Standardized assessment to support integrated care: Use of self-report instruments with vulnerable community-dwelling older adults during the pandemic

Abstract

Introduction: Older adults have been especially vulnerable to adverse outcomes of COVID-19 and measures to control its spread. Many avoided accessing care, and vital community-based services that support them to live independently were largely restricted or made virtual. In response, interRAI created a two-stage standardized system to screen and assess at-risk community-dwelling older adults. This system enables patients and caregivers to share their preferences, goals, needs and strengths, and supports core functions of integrated care, including proactive patient identification, individualized care planning, shared decision-making, care coordination, transitions and navigation, data harmonization, sharing and use across organizations, sectors and systems. Objectives: The objectives of this presentation are to describe the implementation of the COVID-19 Vulnerability Screener (CVS) and the Check-Up (CU) in support of integrated community-based health and social care during the pandemic. The CVS is a standardized surveillance instrument to identify individuals at-risk for COVID-19 and geriatric syndromes, and facilitates triage for further assessment and referral to health/social services. The CU is a standardized comprehensive assessment to assess individuals' functioning and quality of life, and inform care planning. Both tools may be administered by lay personnel but share common language with clinicianadministered instruments widely used in home, community, and long-term care in Canada. This compatibility supports information sharing and care coordination across settings and along the care continuum. Highlights: The CVS and CU were implemented in several community-based settings in Ontario, Canada, including community support services, home care, primary care, outpatient geriatric medicine clinics, and retirement homes. Personnel in each care setting administered the self-report instruments largely over the phone. Over 6,000 assessments were completed between April 2020 and March 2021. Each organization developed their own processes to identify individuals for screening/assessment and to respond the results, including measures related to COVID-19, and physical and psychosocial indicators of vulnerability. In one example, a community support services organization was able to use the information collected through the CVS to connect their clients to additional internal services, such as meals-on-wheels or friendly visitor, and to external services, including community health centres, mental health services, and food banks. Additionally, they developed a post-screening process for those identified by as high risk by providing regular followup and care coordination. Conclusions: The CVS and CU allowed providers across a variety of community settings to stay connected with vulnerable individuals and obtain a better understanding of their needs during the pandemic. It also allowed providers to coordinate and support navigation of services beyond their setting for clients during this isolating time. Implications: The CVS and CU provide a standardized way to quantify and understand needs to support care planning at the individual level but also the aggregate levels over time. While developed in response to COVID-19, this standardized assessment system could be adapted for a variety of disaster management applications.