Chances are, if you’re reading this, you’ve already recognized that change is needed.
Adapting care delivery to the new reality of frailty is a daunting task and everyone must start somewhere. Through PATH, your organization can begin to address this challenge at a pace and scale that works for you to achieve improved sustainability and enhanced patient outcomes.
PATH provides 4 levels of implementation, with benefits to patients and providers at each level. The program is designed to be implemented by reorganizing existing processes. Each level focuses on frontline staff (physicians, RNs, LPNs, SW, OT, pharmacists, etc.) as key participants.
PATH Offers:
- E-learning modules on frailty and its most common drivers, including dementia
- Onsite hands-on training
- Frailty screening techniques using video training and web-based applications
- Mentorships and internships for team leads
- Change management and evaluation resources
Level 1:Identify frailty at the frontline using a shared language
Use a common language to identify and respond to frailty in settings such as:
- Pre-operative care
- Medical and surgical specialty clinics/consult services (example priorities include: transcatheter aortic valve implantation (TAVI), medical oncology, heart failure, COPD)
Outcomes
- Clinic staff identifies frailty as a routine process of care for risk stratification.
- Frailty status is considered when making important clinical decisions
Level 2:Use common team-based assessment tools
Use shared assessment tools to streamline team-based assessment in settings such as:
- Health Care Teams
- Long-term Care
- Home Care
- Inpatient Care
Outcomes
- Healthcare teams efficiently recognize frailty and implement frailty-specific care plans
- Decreased redundancy of assessment to prioritize treatment recommendations across disciplines
Level 3:Integrate the full PATH model into an existing clinical stream
Align expectations and develop shared, prioritized goals using comprehensive assessment, communication techniques, and PATH consultation in such settings as:
- Geriatric Medicine Programs
- General Medicine Programs
- Family Medicine/Primary Care
- Long-term Care
- Home Care
Outcomes
- Healthcare teams efficiently recognize frailty and develop frailty-specific care plans
- Program provides consultation services for challenging cases in frailty
Level 4:Implement a full PATH model across multiple healthcare sectors
Share information, processes and decisions from one setting to another (e.g. home care, emergency department, specialty programs, and long-term care) to improve transition and care. PATH consultation is available for challenging cases in frailty.
Outcomes
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- Healthcare teams efficiently recognize frailty and implement frailty-specific care plans
- Unnecessary assessment and treatments avoided
- Improved transitions of care and enhanced experience during transitions
- Careful decision-making using consultation services for challenging cases in frailty