005b). The
conceptualization of frailty will directly influence management strategies and access to
services. Once frailty is conceptualized, "proactive, individualized, multi-disciplinary
interventions, either targeted at the individual or environment, can be developed to identify
and strengthen available resources, thereby reducing frailty and the use of costly health care
resources" (Markle-Reid & Browne, 2003 , p. 65).
The Canadian Initiative on Frailty and Aging has operationalized the term frailty by
summarizing frailty definitions as belonging to one of four classes: "(i) physiological
definitions; (ii) definitions based on frailty as a complex syndrome; (iii) frailty based on a
balance model (which adds to the complex syndrome social elements); and (iv) frailty
defined on the basis of a geriatric syndrome, such as delirium and falls" (Hogan, Macknight,
& Berman, 2003 as cited in Rockwood, 2005b, p. 432). From this, the Canadian Study of

Health and Aging (CHSA) Clinical Frailty Scale was developed. The tool addresses seven
key indicators of frailty and is considered to be an effective and comprehensive measurement
tool (Health Canada, 1996). Northern Health Authority's Integrated Health Network (IHN)
for At-Risk Seniors will utilize this tool to assist in the identification, planning, and tracking
of patients at risk for frailty (Northern Health, 2007b ).
Collaborative Practice
Collaboration between health care professionals may be defined as a dynamic interprofessional process of interaction that synergistically influences client care (Way, Jones, &
Busing, 2000). Interdisciplinary collaboration may also be described as "sharing in planning,
making decisions, solving problems, setting goals, assuming responsibility, working together
cooperatively, coordinating and communicating openly" (Baggs & Schmidt, 1988, p. 145 as

4

cited in Neale, 1999. p. 254). According to Way, et al. (2000), collaborative practice can also
be defined as:
A way of working, organizing, and operating within a practice group or network in a
manner that effectively utilizes the provider resources to deliver comprehensive
primary health care in a cost efficient manner to best meet the needs of the specific
practice population. (p. 4)
Regardless of the definition of collaboration, it is imperative for nurse practitioners and
physicians to not only comprehend what collaborative practice is, but to also clarify how
collaborative practice will develop in those particular nurse practitioner and physician health
care service settings for program success.
The initial efforts put forth into the development of collaborative practice between
nurse practitioners and family physicians will be beneficial in the long term as "collaborative
professional relationships between NP's (nurse practitioners) and physicians appear to be
more cost effective and comprehensive than independent practice" (Mundinger, 1994 as cited
in Neale, 1999, p. 254). Role definition and communication amongst nurse practitioners and
physicians is vital to the success of collaborative practice as partnerships between these two
professions can provide a vital link for the provision of care to homebound frail elders by
"addressing barriers to primary care, combining access, quality, and cost-effective case
management" (Cestari & Currier, 2001 , p. 357).
McGee (2004) asserts that collaboration with members of an interdisciplinary team is
essential to the management of the care of homebound frail elders in order to effectively meet
these individual ' s complex medical, social and psychological health care needs. When care
of the elderly is provided by a health care team, "productivity is enhanced by maximizing the
expertise of each team member" (Kavesh, 1993 as cited in Womack, 1997, p. 33).

5
Throughout the literature, collaborative practice between physicians and nurse practitioners
in long term care and nursing home settings has proven to be a very effective model of health
care service provision. Collaborative practice has been deemed to be the precursor to success
in the provision of care to the institutionalized elderly (Ryan, 1999). "As the NP and
physician work together, there should be awareness that they each bring unique talents,
knowledge, and abilities to the situation, and that they are not interchangeable but rather
interdependent" (Ryan, 1999, p. 128).
Upon further examination of collaborative physician and nurse practitioner health care
service provision in long term care institutional settings, Caprio (2006) maintains that
"potential cost savings from NP and physician collaboration in the nursing home has been
reported in the literature since the 1970's" (Schultz & McGlone, 1977 as cited in Caprio,
2006, p. 22). More specifically, Caprio's (2006) literature search extrapolated research
evidence that overall emergency department transfers and acute hospitalizations were
significantly reduced through collaborative nurse practitioner and physician services
provided to nursing home residents. This type of service provision has translated into a
corresponding increase in the number of nursing home resident visits, but still has netted a
significant cost savings secondary to decreased total associated costs of acute care services
and hospitalization (Caprio, 2006). It is feasible that the success and cost savings of
collaborative nurse practitioner and physician services in long term care institutions could
also translate into cost savings in the provision of care to homebound frail elders in the
community setting.

Primary Health Care Service Planning for At-Risk Seniors in British Columbia
The frail elderly have been identified by the British Columbia Ministry of Health

6

(BCMOH), the British Columbia Medical Association (BCMA), and Northern Health
Authority (NHA) as a high priority population. As a group, the frail elderly are high system
users presenting with multiple chronic conditions and complex care needs contributing to
increased emergency department utilization, and admissions to hospitals and long term care
institutions (British Columbia Medical Association, 2002). The Primary Health Care

Charter set forth by the British Columbia Ministry of Health (2006) emphasises that "coordinated patient centered team planning; including advanced health care planning is central
to the care of the frail elderly" (British Columbia Ministry of Health, 2006, p. 33). The

Charter identifies physicians as the cornerstone of primary care and as part of a community
network and professional team that includes but is not limited to "nurse practitioners,
community nurses, mental health professionals, dieticians, home and community care
workers .. .. and non-governmental organizations who work as a team with patients and their
extended families" (British Columbia Ministry of Health, 2006, p. 1).
In response to the Primary Health Care Charter, Northern Health Authority's primary
health care renewal initiative, Care North, was set forth as a strategy to improve access and
to improve the quality of primary health care services for residents in Northern BC (Northern
Health, 2008). As part of this initiative, Northern Health Authority (NHA) is in the process
of developing an Integrated Health Network (IHN) for At-Risk Seniors. This IHN is
described by the Northern Health Authority (2007b) as a "primary health care initiative
focused on improving care for frail seniors living in the community" (p. 1). The aim of the
collaborative is to "improve care provided to frail seniors living in the community through a
coordinated, multidisciplinary approach" (Northern Health, 2007a, p. 6).

7

Primary Health Care Service Planning for At-Risk Seniors in Fort St. John, B.C.
In November 2006, the Fort St. John and Area Seniors' Needs Project: Population
Background and Trends Report was completed by the Community Development Institute at
the University ofNorthem British Columbia (Doddridge, Van De Keere, Hoffman, Halseth
& Hanlon, 2006). This project estimated that Fort St. John may be adding between 602 and

792 new seniors to the city between 2001 and 2011 with an additional 55 to 73 new seniors
in the nearby community ofTaylor. Accessibility and quality of primary health care services
in rural areas such as Fort St. John and the surrounding area are challenging issues,
particularly for the elderly and those with chronic or complex medical conditions. "Rural
and remote communities in Canada face significant health disadvantages as a result of poorer
access to health care services, geographical and climatic factors, lack of infrastructure, and
challenges in recruiting and retaining healthcare professionals" (Banner & MacLeod, 2008,
p. 38). Chronic disease management and primary health care reform is a modality that has
the potential to impact positively on the present and future burden of health care services in
Fort St. John, B.C. by maintaining and improving the health status of aged and aging persons;
thus possibly contributing to reduced health care expenditures.
Fort St. John, B.C. is one of three leading communities within Northern Health
Authority moving forward with the Integrated Health Network (IHN) for At-Risk Seniors in
order to respond to the above described needs of this community and the surrounding area.
The scope of the Integrated Health Network in Fort St. John is to improve primary care
provided to at-risk seniors incorporating "significant changes to the service delivery model
across the continuum of care for at-risk-seniors involving changes to policies, processes,
roles, job descriptions, location of service delivery, relationships between NHA providers

8
and physicians" (Northern Health, 2007b, p. 2). The objectives of the Integrated Health
Network for At-Risk Seniors are to improve quality of life for seniors and their care
providers, to increase the level of satisfaction amongst health care providers and to reduce
hospital utilization by frail elders. Reductions in hospital utilization are more specifically
aimed at reductions in emergency attendance, acute-care
hospital days, reductions in ALC (alternate level of care) bed days, and fewer clients in acute
care hospital waiting for placement in residential care facilities (Northern Health, 2007b).

Statement of the Problem
The frail elderly are particularly vulnerable to disability and frequently present with
multiple chronic illnesses and complex care needs (Northern Health, 2007a). "Social support
networks are often overextended or at risk of breaking down" which can "easily lead to
increased use of medical and social resources" (Bergman & Beland, 2000, para. 7). In the
absence of early identification, comprehensive assessment, care planning and responsive
interventions, frail elderly individual's health is likely to deteriorate requiring urgent care and
taxation of acute care resources. The Northern Health Authority Integrated Care Network for
At-Risk Seniors was developed as a primary health care strategy as a response to this
dilemma. This collaborative is focusing on "bringing physicians and other providers together
to create the interdisciplinary teams that can ensure comprehensive and integrated patient
care" (Northern Health, 2007a, p. 9). Nurse practitioners, working in collaborative practice
with physicians in the care of the frail elderly, and as a part of the integrated health care
team, have the potential to improve access and health care service provision to frail elders
without additional cost. However, is not known specifically how collaborative practice
contributes to positive outcomes, nor is it known what specific interventions are most

9

effective in sustaining the health and well being of frail elderly individuals for as long as
possible.
Purpose of the Project

The purpose of this project is to explore the evidence based research to address the
following question: In frail and elderly persons living in community settings, how does
primary health care service provision provided collaboratively through nurse practitioner and
physician services, reduce emergency department utilization, reduce admissions to hospital
and long term care institutions, and maintain or improve functional capacity? The overall
purpose of this paper will be to examine the research literature to explore outcomes regarding
primary health care service provision to the frail elderly, provided collaboratively through
nurse practitioner and physician services. Integrated health care service delivery models will
be discussed, critiqued, and integrated into the research findings extracted from the review of
literature to serve as a guiding framework in the proposed application of these research
findings towards the Northern Health Authority Integrated Health Network for At-Risk
Seniors in Fort St. John, British Columbia.
Significance of the Project
It can be anticipated that the conclusions drawn through a critical appraisal of the

evidence set forth this project paper, will contribute to a better understanding of collaborative
nurse practitioner and physician primary health care service provision in the care of frail
elders, as nurse practitioners are new health care providers within the province of British
Columbia. Upon the application of these research findings to primary health care service
provision for frail elders in Northern British Columbia, this project may inform the provision
of appropriate and cost effective health care service provision for frail elders. Locally, this

10
project will provide additional insight into processes and modalities to formulate a responsive
interdisciplinary team for the care of at-risk seniors in Fort St. John, B.C.

Summary
Fort St. John, B.C., not unlike the rest of British Columbia and Canada, is anticipating
an increase in its aging and aged population. Functional decline in health status in elderly
persons and the associated impact on health care resources may be able to be averted through
responsive primary care systems such as the Northern Health Authority Integrated Health
Network (IHN) for At-Risk Elders. It is recognized by this Integrated Health Network that
interdisciplinary teams can "improve care provided to frail seniors living in the community
through a coordinated, multidisciplinary approach" (NHA, 2007a). Nurse practitioner and
physician collaborative practice in the care of frail elders is a modality of primary health care
service provision that is proposed to improve access and health outcomes which will be
explored in the next section.

11
Appraisal of Evidence

Introduction
This section describes the search strategy and subsequent critique of the evidence based
literature to examine the question: In frail and elderly persons living in community settings,
how does primary health care service provision provided collaboratively through nurse
practitioner and physician services, reduce emergency department utilization, reduce
admissions to hospital and long term care institutions, and maintain or improve functional
capacity? Three of these four outcome measures were extracted from twelve research
articles. These outcome measures were emergency department utilization, hospital
admissions, and nursing home admissions. The outcome measure of health status/functional
capacity was added as it was determined to be an important measure of relevance to the
planning of care for at-risk seniors in Fort. St. John, B.C. Additionally, three integrated
health care service delivery models will be discussed, critiqued, and integrated into the
findings of the review of literature.

Sources and Search Process
A variety of search strategies were utilized to complete a comprehensive and
methodical review of the literature. The search was confined to systematic reviews, metaanalyses and randomized control trials as these are regarded as the 'gold standard' of medical
research evidence and the hierarchy of research evidence (Barton, 2000). The University of
Northern British Columbia online library was accessed to obtain relevant and related research
articles. The Biomedical Reference Collection, Medline (Ovid), Medline (EBSCO),
CINAHL, the Johanna Briggs Institute, the Cochrane Central Register of Controlled Trials
and the Cochrane Library of Systematic Reviews data bases were searched. The literature

12
search was confined to these search engines to ensure the inclusion of quality articles. The
literature search was intended to capture English language articles for ease of interpretation
of results. Articles from the United States, Canada, Europe and Australia were identified and
retrieved. The available articles spanned the time frame from 1985 to 2007. More recent
studies were sought out but were not available. Key words, used singularly or in
combination, for the search included: 'frail older people', 'frail elderly', 'frail elder',
'frailty', 'aged', 'nurse practitioners', 'advanced practice nurses', "advanced practice
nursing' 'hospitalization', 'emergency department use', 'home care services', 'primary care',
'nursing homes' and 'long term care institutions'. Reference lists from each selected article
were retrieved and examined for additional relevant articles not identified through the
described electronic search strategy. This search strategy derived nineteen articles of which
twelve articles were determined to be appropriate in an attempt to address the question of
inquiry set forth in this paper. These twelve articles include one systematic review (Van
Haastregt, Diedericks, van Rossum, de Witte, Crebolder, 2000), two meta-analyses (Ploeg
et al., 2005; Stuck & Siu, 1993), one combined systematic review and meta-analysis (Elkan
et al., 2001 ), five randomized control trials (Leveille, et al. , 1998; Sledge et al., 2006; Stuck,
et al., 1995; and Stuck et al., 2000; Zimmer, Groth-Juncker, & McCusker, 1985) and three
variations of randomized control trials (Bula et al., 1999; Kravitz, et al., 1994; and Naylor &
McCauley, 1999). It was noted that the randomized control trial conducted by Levielle, et al.
(1998) was utilized in the meta-analysis conducted by Ploeg, et al. (2005). No other RCT's
were noted to be contained within the systematic reviews and/or meta-analyses selected for
this literature review. These twelve research articles will be overviewed in an attempt to
formulate a critical appraisal of evidence.

13

Literature Review and Analysis
Three outcome measures were sought out and identified for the retrieval of evidence in
order to address the question of inquiry set forth in this paper. These are as follows: reduced
emergency department utilization, reduced hospital admissions, and reduced nursing home
admissions. The outcome measure of health status/functional capacity was determined to be
an additional relevant outcome measure that was extracted from these articles. Thus, the
original question of inquiry was reformatted and this fourth outcome measure was
additionally utilized as a means to extract information from the research towards the
application of findings in Fort St. John, B.C. A summary of the twelve articles is presented
in Appendix A.

Emergency Department Utilization
Two of the twelve articles address emergency department utilization as an outcome
measure including two randomized control trials by Zimmer, et al. (1985) and Sledge et al.
(2006). In the first RCT, Zimmer, et al. (1985), found that patients cared for by a home care
team consisting of a physician, a nurse practitioner, and a social worker in the delivery of
home based primary care ~

to homebound chronically or terminally ill elders living in

Rochester, New York, experienced lower emergency department utilization than those
individuals not receiving this service. The nurse was a master's degree prepared nurse
practitioner who performed many of the physical assessments, routine and emergency, in the
community. She was responsible for the nursing plan and supported medical care in close
cooperation with the physician. Elderly patient eligibility was based upon the patient being
home-bound, wishing to remain at home, having significant illness (not primarily
psychiatric), requiring medical care, not having a physician who would make home visits,

14
and having a friend or family member available to assist in their care at home. One notable
aspect of this study is that twenty four hour, seven day per week emergency access to the
team was available through telephone support. Another notable aspect of this study is that
physical and psychological support and education was provided by the home health care team
to informal care providers and friends. The authors indicate that their utilization data showed
that savings in hospital days can be attributed almost entirely to the fact that more patients
spent their days ofhighest care needs at home, where much of the service was provided by
informal family caretakers at no cost to the system. The relative strengths of this RCT are
that it included an adequate sample size of 210 patients and it utilized a rigorous
methodology and statistical analysis. Even though the study and interventions took place in
New York and the study is over a decade old, the interdisciplinary team network for frail
elders could be generalizable to rural and remote locales such as Fort St. John, B.C.
Questions for further inquiry regarding this study arise in regards to whether or not the nurse
practitioner had received additional gerontological training and what was the nature of
collaborative practice between the nurse practitioner and physician.
The second RCT that cited emergency department utilization as an outcome measure
was conducted via means of a clinic-based ambulatory care intervention in the northeastern
United States (Sledge, et al., 2006). A team approach was again utilized with a nurse
practitioner serving as a case manager for 12 months of follow-up intervention for primary
care patients who had a record ofhigh use of inpatient services in the previous 12-18 months.
The nurse practitioner held advanced practice certifications in medical and psychiatric
nursing. The intervention consisted of comprehensive interdisciplinary medical and
psychosocial assessments, and follow-up ambulatory case management consisting of a social

15
worker, a psychiatrist, and a general internist, in addition to the nurse practitioner. This
study's research findings found that the proposed interventions did not contribute to
decreased utilization of emergency department services. The authors assert however, that
inadequate sample size (47 patients in the intervention group and 49 patients in the control
group) was a considerable limitation to their study, which contributed to inadequate statistical
power. "A sample size of approximately 75 patients in each comparison group would be
needed in order to detect a moderate effect" (Kraemer & Thiemann, 1987 as cited in Sledge
et al., 2006). The authors state, "there was a trend toward reduced emergency department
utilization after enrollment" (Sledge eta!., 2006, p. 335), and that the low sample size may
have contributed to a lack of statistical significance. Taking into account the lack of statistical
significance, this research finding for no reductions in emergency department utilization
raises a further question about the value of additional interventions such as home based
service provision, caregiver support, and 24 hour 7 day per week access in combination with
these clinic based interventions. An additional question for further consideration is whether
or not additional advanced training of nurse practitioners contributes to better outcomes when
working with at-risk elders. Consequently, the validity of the application of these findings to
Northern Health Authority is in question as this intervention incorporated specialists such as
a psychiatrist and general internist. In rural and remote regions of British Columbia such as
Fort St. John, specialist services may not be readily available to devote to this initiative for
at-risk seniors.

Hospital Admissions
Decreased hospital admissions as an outcome measure is addressed in eight of the
twelve research articles. Four of these eight studies found that the research interventions did

16
not decrease hospital admissions. These four studies consisted of the systematic review by
Van Haastregt, et al. (2000), the meta-analysis by Ploeg, et al. (2005), the combined
systematic review and meta-analysis by Elkan, et al., (2001) and the RCT conducted by
Sledge et al. (2006). The four studies that did determine that their interventions contributed to
reduced hospital admissions consisted of a meta-analysis conducted by Stuck and Siu (2000),
a RCT by Naylor and McCauley (1999), a RCT by Zimmer, et al. (1985), and a RCT
conducted by Leveille, et al. (1998).
Seven of the fifteen RCTs included in the systematic review conducted by Van
Hasstregt, et al. (2000) found favorable effects of home visits. Their review failed to confirm
that home visits have an appreciable effect on the number of subsequent hospital admissions.
The authors do claim however, that a limitation to their study was that some of the trials
appeared to be underpowered and thus it was possible that the effectiveness of home visits
was underestimated. Only two of the fifteen RCTs in this systematic review utilized nurse
practitioners and only one of the twelve RCTs took place in Canada, with the others taking
place in the USA, the UK, Denmark, and the Netherlands. None of these twelve studies
implemented 24 hour 7day per week access and only two of the inclusive trials consisted of a
collaborative team. More specifically, one of the RCTs collaborative teams consisted of only
one geriatric nurse practitioner and an unknown number of geriatricians, and the other
consisted of a only a nurse and a physiotherapist. The generalizability of this research to the
Integrated Health Network for At-Risk Seniors in Fort St. John, B.C. is limited as even the
authors indicate that "most trials provided little or no information about the extent to which
the intervention programmes were implemented" (Van Haastregt, et al., 2000, Implications
section, para. 2).

17
In their combined systematic review and meta-analysis of health studies, Elkan et al.
(200 1) determined that the interventions employed in 15 inclusive studies also failed to elicit
findings of decreased hospital admissions. It is unknown however, which health care
professionals carried out home visits to older persons. The authors only stated that they
"excluded studies in which the home visitor was a specialist in a brand of nursing other than
health visiting" (Elkan, et al., 2001, Inclusion criteria section, para 1). Furthermore, Elkan,
et al. (200 1) state that the descriptions of what the home visitors did was brief and that
further studies in this area should focus on the process of care delivery and the components
of these interventions. The generalizability of this research to the Integrated Health Network
for At-Risk Seniors in Fort St. John, B.C. is limited as the findings from this combined
systematic review and meta-analysis are inconclusive.
In a meta-analysis conducted by Ploeg, et al., (2005), nineteen preventative primary
care intervention randomized control trials involving patients 65 years and over who received
preventive primary care through home visits, office visits, and/or telephone contacts did not
lead to reductions in admissions to acute care hospitals. However, the authors determined
that preventive primary care outreach interventions aimed at older people resulted in a "23%
increased likelihood of continuing to live in the community" (Ploeg et al., 2005, Abstract
section para. 1). The interventions were provided by nurses, physicians, other professionals,
or volunteers. The authors indicate the study brings to light implications for further research
in regards to primary care outreach interventions such as geriatric evaluation and
management as these "may result in more positive outcomes when targeting specific groups
of frail elderly people" (Ploeg et al., 2005, Implications for further research section, para. 1).
Again, the generalizability of this research to the Integrated Health Network for At-Risk

18
Seniors in Fort St. John, B.C. is limited as the findings from study are inconclusive. This
study does however raise a question in regards to what would be considered to be the
composition of successful geriatric interventions and management strategies. An additional
question that arises from this meta-analysis is whether the exclusion of nurse practitioners in
some of the inclusive trials may have contributed to less statistically significant findings.
A RCT conducted by Sledge, et al. (2006) found no observed effect for admissions to
hospital. The clinic based interventions in this RCT utilized comprehensive interdisciplinary
psychosocial and medical assessments carried out by the team social worker, psychiatrist,
and general internist. Team reports were developed and recommendations were directed
towards primary care providers. In addition to the limitation of the small sample size, the
authors state that primary care clinics may not have been able to concentrate on these patients
as it is difficult to direct expertise and effort on complex care patients to reduce variations in
services offered. Even though this randomized control trial's interventions are directed
towards client-centered care, additional supports and adjunctive services are not provided.
Thus, the generalizability of these findings in Fort St. John, B.C. is limited as Northern
Health Authority has already recognized adjunctive services beyond primary prevention
strategies as important to support frail elders.
In a meta-analysis conducted by Stuck and Siu (2000), twenty eight international
randomized control trials were reviewed. The authors determined that comprehensive
geriatric assessment (CGA) programs linking geriatric evaluation with strong long-term
management are effective in improving function in older adults. "CGA determines an elderly
person's medical, psychosocial, functional, and environmental resources and problems,
linked with an overall plan for treatment and follow-up" (Stuck & Siu, 2000, Introduction

19
section, para. 1). The authors determined that "all CGA programs taken together reduced
hospital (re)admission during follow-up by 12%" (Stuck & Siu, 2000, Hospital Admission
section, para. 1). Six of the twenty eight RCT's described home assessment service with 2 of
these 6 trials showing statistically significant reductions in hospital admissions. No further
description was provided as to what these home assessment services were. Additionally,
statistically significant findings for maintenance of health status were found in 14 of the 28
trials. A rigorous search strategy is described and the authors indicate that they did not solely
rely on computer databases, and obtained additional RCTs, some of which were only
available in abstract form. This is a relative strength of this meta-analysis as the authors
limited the commonly occurring issue of publication bias evident in most research trials. The
authors assert that some of the inclusive studies were small and some had no available data
about certain outcomes which resulted in fairly wide confidence intervals, which was a
limitation to this meta-analysis. Again, it is unknown which health care professionals carried
out the CGAs. Additionally the question arises as to what was the specific makeup of these
CGAs. Therefore, the extent to which these conclusions are generalizable to Fort St. John,
B.C. is suboptimal.
One noteworthy trial, a secondary analysis of a RCT, deemed that comprehensive
discharge planning and home follow-up provided by advanced practice nurses (APNs) for
medical and surgical patients with cardiac conditions, contributed not only to fewer multiple
readmissions, but also to a reduction in the total number of days of re-hospitalization for both
medical and surgical elderly cardiac patients (Naylor & McCauley, 1999). The intervention
consisted of weekly telephone calls and a minimum of two home visits provided only by
APNs, not by a collaborative team, over a 24 week period of time. Initial assessments of

20
patient and caregiver needs occurred within 48 hours of hospital admission and at least every
48 hours thereafter. Home visits occurred within 48 hours after discharge home from
hospital. The APNs were masters prepared with at least 1 year of in-hospital or home care
experience working with older adults. The findings from this study indicate that coordinated
discharge planning and home follow-up that includes telephone and home visits provided by
APNs benefits high risk elders with significant cardiac problems (Naylor & McCauley,
1999). The findings from this study emphasize that coordinated discharge planning and
home follow-up that includes telephone and home visits provided by APNs benefits high risk
elders with significant cardiac problems (Naylor & McNauley, 1999). The generalizability of
these findings to the Fort St. John Integrated Health Network for At-Risk seniors is most
feasible with a question arising as to how the addition of physician' s in collaborative practice
with APNs could result in even more statistically significant findings .
The noteworthy RCT by Zimmer, et al. (1985), which was previously discussed for
their intervention of a 24 hour ?day per week accessible home health care team, contributed
not only to decreased emergency department utilization but also to decreased hospital
admissions. The authors report that "high intensity home health care can be cost effective
(Zimmer, et al., p. 140). Additionally, the authors indicate that 24 hour 7 day per week
intervention provided through a physician, a nurse practitioner, and a social worker home
health care team, was especially statistically significant for caretaker satisfaction. The
authors comment that it is "most remarkable that these caretakers, who contributed most
significantly with their time and effort to lowering costs are also the group most satisfied
with this care approach" (Zimmer, et al. , p. 141). In spite ofthe relative age ofthis RCT,
these statistically significant findings would be applicable to Fort St. John, B.C. as this study

21
utilized 24 hour 7 day per week access, and support for informal care providers with health
care service provision for at-risk seniors provided by the home health team.
The last study in this appraisal of evidence, for the outcome measure of reduced
hospital admissions, determined that a 1 year senior's center chronic illness self-management
and disability prevention program in Seattle, led by a geriatric nurse practitioner, contributed
to the findings that the number of hospitalized patients in the control group increased by
69%, whereas the number of hospitalized patients in the intervention group decreased by
38% (Leveille, et al., 1998). Additionally, the total number of inpatient hospital days during
the study year was significantly less in the intervention group. Physical activity and chronic
illness self-management were the two key components of the intervention. The strength of
this RCT is that it contains an adequate sample size of201 chronically ill seniors aged 70 and
older recruited through medical practices. Rigorous research methodologies, comprehensive
interpretation of findings, and implications and recommendations are all clearly set forth in
this trial. "This project provides evidence that a community-based collaboration with
primary care providers can improve function and reduce inpatient utilization in chronically ill
older adults" (Leveille, et al. , 1998, p. 1,191 ). Unlike, the clinic based intervention carried
out by Sledge et al. (2006), this RCT provided adjunctive client-centered care services
including physical activity and chronic illness self management strategies. Thus the
generalizability of these findings to the Integrated Health Network is in question as it is still
debatable whether or not home visits are cost effective in the long term.
Nursing Home Admissions
Seven of the twelve articles selected for this critique assert that proposed interventions
contributed to reduced nursing home admissions. These seven studies are comprised of one

22
systematic review (Van Haastregt, et al., 2000), one meta-analysis (Ploeg, et al., 2005), one
combined systematic review meta-analysis (Elkan, et al., 2001), two RCT's (Zimmer, et al.,
1985; Stuck, et al., 1995), one subgroup analysis of a 3-year RCT (Bula, et al., 1999), and
one stratified RCT (Stuck, et al. , 2000).
In the systematic review by Van Haastregt, et al. (2000), seven of fifteen inclusive
RCT's utilized nursing home admissions as an outcome measure. Two of these trials found a
significant reduction in permanent nursing home admissions. These trials all focused on
preventative home visits, however the authors indicate that "most trials provide only general
information about the characteristics of the interventions" and "most trials provide little or no
information about the extent to which the intervention programmes were implemented" (Van
Haastregt, et al., 2000, Implications section, para. 2). Thus, the generalizability of these
findings to the Integrated Health Network for At-Risk Seniors in Fort St. John questionable
as the findings from this systematic review is vague.
Elkan, et al. (200 1) report that home visiting was associated with a significant
reduction in admissions to long term institutions amongst members of the general elderly
population and frail older people who are at risk of adverse outcomes·The fifteen inclusive
randomized and non-randomized control trial interventions focused on surveillance, support,
health promotion, and the prevention of ill health. Elkan et al. (200 1) make reference to the
systematic review conducted by Van Haastregt, et al. (2000), and state that "our findings are
in marked contrast to those of Van Haastregt, et al, who failed to find evidence that home
visiting resulted in any consistent positive outcomes. "It seems that the decision of Van
Haastregt et al. not to perform a meta-analysis might have led them to underestimate the
effectiveness of preventive home visits to older people" (Comparisons with other studies

23
section, para. 1). In comparing their work with Stuck et al. (2000), Elkan et al. (200 1)
indicate that they "confirmed the earlier promising findings of Stuck et al" (Comparisons
with other studies section, para. 2) which provides even more evidence that these findings
towards may be applicable in the implementation of home visits for at-risk seniors in Fort St.
John, B.C.
In their systematic review/meta-analysis, which included nineteen randomized control
trials, Ploeg et al., (2005) identified that primary preventative care outreach interventions do
not reduce admissions to nursing homes even though their statistical analysis revealed that
these interventions contributed to a "23% likelihood of continuing to live in the community"
(Ploeg et. al., 2005, Abstract section para. 1). One particular drawback to this research is that
the authors report that many of the included studies provided only a minimal description of
the primary preventative care outreach interventions which negates the generalizability of
these research findings to the Integrated Health Network for frail elders in Fort St. John, B.C.
One RCT found that the interventions of 24 hour 7 day per week access and the
provision of support and education to informal caregivers by a collaborative team consisting
of a social worker, a nurse practitioner, and a physician (internist) experienced in geriatric
care reduced nursing home admissions (Zimmer, et al., 1985). The team was available for
emergency consultation through telephone services as patients were given the home phone
numbers of the physician and nurse practitioner and the physician's pager number. It was
discovered that off hour telephone calls were surprisingly limited and that "more than 70 per
cent of the calls could be handled by a phone call alone without the need for immediate
follow-up" (p. 135). Additionally, informal care providers were provided with the
"necessary physical and psychological support and education to take on or continue home

24
care" (p. 135). The generalizability of these findings towards health care service provision
for frail elders in Fort St. John, B.C. is most applicable as 24 hour 7 day per week access is
an already established objective of Northern Health Authority. This study substantiates the
potential usefulness of this intervention strategy towards reduced nursing home admissions.
However, the question arises whether or not specialists, such as an internist in this RCT,
contribute to more positive outcomes as compared to family physicians.
Another RCT that is of particular interest was conducted by Stuck, et al. , (1995). This
trial took place in Santa Monica, California over the course of three years in which
collaborative practice between geriatricians and nurse practitioners elicited evidence that
annual comprehensive geriatric assessments (CGAs) and follow-up for patients living in the
community can reduce permanent admissions to nursing homes. The CGAs were performed
in the patient's homes by gerontologic nurse practitioners. Each case was then discussed
with the geriatrician(s) and the nurse practitioners continued to follow the patients through
in-home follow-up every three months. If additional contact was considered necessary, the
nurse practitioner telephoned the patient or was available by telephone. The study does not
indicate 24 hour 7 day per week access was available. The focus of the interventions was
self care management and physical activity to reduce risk factors for disability. The results of
this RCT yielded a higher mean functional status which is believed to have resulted in
reduced nursing home admissions (Stuck, et al. , 1995). The sample size of 414 persons aged
75 years and older was sufficient to establish statistical significance. The generalizability of
these findings towards the Integrated Health Network for At-Risk Seniors in Fort St. John,
B.C. is applicable as "patients are partners in their own care, with emphasis on enabling self

25
managed care" which is a key feature of integrated health networks (Impact BC, Key
Features section, para. 2).
Stuck, et al. (2000) utilized what they term as in-home preventative multidimensional
geriatric assessments for a 3 year period of time in their intervention with 791 study
participants in Bern, Switzerland. Their research determined that their intervention elicited
statistically significant findings that nursing home admissions were reduced. The
intervention consisted of nurses, who received additional training in public health nursing
focusing on physical assessments and gerontology. These nurses were responsible for
performing comprehensive geriatric assessments (CGAs), formulating a problem list of24
defined problem categories and then discussing client cases with geriatricians. In home
follow-up visits were then carried out every three months to monitor implementation of the
geriatricians recommendations. This intervention was found to have contributed to an
"unfavorable increase in nursing home admissions amongst high baseline risk patients, but
reduced nursing home admissions amongst low risk subjects, which resulted in net cost
savings in the third year (US $1403 per person per year)" (Stuck, et al., 2000, Results section,
para. 1). The one limitation to this study, as asserted by the authors, is that this analysis is
classified as a secondary analysis. However, this analysis was conducted according to an
analytical plan with hypothesis formulated before outcome data collection (Stuck, et al.,
2000). These findings are somewhat applicable towards the Integrated Health Network for
At-Risk Seniors in Fort St. John, B.C. as this study indicates that comprehensive geriatric
assessments and associated management plans are effective intervention strategies for
reducing nursing home admissions. This study did not utilize nurse practitioners; however
advanced practice training was portrayed to be a vital aspect of these nurses practice which

26
could be considered to be more or less equivalent to nurse practitioner practice. Additionally,
geriatricians were utilized in this study. Geriatric specialists in northern locals such as Fort
St. John, B.C., are available through the Geriatric Outreach Team four times per year with
the availability for consultation in between times (Northern Health, 2005). Thus, a question
for further consideration arises as whether physicians and nurse practitioners without
additional geriatric specialization, but who work in consultation with this resource, can
contribute to statistically significant outcome measures for reduced nursing home admissions
in Fort St. John, B.C.

Health Status/Functional Capacity
Outcome measures of health status and/or functional capacity are addressed in seven of
twelve inclusive research studies which include: one combined systematic review metaanalysis (Elkan, et al., 200 I), one secondary analysis of a RCT (Naylor & McCauley, I999),
three randomized control trials (Sledge et al., I995; Leveille, et al., 1998; Stuck, et al., 1995;)
one subgroup analysis of a RCT (Bula, et. al., 1999), one stratified RCT (Stuck, et. al., 2000),
and one observational study nested withon a RCT (Kravitz, et al., I994).
Elkan, et a!. (200 I) determined that three of the fifteen randomized and nonrandomized control trials selected for their systematic review and meta-analysis, showed no
significant effect on health and four studies showed no effect on the activities of daily living.
However, two of the fifteen inclusive trials measured instrumental activities of daily living
(IADLs) and reported significant improvements. The authors include in their summation of
these findings that the "absence of evidence of improved health and functional status requires
explanation" (Elkan et al., 2001, Impact on Health and Functional Status section, para. 1) and
state that the difference between the intervention and control groups was that those in poorest

27

health died. Thus, this outcome was measured as only a subset of the original sample.
Additionally, Elkan, et al. (2001) suggest that self rated measures may not have been
sensitive to detect improvements in health or functional ability. Thus the generalization of
these findings towards the care of at-risk seniors in Fort St. John, B.C. is questionable.
In spite of the statistically significant research findings for the outcome measure of
reduced hospital admissions, Naylor and McCauley ( 1999), in their secondary analysis of a
RCT, found no difference in functional status in either surgical or medical cardiac patients
who received advanced practice nursing 24-week home based post-discharge follow-up.
Likewise, Sledge, et. al. (2006) in their RCT did not find any appreciable differences in
functional status between the intervention and control groups in which the intervention
consisted of clinic based ambulatory care management interventions provided by nurse
practitioners over a 12 month period of time. Inadequate sample size is a limitation in both
of these studies. Consequently, the generalizability of these two study findings to the
Integrated Health Network for At-Risk Seniors in Fort St. John, B.C. is not supported.
Three of the research articles that utilize functional capacity as an outcome measure
(Bula, et al. , 1999; Stuck, et al. , 1995; Stuck et al. , 2000) found that activities of daily living
(ADLs) and instrumental activities of daily living (IADLs) were both maintained. Bula, et al.
(1999) found through their annual in home comprehensive geriatric assessments with
quarterly home visits by gerontologic nurse practitioners that intervention subjects spent
significantly fewer days dependent in both ADLs and IADLs. Through annual in-home
comprehensive geriatric assessments, Stuck, et al. (1995) also found that persons in the
intervention group displayed a higher mean functional status, in both ADLs and IADLs, than
those in the control group. Furthermore, these interventions by Stuck, et al. (1995) also

28
contributed to significant statistical findings for reduced nursing home admissions. Stuck et
al. (2000) found that in low risk subj ects who received in-home comprehensive preventive
visits with multidimensional geriatric assessments, ADLs and IADLs were both maintained
and additionally reductions in nursing home admissions occurred. High risk subjects,
however, were determined not to show an appreciable difference between intervention and
control groups for maintenance of ADLs or IADLs. And in a randomized control trial
conducted by Leveille, et al. ( 1998), an increase in participants functional capacity occurred
through a 1 year geriatric nurse practitioner case managed senior center based chronic illness
self management and disability prevention program. This program was also statistically
significant for decreased hospital admissions and reductions in the number of inpatient
hospital days.
The study by Kravitz, et al. (1994 ), identified a "high yield of important and potentially
reversible clinical problems" (p. 1229) from their proposed intervention of post-discharge
geriatric home assessments in southern California. The sample consisted of 152 intervention
subjects aged 65 years and older who had one or more specific risks for functional decline
and who were waiting discharge from a teaching hospital. A geriatric nurse practitioner
conducted comprehensive geriatric assessments (CGAs) while in hospital and again within
24 to 72 hours after discharge home from hospital. New or worsening conditions were
identified in 150 patients (99%) by the nurse practitioner, which were then reviewed in
collaboration with a geriatrician. "Fifty percent had medical problems, 58 percent functional
problems, and 90 percent had problems in understanding follow-up instructions" (p. 1,231 ).
The team additionally consisted of a physical therapist and a gerontologic social worker. The
most common recommendation categories were diagnostic evaluation and monitoring (51 %),

29
advance directives (50%), physical and occupational therapy (44%), and alterations in
medication regimens (44%). No further outcome measures were evaluated such as
readmissions to hospital; however, the authors do indicate that further research is needed to
identify potential links between short hospital stays, health outcomes, and costs. The
generalization of these findings towards the Integrated Health Network for At-Risk Seniors
in Fort St. John, B.C. is most applicable as this research again substantiates Northern Health
Authority's objective of including coordinated hospital discharge planning with at home
follow-up within 48 hours. The study did however utilize specialists such as a geriatric nurse
practitioner and a geriatrician. Thus the question again arises as to the necessity for inclusion
of specialists in the interdisciplinary teams who would directly provide interventions versus
consultation services with geriatric specialists available though Geriatric Outreach Services.
Discussion
It can be concluded that this literature substantiates the contention that community-

based interdisciplinary primary health care service provision to the frail elderly, provided
collaboratively through nurse practitioner and physician services, has the potential to
improve access, ensure quality, and promote cost effective primary health care and case
management for at-risk seniors. Four successful intervention strategies were extracted from
an analysis of the literature towards the application of achieving the outcome measures of
reductions in emergency department utilization, reductions in admissions to hospital and long
term care institutions, and to delays in functional decline. These intervention strategies
include: (1) comprehensive geriatric assessments (CGAs) linked to overall plans for
treatment and strong long-term management; (2) 24 hour 7 day per week access to a home
health care team; (3) comprehensive, collaborative, and coordinated discharge planning and

30
subsequent at-home follow-up by a nurse practitioner and the attending physician within at
least a 48 hour time period after discharge home from hospital; (4) education and support for
informal caregivers providing care for at-risk seniors in the community setting. These will be
further discussed towards the application of the Integrated Health Network for At-Risk
Seniors in Fort St. John, B.C.

Synthesis of the Research for Emergency Department Utilization
From a synthesis of the articles that utilized reduced emergency department use as an
outcome measure, 24 hour 7 day per week telephone access to a home health care team and
physical and psychological support and education provided to informal care providers were
both successful implementation strategies. Clinic based interventions alone without the
addition of services provided in the home showed no appreciable gain in reducing emergency
department utilization. Interventions were provided through collaborative nurse practitioner
and physician health care service provision, in combination with interdisciplinary teams, with
nurse practitioners acting as case managers. The application of these findings towards the
Integrated Health Network in Fort St. John, B.C would be most generalizable as it
substantiates Northern Health Authority's objectives to take "responsibility 24/7'' (Northern
Health, 2007a, p. 6) and to "evolve .... the relationships that will best support frail seniors and
care providers (both formal and informal)" (Northern Health, 2007a, p. 6). However,
according to the findings extracted from this literature review it would be advisable for this
IHN take the objective of supporting informal care providers one step further to include both
physical and psychological support and education.
A question for further inquiry that arises from this research is whether or not specialists
such as geriatricians and psychiatrists, as well as additional specialized training for nurse

31
practitioners is required for more positive outcomes, or would the availability for
consultation through the Geriatric Outreach Service Team be sufficient to contribute to
statistically significant findings. Additionally, a question arises as to the exact nature of
collaborative practice amongst nurse practitioners and physicians as these relationships have
the potential to impact on the successful or unsuccessful implementation of these strategies.

Synthesis of the Research for Hospital Admissions
Through a synthesis of these articles that utilized reduced hospital admissions as an
outcome measure, comprehensive geriatric assessments (CGAs) linked with an overall plan
for treatment with strong long-term management, coordinated hospital discharge planning
with home follow-up within 48 hours, and 24 hour 7 day per week access were deemed as
successful interventions. Of interest, a seniors center chronic illness and disability
prevention program without home based interventions which focused on self management
strategies and physical activity, led by a geriatric nurse practitioner, was statistically
significant for reductions in hospital admissions (Leveille, et al., 1998). However, another
study which provided clinic based comprehensive interdisciplinary psychosocial and medical
assessments in which a nurse practitioner worked closely with primary health care providers
to achieve the recommendations set forth from their assessments, contributed to no
observable effect for reductions in hospital admissions (Sledge, et al., 2006). A further study
offering office, home, and telephone visit interventions that focused upon primary care
prevention strategies only, also failed to achieve positive outcomes (Ploeg, et al., 2005). It
can be noted that there were other variables to account for the inconsistent findings in these
articles, yet a question arises as to whether primary preventive care strategies directed
towards frail elders are enough to prevent hospital admissions. Without the incorporation of

32
acute and long term care management strategies, regardless of whether or not the
interventions are home based or not, it is debatable if reductions in hospital admissions can
be achieved.
The generalizability of these findings to the Integrated Health Network for At-Risk
Seniors in Fort St. John is most applicable as the aim of Northern Health Authority is to
"improve care provided to frail seniors in the community through a coordinated
multidisciplinary approach, which includes planning and implementing client-centered care"
(Northern Health, 2007a, p 6). Northern Health Authority recognizes that coordinated care
planning and crisis response is required for health care service provision to frail elders and as
such these studies substantiate the objectives of the Integrated Health Network for At-Risk
Seniors in Fort St. John, B.C. From this research it is deemed feasible for Northern Health
Authority to integrate already proposed objectives for comprehensive geriatric assessments
(CGAs) linked with treatment and associated long-term care management strategies,
coordinated hospital discharge planning with follow-up within 48 hours, and 24 hour 7 day
per week access into their Integrated Health Network for At-Risk Seniors in Fort St. John,
B.C. Additional consideration should be given to the development of a seniors center
chronic illness and disability prevention program for frail elders who are still mobile and
could be transported to the center. Group visits provide informal peer support structures and
cost effective service care provision and are a key feature of integrated health networks
"where a critical mass of clients with a particular condition, or group of conditions is
present" (Impact BC, 2007, Key Features section, para. 9).

33
Synthesis of the Research for Nursing Home Admissions
Through a synthesis of the articles that utilized decreased nursing home admissions as
an outcome measure, it can be drawn from these that 24 hour 7 day per week access,
comprehensive geriatric assessments, and the provision of support and education to informal
care providers were all successful implementation strategies. Some debate again arose about
the utility of preventive primary care in two of the articles, with the systematic review by
Van Haastregt, et al. (2000) and the meta-analysis by Ploeg et al. (2005) showing
inconclusive results. However, a combined systematic review/ meta-analysis by Elkan, et al.
(200 1) showed conclusive results that home visits focused on surveillance, support, health
promotion, and prevention of ill health were successful in reducing nursing home admissions.
Little or no information about the characteristics of the preventative visits interventions was
provided and thus it is not possible to formulate any recommendations to propose to Northern
Health Authority about the validity of expanding the Integrated Health Network for At-Risk
Seniors to provide preventative home visits to those seniors at low risk or no risk.
Northern Health Authority has already recognized that "24/7 responsibility" and that
self-management by the client and the family must be built and/or fostered (Northern Health,
2007a). "Proactive, planned care methods that employ a common care plan for each client
embraced by all health service delivery components" (Impact BC, 2007, Key Features
section, para. 3) such as comprehensive geriatric assessments are key features of integrated
health networks. Thus the generalizability of these findings to the Integrated Health Network
for At-Risk Seniors in Fort St. John is most applicable as they substantiate the already
established future direction of interventions towards the reduction of nursing home
admissions in Fort St. John, B.C.

34

Synthesis of the Research for Health Status/Functional Capacity
Through a synthesis of the articles that utilized maintenance of functional capacity as
an outcome measure, comprehensive geriatric assessments (CGAs) and coordinated hospital
discharge planning with timely in home follow-up were both deemed to be successful
strategies in reducing functional decline. Comprehensive in-home geriatric assessments with
long-term management follow-up were again deemed successful intervention measures as
they contribute not only to reductions in functional decline but also to associated nursing
home admissions (Stuck, et al. , 1995; Stuck, et al., 2000). A seniors center chronic illness
self management and disability prevention program managed by a geriatric nurse practitioner
indicated that these interventions contributed not only to reductions in functional decline but
also to associated reductions in hospital admissions and the number of inpatient days
(Leveille, et al., 1998). An additional study by Kravitz, et al. (1994) provided specific
insights into the spectrum of significant problems identified during home assessments by
gerontologic nurse practitioners in which ninety nine percent of patients discharged home
from hospital were determined to have new or worsening problems. The authors do state that
"more research is needed to identity additional links between short hospital stays, impairment
or instability at discharge, and adverse outcomes" (Kravitz, 1994, p. 1229) however, this
research does give an indication of the value of early in-home follow-up after discharge
home from hospital as it can be surmised that through the nurse practitioners early
interventions, subsequent hospital admissions were prevented.
These study findings suggest that home visits with comprehensive geriatric
assessments are invaluable in maintaining the health status of higher functioning seniors but
not necessarily those with lower functional capacity. As such, it may be advisable for

35
Northern Health Authority to take this research finding into account when planning future
intervention strategies that are linked to outcome measures as this subset of seniors could
skew outcome measure results. Again, this research indicates that consideration should be
given to the development of seniors center chronic illness self management and disability
prevention program for seniors who are still mobile and could participate and benefit from a
group setting environment.
Overview ofProposed Health Service Delivery Models
In order to ensure service co-ordination, quality of outcomes, efficiency, and ultimately
cost effectiveness, an implementation framework for health care service provision for at-risk
seniors must encompass effective intervention strategies. Integration of health care services
became a buzz word in the 1990's as it was recognized that health care service provision was
fragmented with disjointed care, less than optimal quality, system inefficiency and difficultto-control costs (Kodner, 2000). Integrated care is defined by Kodner and Spreeuwenberg
(2002) as a "discrete set of techniques and organizational models designed to create
connectivity, alignment, and collaboration within and between the cure and care sectors at the
funding, administrative and/or provider level" (Kodner and Spreeuwenberg (2002) as cited in
Kodner, 2006, p. 385). Integrated health care has become a major theme in health care
reforms related to the poor quality of care being delivered to those with chronic conditions,
particularly the elderly (MacAdam, 2008).
Multiple integrated health care service delivery models have been developed in Canada
and internationally. MacAdam (2008) performed a systematic review which incorporated
eight Canadian and international evaluated trials of integrated health care delivery models for
the elderly. The program models with the strongest results for the outcome measures of

36
reductions in hospital utilization, reductions in nursing home utilization, cost effectiveness or
savings and client satisfaction and quality of life included the SIPA (Systeme de services
integers pour personnes agees en perte d'antonomie) model (Canada), Integrated Care in
Italy, the PACE (Program Of All-Inclusive Care For Elderly People) model (USA), and the
SA HealthPlus Model (Australia) (MacAdam, 2008). Canada's PRISMA (Program of
Research to Integrate Services for the Maintenance of Autonomy) model was not included in
the systematic review, as even though it shows promising results, it has not been effectively
evaluated (MacAdam, 2008). Kodner (2006) expanded his research outside of the American
validated PACE model by comparing Canada's SIPA and PRISMA models. A discussion of
the SIPA model and the PRISMA model follows. Another lesser known and unevaluated
model, the Medical House Calls Program (MHCP), a US model, will be reviewed it is a
framework that "can provide high quality primary health care to frail elderly at home,
improve the continuity of care between the home, and the hospital, provide support and
education to families or caregivers, and provide linkage to a broad range of social and
supportive services in the community" (Gammel, 2007, Medical House Calls Program
Overview section, para. 3). A general overview of the SIPA, the PRISMA, and the MHCP
service delivery models follows.
SIPA Model
The fundamental premise of the SIP A model is that it is a community based primary
care system that is responsible for a full range of health and social services in community
settings, acute care hospitals, and long term care institutions (Bergman, et al., 1997; Health
Canada 1998). SIPA is a fully integrated model that "maintains and promotes autonomy of
frail elderly people; and promotes optimal utilization of community-based services as a

37
substitute for hospital and nursing home care" (Kodner, 2006, p. 388). Furthermore, SIPA is
a "patient-focused model designed to meet the needs of the frail elderly to assure
comprehensive care, integration of all available services and continuity of care by all
professionals and institutions involved" (Bergman, et al., 1997, pp. 1,117-1,118). Important
features associated with the SIPA model include multidisciplinary teams, case management,
and the application of guidelines and services based on the latest knowledge (Beland, et al. ,
2006). The SIP A model is a system that assesses the quality of services and adapts to
personal circumstances via rapid response and on-call services and provides linkage and
coordination amongst service providers (Beland, et al., 2006). The utility of the SIPA model
was evaluated through a randomized control trial in which Beland et al., (2006) reported that
the SIPA model "was highly effective in increasing access to community based health and
social services, and reducing acute hospitalizations (by 50%) of alternate level of care
patients (i.e. 'bed blockers' who are chronically ill and disabled" (Kodner, 2006, p. 387).
However, "no significant differences were discerned in emergency department, hospital or
nursing home stays or costs" (Kodener, 2006, p. 387). Due to a lack of policy consensus, the
SIPA model has not become a permanent program. The Quebec government is considering
incorporating certain elements of the model into this province's existing health care system
(Hollander, et al., 2002 as cited in Kodner, 2006). The Solidage Research Group at McGill
University (n.d.) states the "SIPA model represents a major challenge and change to the
existing system of care for the frail elderly" and that before proposing major reforms "issues
raised by the introduction into Canada's health care system need to be addressed" (p. 3).
PRISMA Model
The PRISMA model is an innovative health care service framework with a goal of

38
integrating service delivery to ensure individuals functional autonomy (Kodner, 2006). The
mechanisms and tools of the PRISMA model include co-ordination between decision-makers
and managers, a single entry point, a case management process, individualized service plans,
a single assessment instrument based on the clients' functional autonomy, and computerized
clinical charts for communicating between institutions for client monitoring purposes
(Hebert, et al., 2003a; Kodner, 2006). The key feature of the PRISMA model is that all
service organizations maintain their own structure but "agree to participate in an umbrella
system and to adapt its operations and resources to agreed-upon requirements" (Hebert, et al.,
2003b). Services covered by this model include existing acute care, long term care,
rehabilitative, and supportive services (Kodner, 2006). Service management is provided by
case managers who work closely with family physicians (Kodner, 2006). The PRISMA
model has been implemented in two territories in the Victoriaville region in Quebec (Hebert,
et al., 2003b). Kodner (2006) reports that a three year quasi-experimental design was
undertaken to evaluate the PRISMA model which found the model contributed to a
"declining trend in institutionalization" (p. 388).

MCHPModel
The basic premise of the ofthe MHCP model is the provision oftimely,
comprehensive, coordinated care management to offset the effects and associated costs of
delayed or crisis intervention of the homebound frail elderly (Gammel, 2005). This program
provides comprehensive, ongoing medical care and chronic care management instead of time
limited intermittent care focused only on treating specific acute care events (Sanders &
Harahan, 2008). This model is additionally being utilized by oncology physicians and
associated oncology programs in the United States. "Managing cancer patients in the home

39

is the most humane and cost-effective method of care if appropriate medical, educational, and
supportive services can be made available in the home" (Gammel, 2005, p. 45). The MHCP
model is a framework whereby the designated MHCP physician manages or co-ordinates
patient care of the frail elderly ensuring continuity of care. Primary health care services are
delivered in the home through physicians, nurse practitioners, and a social worker (Gammel,
2005). The programming goals ofthis model are to improve access, improve continuity with
coordination of support services, provide counselling and education to family members and
caregivers and provide palliative elderly persons with the opportunity to die at home
(Gammel, 2007). Gammel (2005) proclaims that "because MHCP clinicians treat the patient
in the home, they have access to a tremendous amount of information about caregiver
abilities and the home environment" allowing "clinicians to make better informed decisions
than would otherwise be possible" (p. 40). This consistent and co-ordinated means of care
delivery often results in decreased days of hospital admission and shorter hospital stays as a
support system is already in place prior to discharge home (Gammel, 2007). It is important
to keep in mind that this model has as yet not been validated through a formal research
evaluation, however multiple sites in the United States are reporting "a decreased rate of
unnecessary emergency room visits, an average length of stay for hospital admissions that is
almost three days shorter than for the comparable elderly population" and "triple the national
average of persons being able to die in their own homes" (Gammel, 2007, Benefit to the
Sponsor Hospital and Health System section, para. 2). This program was originally instituted
in Northern Kentucky in 2002 through a hospital based program. Since then, the MCHP
program as been utilized in several regions throughout the United States with these programs

40
being operated "under the auspices of a health system, a hospital, a home health agency or an
HMO" (Sanders & Harahan, 2008, p. 4).
Synthesis ofEvidence Based Research with Models of Integrated Health Care
The Federal/Provincial/Territorial Committee (Seniors) for the Ministers Responsible
for Seniors developed a report entitled Innovations in Best Practice Models of Continuing
Care for Seniors (Minister of Public Works and Government Services Canada, 1999). The
report was formulated to assist "planners, practitioners, researchers and policy makers
regarding innovative best practice models of continuing care for seniors" (Minister of Public
Works and Government Services Canada, 1999, p. 3). Six common features of best practice
models were identified by respondents who consisted of key contacts in continuing care
divisions in all Canadian provinces and territories. Six best practice features towards the
relevance for analysis of health care service delivery models were identified: (1)
consumer/client focus; (2) coordination and integration; (3) efficiency and flexibility; (4)
access; (5) program assessment; and (6) program evaluation and education for staff. The first
four listed features ofbest practice models will be utilized to analyze the SIPA, PRISMA and
MHCP health care service delivery models. The two best practice features of program
assessment, and program evaluation and education for staff, are assumed to be aspects of
each of these health care delivery models, and thus will not be utilized as part this review.
Consumer/Client Focus
Consumer/client focus is defined as "the degree to which the client's right to provide
input into service planning is recognized and the extent to which the services are relevant to
the client's needs" (Minister of Public Works and Government Services Canada, 1999, p.
11). Neither the SIPA nor the PRISMA models key features specifically lists or recognizes

41

consumer/client focused care. The MHCP model explicitly recognizes and values the role of
families and caregivers which coincidentally was one of the successful program intervention
themes identified in the review of the literature. Education and support of informal
caregivers is emphasized in the MHCP model, as the burden of care giving is incremental.
And yet for elderly persons to remain in their own homes these same care givers are
considered to be a vital part of the team (Gammel, 2005). The aim of the Northern Health
Authority Integrated Health Network for At-Risk Seniors is for client-centered care and value
is placed on approaches and strategies which "evolve the care/practice model and the
relationships that will both support frail seniors and care providers (both formal and
informal)" (Northern Health, 2007, p. 7). The Care North strategy emphasizes that "we will
work in partnership with patients and communities in making decisions- respecting choices
that are made (Northern Health, 2008, p. 18). The MHCP model is integrally aligned with
this objective of the Care North strategy. Thus, for the purpose of selecting a best practice
service delivery model in Fort St. John, B.C., it could be argued that with respect to client
focused/consumer care, the Medical Health Call Program (MHCP) service delivery model
would be a most appropriate fit.
Coordination and Integration

Coordination and integration is defined as "the ability to provide uninterrupted,
coordinated service across programs, practitioners, organizations and levels of care, over
time" (Minister of Public Works and Government Services Canada, 1999, p. 12). The aim of
the Integrated Health Network for At-Risk Seniors in Northern Health Authority is "to
improve care provided to frail elders living in the community through a coordinated,
multidisciplinary approach" (Northern Health, 2007, p. 6). Key elements ofboth the SIPA

42

and PRISMA models are that these models have "umbrella organizational structures to guide
integration of strategic, managerial and service delivery levels; encourage and support
effective joint/collaborative working; ensure operations; and maintain overall accountability
for service, quality, and cost outcomes (MacAdams, 2008, p. 10). The MHCP model
acknowledges the importance of the continuity of care for frail elders by providing care in the
home and in the hospital, and coordination of all support services" (Gammel, 20007, Medical
House Call Program Overview section, para. 3). The review of the literature in this paper
revealed that comprehensive geriatric assessments, comprehensive, collaborative, and
coordinated discharge planning and subsequent follow-up with early home based
intervention(s) within a 48 hour time period after discharge home from hospital are
successful implementation strategies. Consequently, the SIPA, PRISMA and MHCP models
of health care service delivery to frail elders all meet this best practice feature of coordination
and integration. Using this best practice feature of coordination and evaluation, all three
models could serve as the framework for health care service delivery for the Integrated
Health Network for At-Risk Seniors in Northern Health Authority.

Flexibility and Efficiency
In Innovations ofBest Practice Models of Continuing Care for Seniors (Minister of
Public Works and Government Services Canada, 1999), flexibility was defined as the "ability
to respond to changing client demographics and needs" and efficiency was defined as
"achieving the desired results with the most cost-effective use of resources" (p. 12). The
review of the evidence based literature ascertained four successful intervention strategies that
all encompass the best practice feature of efficiency and flexibility and include: (1)
comprehensive geriatric assessments (CGAs) linked to overall plans for treatment and strong

43
long-term management; (2) 24 hour 7 day per week access to a home health care team; (3)
comprehensive, collaborative, and coordinated discharge planning and subsequent at-home
follow-up by a nurse practitioner and the attending physician within at least a 48 hour time
period after discharge home from hospital; (4) education and support for informal caregivers
providing care for at-risk seniors in the community setting. The SIPA, PRISMA and MHCP
models all provide overall flexible health care service provision as their key features to
address the ability to respond to changing client demographics and needs.
The Care North strategy has recognized that "system-wide change- deliberate,
participative, supportive change" (Northern Health, 2008, p. 5) is required. As a part of this
shift in thinking, Northern Health is planning on "quality initiatives/milestones for
comprehensive services for those living with chronic conditions including the frail elderly
through multidisciplinary teams including the nurse practitioner role" (Northern Health,
2008, p. 22). The MHCP model recognizes and incorporates the role of nurse practitioners as
part of the interdisciplinary medical team (Sanders & Harahan, 2008), whereas the SIPA
model and PRISMA models do not. In regards to this aspect of flexibility, the MCHP model
would be the most integrally aligned with this goal of the Care North strategy.
In terms of the best practice feature of efficiency, the SIP A model has been evaluated
through a randomized control trial. Results revealed that this model achieved overall
reductions in hospital and nursing home use but no significant differences in emergency
department, hospital or nursing home stays or any of these associated costs. Additionally, no
differences in health outcomes or total costs were found between control and experimental
groups (Kodner, 2006). A quasi experimental evaluation of the PRISMA model revealed a
declining trend in institutionalization and maintenance of functional capacity at the beginning

44
of the experiment but the effect disappeared by the end of the experiment. No formal
research evaluations of the MHCP model are known to have taken place at this time and the
cost effectiveness of this model is only through observations reported by Gammel (2007) as
discussed previously in this paper. However, it should be recognized that "while client
outcomes improve, cost savings are not immediate. Investments have to be made to realize
the potential of integrated care" (Singer, 2008, as cited by MacAdam, 2008, Forward section,
para. 3). It is impossible at this point to comment on the efficiency or cost effectiveness of
any of these health care delivery models. Thus it could be recommended that any of these
three delivery models could serve as the overarching framework in regard to efficiency for
service to frail elders in northern British Columbia.
Access

Access is defined as "the ability of the individual to obtain services at the right place
and at the right time, based on respective need" (Minister of Public Works and Government
Services of Canada, 1999, p. 13). The Northern Health Authority Integrated Network for AtRisk Seniors is aiming to take 24/7 responsibility "meaning that this requires the ability to
respond to crisis when they happen" (Northern Health, 2007, p. 6). The research evidence
uncovered in the review of the literature in the paper indicated that 24 hour 7 day per week
access to a home health care team and early home based interventions within at least 48
hours after discharge home from hospital are successful implementation strategies to provide
accessibility to frail elders and their care providers. The SIPA model promotes intensive
home care, 24 hour on-call availability and rapid team immobilization (Kodner, 2006). The
PRISMA model promotes a single point of entry through 24 hour 7 day per week access
(Kodner, 2006) as does the MHCP model (Gammel, 2005).

45
Northern Health Authority has placed emphasis on the establishment of"primary care
homes - early access and long term relationships for patients with a multidisciplinary primary
care team" (Northern Health, 2008, p. 3). The SIPA and MHCP models both emphasize
ongoing-follow-up of patients. The PRISMA model does not recognize this aspect as one of
its key features. MacAdams (2008) states that ongoing follow-up of patients is one ofthe
main characteristics of care coordination programs that accomplish their goals. The MCHP
health service delivery model additionally emphasizes and recognizes end-of-life care. The
Care North Strategy has recognized end of life care as a primary care access issue (Northern
Health, 2008). This component of end-of life care is only assumed to be an aspect of the
SIPA and PRISMA models as direct mention of end-of-life care is not listed as a key feature
of these models as per the discussion in Hebert, et al. (2003), Kodner (2006), and MacAdams
(2008). The SIPA, PRISMA or MHCP model could all be utilized as frameworks to promote
accessibility for frail elders in northern British Columbia. However, the MHCP model stands
out in regards to the provision for client centered primary care homes and of end-of-life care
health care service provision.

Discussion
For the purpose ofthis project, the SIPA model appears to be the most validated
framework to recommend as serving as the overarching framework to implement into the
Northern Health Authority Integrated Health Network for At-Risk Seniors. According to
criteria for best-practice models, the SIPA model would appear to be the most consistent
framework in answering the question of inquiry: In frail and elderly persons living in
community settings, how does primary health care service provision provided collaboratively
through nurse practitioner and physician services, reduce emergency department utilization,

46
and reduce admissions to hospital and long term care institutions, and maintain or improve
functional capacity? Even though the Medical Health Calls Program (MHCP) model is
formally unevaluated, it deserves consideration.
Through means of a randomized control trial, the SIP A model was found to contribute
to reductions in acute care hospitalizations of alternate level of care patients and is a
"community based primary care system based on a patient-focused model designed to meet
the needs of the frail elderly to assure comprehensive care, integration of all available
services and continuity of care by all professions and institutions involved" (Bergman et al.,
1997, p. 1,117-1, 118). The Medical Health Calls Program (MHCP) model, even though it is
an American model and has not been formally evaluated, appears to align very well with
objectives set forth by the Care North strategy in more aspects of the best practice features of
health care service delivery models than even the SIPA model. Unlike the SIPA and
PRISMA models, the MHCP model recognizes the utility, and indeed the necessity of
informal care providers, to provide support and care to frail elders in the community setting.
"Family caregivers provide a vast array of emotional, financial, nursing, social, homemaking,
and other services on a daily or intermittent basis" (Gammel, 2005, p. 42). Additionally, the
MHCP model promotes end-of-life care to provide medical care for patients to die in their
own homes. Furthermore, nurse practitioners are recognized as valued care providers in
multidisciplinary care teams. Thus, the MHCP model could provide great utility to the
Integrated Health Network for At Risk Seniors in northern British Columbia especially if it
was blended with the SIP A model. At the time of writing of this project paper, the Northern
Health Authority Integrated Health Care Network for At-Risk Seniors had not yet selected a
service delivery model (R. Schellenberg, personal communication, August 2008) and as such

47
this evaluation of these integrated health care service delivery models could serve as a
broader scope of insight for health policy makers in Northern Health Authority when
determining appropriate and cost effective health care service provision for frail elders.
Summary

In summary, this research critique has demonstrated that nurse practitioner and
physician collaborative practice has the potential to decrease emergency department
utilization, decrease admissions to hospitals and long term care institutions, and maintain
health status/functional capacity of frail elders. Four emergent implementation strategies
were identified through this literature review and include: (1) comprehensive geriatric
assessments (CGAs) linked to overall plans for treatment and strong long-term management;
(2) 24 hour 7 day per week access to a home health care team; (3) comprehensive,
collaborative, and coordinated discharge planning and subsequent at-home follow-up by a
nurse practitioner and the attending physician within at least a 48 hour time period after
discharge home from hospital; (4) education and support for informal caregivers providing
care for at-risk seniors in the community setting. These implementation strategies were
woven together with best practice key features used to evaluate three health care service
delivery models that could serve as a framework and be integrated into the Northern Health
Authority Integrated Health Network for At-Risk Seniors in Fort St. John, B.C.

48
Limitations, Implications for Practice and Research, and Concluding Recommendations
Introduction
The findings of this project provide insight and direction to collaborative nurse
practitioner and physician health care service provision for at-risk seniors living in northern
British Columbia. The question of inquiry set forth in this project was addressed through a
review of the literature. The evidence indicates that primary health care service provision
provided collaboratively through nurse practitioner and physician services reduces
emergency department utilization, reduces admissions to hospitals and long term care
institutions, and maintains or improves functional status of frail elders. Successful
implementation strategies were extracted through this same literature review and were
encompassed through a synthesis health care service delivery models that could serve as a
framework and be integrated into the Northern Health Authority Integrated Health Network
for At-Risk Seniors in Fort St. John, B.C. However, research evidence is never absolute and
thus limitations of the literature review and the consequent assumptions drawn will be
discussed. Implications for nurse practitioner practice and nursing research will be explored
and concluding recommendations will be proposed to improve continuity and increase
efficiency of community based primary health care services in the Northern Health Authority
Integrated Health Network for At-Risk Seniors in Fort St. John, B.C.
Limitations and Assumptions
The literature review is limited to articles found in a non-exhaustive search utilizing
specific search engines during the time span from October 2007 to February 2008 focusing
only upon retrieving the "gold standard" of research evidence including systematic reviews,
meta-analyses and randomized control trials. The assumption has been made that these were

49
the best method for studying the diversity of the field for the application of collaborative
nurse practitioner and physician primary health care service provision for at-risk seniors in
northern British Columbia.
Additional investigation is warranted to ensure that all relevant data regarding
collaborative nurse practitioner and physician primary health care service provision for the
frail elderly have been identified. Further consultations with stakeholders for the Northern
Health Authority Integrated Health Network for At-Risk Seniors must also be completed to
obtain additional information upon which to comprehensively plan collaborative practice in
the provision primary health care services to frail elders living in rural and remote regions of
northern British Columbia. Additionally, complete analysis of the medical data bases for atrisk seniors through the Fort St. John and District Hospital and the Home and Community
Care Departments should be undertaken to form a baseline for evaluation.
One recurring limitation was discovered in the research articles utilized for this project
paper. The systematic reviews, meta-analyses and several of the randomized control trials
failed to describe the particular aspects of interventions that led to their described outcome
measures. Overall, this acts as a substantial impediment in drawing further conclusions about
interventions in which collaborative nurse practitioner and physician practice provide acute,
emergent, and primary health care services to the frail elderly and limits insight towards the
application of these study findings for the care of at-risk seniors in Fort St. John, B.C.

Implications for Nurse Practitioner Practice
The critical appraisal of the evidence based literature illustrated in this paper provides
an in-depth portrayal of collaborative nurse practitioner and physician practice in the delivery
of primary health care services to the frail elderly. The implementation of nurse practitioner

50
collaborative services into community settings is the crux of inquiry and thus this project
paper will contribute to nursing practice by substantiating the unique contributions of nurse
practitioner practice towards health service care provision for the frail elderly and at-risk
seniors. This project paper has raised issues regarding the specifics of collaborative practice.
The implementation strategies in the review of literature demonstrated the positive effects of
collaborative nurse practitioner and physician practice on patient outcomes; however few of
these studies described the exact organizational arrangements. Therefore, implications for
practice are that existing structures need to change to enable collaborative roles to be
developed towards achieving expected positive outcomes of integrated health service
delivery. The question remains as to how these should change. Additional implications for
nurse practitioner practice are that through an evolution of projects such as the Integrated
Health Network for At-Risk Seniors in northern British Columbia and the possible
incorporation of nurse practitioners into this initiative, nurse practitioner practice may very
well expand to settings such as seniors centers and nursing homes and long term care
institutions in British Columbia and across Canada.
Implications for Future Research

It can be surmised that this project will contribute to a broader context of knowledge by
substantiating the unique contributions of nurse practitioners in the care of the frail and
elderly; however, there is a need for further research regarding the relevance and validity of
these contributions.

Existing health care organizational structures have been deemed to be

ineffective. Integrated health care service delivery models have been developed as a means to
address issues of inefficient and fragmented health care service delivery. However,
integrated health care service delivery models are currently being researched and the

51
incorporation of one of these or a combination of these into the Integrated Health Network
for At-Risk Seniors in Northern Health Authority would lend itself to this present day
research as the impetus for change in health care service delivery models is so new.
Implications for further research also arise from the literature review in regards to what
structures or processes would best encourage health care providers and health and social
service agencies with the ability to successfully integrate and collaborate. Future research
implications would also include the need to determine if additional specialized training for
nurse practitioners and physicians is needed, and what role specialists who are available
through the Geriatric Outreach Services Team would have in the care of frail elders for
successful outcomes in the Integrated Health Network for At-Risk Seniors in Northern
Health Authority. Additionally, this review of the literature indicates that more research into
what comprises the successful makeup of comprehensive geriatric assessments and the
linkage to overall plans for treatment and long-term care management needs to occur.

Recommendations
It is recommended that:

1. Northern Health Authority consider implementation of the role of a nurse
practitioner into the Integrated Health Network for At-Risk Seniors in Fort
St. John, B.C. to work collaboratively with physicians (and additional
health care service providers) to establish an interdisciplinary team for the
provision of community based primary health care services to the frail
elderly.
2. The Integrated Health Network (IHN) for At-Risk Seniors consider
comprehensive geriatric assessments (CGAs) linked to overall plans for

52

treatment and strong long-term care management to assist with the
provision of coordinated, cohesive health care service provision for frail
elders. Additionally, this IHN consider the integration and syntheses of the
SIPA (Systeme de services integers pour personnes agees en perte
d'antonomie) and the MHCP (Medical House Call Program) models to
serve as an overarching framework for health care service delivery for atrisk seniors in Fort St. John, B.C.
3. Fort St. John, B.C. serve as a pilot project to research how nurse
practitioner and physician collaborative practice could best contribute to
reductions in emergency department utilization, reductions in admissions
to hospital, reductions in admissions to long term care facilities, and
maintenance of health status for frail elders.
4. The Integrated Health Network for At-Risk Seniors in Fort St. John, B. C.,
develop and implement 24 hour 7 day per week access to the
interdisciplinary health care team as already planned by this IHN.
5. The Integrated Health Network for At-Risk Seniors in Fort St. John, B.C.
consider

nurse

practitioner

and/or

physician

collaboration

and

implementation of comprehensive, collaborative, and coordinated acute
and long term care hospital discharge planning and timely subsequent inhome follow-up within 24-48 hours.
6. Northern Health Authority consider the development of a seniors center
chronic illness self management and disability prevention program to
maximize opportunities for group visits for at-risk seniors.

53
Conclusion
Successfully implementing health care service provision for frail elderly persons is an
enormously complex and difficult challenge. The care of community dwelling frail elders
requires collaborative, coordinated, consistent care focused on prevention, as well as acute
and chronic condition management. Integrated health care systems were developed in
response to problems and issues with current health care systems. The literature identified
successful implementation strategies to serve as part of the foundation of integrated health
care service delivery models. It can be surmised that integration of nurse practitioner and
physician collaborative primary health care services could provide comprehensive continuity
of care to underserved at-risk seniors and ultimately lead to reductions in emergency
department utilization, admissions to hospitals and long term care institutions, and
maintenance of functional capacity for as long as possible. The aim ofNorthern Health
Authority's Integrated Health Network (IHN) for At-Risk Seniors in British Columbia is to
improve care for at risk seniors through a coordinated, multidisciplinary, proactive approach
(Northern Health, 2007b ). Consideration of the integration of nurse practitioners into
collaborative practice with physicians in community based primary health care provision in
rural and remote regions of British Columbia, in conjunction with the evidence extrapolated
from the review of the literature in this paper, may serve as a means for Northern Health
Authority to reach this goal.

54
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