PRP132: Patient goals and health risks: Shaping the delivery of care of an interprofessional team and patient outcomes

Larkin Lamarche, PhD; Ruta Valaitis, PhD, RN; Jacqueline Rintjema, BA; Lisa Dolovich, PharmD, BScPharm, MS; David Price, MD; Dee Mangin, MBChB, DPH, FRNZCGP


Context: There is emerging importance on the practice of routinely collecting patient-reported outcome measures, such as patient health goals. However, unlike care traditionally organized around results of diagnostic tests which are disease-centred, how teams use patient-reported outcome measures in their delivery of care, and how this care is related to patient outcomes, remains unclear. Objectives: To explore how the collection of patient-reported goals and health risks shapes the delivery of patient care of an interprofessional primary care team and is associated to patient outcomes. Study Design: Descriptive study, using retrospective chart audits. Baseline and 6-month follow-up data was used from a larger study testing the reproducibility of the effectiveness of Health TAPESTRY, a program led by the primary care team in partnership with community volunteer organizations. Setting: Six family health teams across Ontario, Canada. Population: Patients aged 70 years or older, community-dwelling. Intervention: Goal and health risk information from patients was collected by trained community volunteers and electronically sent to an interprofessional primary care team huddle for review and action. The health care providers involved in clinical actions were recorded by a retrospective chart audit. Outcome Measures: Rapid physical activity assessment, Screen II for nutrition, and the Friendship scale for social health. Up to three priority goals, collected from the goal setting survey on the Health TAPESTRY Application, were used to map to providers involved in clinical actions. Anticipated Results: Results will show the frequency of involvement of interprofessional healthcare team members in the presence of goal information only, risk information only, and goal and risk information. Results will also show levels of physical activity, nutrition, social health at baseline and at 6-month follow-up to explore patterns of patient health outcome changes based on goal information. Outcomes to be reported: The frequency of three goal and health risk areas (physical activity, nutrition, social life). Risk information for, and levels of, physical activity, nutrition, and social health will be reported for baseline and 6-month follow-up. Frequency of involvement in interprofessional healthcare team members will be reported.

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