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Key stakeholders’ views on the quality of care and services available to frail seniors in Canada Giguere, Anik M C; Farmanova, Elina; Holroyd-Leduc, Jayna M; Straus, Sharon E; Urquhart, Robin; Carnovale, Valerie; Breton, Erik; Guo, Selynne; Maharaj, Nandini; Durand, Pierre J; Légaré, France; Turgeon, Alexis F; Aubin, Michèle Nov 26, 2018

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RESEARCH ARTICLE Open AccessKey stakeholders’ views on the quality ofcare and services available to frail seniorsin CanadaAnik M. C. Giguere1,2,3,4* , Elina Farmanova1,2,3, Jayna M. Holroyd-Leduc5, Sharon E. Straus6, Robin Urquhart7,Valerie Carnovale1, Erik Breton1, Selynne Guo5, Nandini Maharaj8, Pierre J. Durand2,3,9, France Légaré1,3,4,Alexis F. Turgeon4,9,10 and Michèle Aubin1,2,3AbstractBackground: Frail seniors often receive ineffective care, which does not meet their needs. It is still unclear howhealthcare systems should be redesigned to be more sensitive to the needs and values of frail seniors and theircaregivers. We thus aimed to describe key stakeholders’ perspectives on the current healthcare and servicesavailable to frail seniors.Methods: In this qualitative descriptive study, we conducted semi-structured interviews with a convenience sampleof 42 frail seniors, caregivers, clinicians, or healthcare administrators/decision makers involved in frail senior carefrom five Canadian provinces. We explored participants’ perspectives on the quality of care and services for frailseniors. We used an inductive/deductive thematic data analysis approach based on the Square-of-Care model,including emerging themes using the constant comparison method.Results: We grouped participants’ perspectives into strengths, weaknesses and opportunities for improvement, andthen into nine themes: care processes, continuity of care, social frailty, access to healthcare and services, models ofhealthcare delivery, cost of care, healthcare staff management and professional development of healthcareproviders, material resources and environmental design of healthcare facilities, and coordination of care. Ourfindings suggest redesigning assessment, communication with frail seniors and their caregivers, targeting care andservices to the needs, and integrating care better across settings and in time.Conclusions: A systematic identification of frail older people is the first step to adapt healthcare systems to thispopulation’s needs. Participation of frail older people and their caregivers to decision making would also allowchoosing care plans meeting their care goals. The integration of care and services across settings, over time, andwith various providers, is also needed to meet frail senior needs.Keywords: Delivery of health care, Frailty, Health planning, Health services needs and demand, Quality of health care,Quality improvement* Correspondence: anik.giguere@fmed.ulaval.ca1Department of Family Medicine and Emergency Medicine, Laval University,Pavillon Ferdinand-Vandry, room 2881-C, 1050 avenue de la Médecine,Quebec, QC G1V 0A6, Canada2Quebec Centre for Excellence in Aging, St. Sacrement Hospital, Quebec, QC,CanadaFull list of author information is available at the end of the article© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Giguere et al. BMC Geriatrics          (2018) 18:290 https://doi.org/10.1186/s12877-018-0969-yIntroductionFrailty is a clinically recognizable state of vulnerabilitycaused by aging-associated decline across multiplephysiologic systems, which compromise the ability tocope with normal or minor stresses [1]. Compared totheir age-matched non-frail counterparts, frail seniorsare at much higher risk of fall, infection,hospitalization, institutionalization, and death [1, 2].Frailty represents a global health concern due to itsmultiple clinical and societal consequences and accel-erated aging of populations worldwide.In Canada, an estimated 5 to 15% of people are frail, de-pending on the province [3]. Frail seniors are high users ofhealth services, which translate into a greater number ofvisits to healthcare providers, more hospital admissions,longer hospital stay, higher use of home care services, andmore visits to the emergency department [4–7].Frail seniors often receive ineffective and even harmfulcare [8]. They commonly face care coordination andsafety problems due to lack of communication betweenphysicians [9]. Many community-dwelling frail seniorsdo not receive continuing care by the same provider,which results in (preventable) visits to emergency roomsand medical escalation [10]. Such gaps in care mayintroduce additional health risks, unnecessary financialand social costs associated with recurrent admissions,loss of independence and diminished quality of life [8].It is still unclear how healthcare systems should beredesigned to be more sensitive to the needs and valuesof frail seniors and their caregivers. Therefore, we soughtto describe the perspectives of users, healthcare pro-viders and decision makers about the current state ofthe healthcare system for frail seniors and specific op-portunities for improvement.MethodsIn this qualitative descriptive study, we conductedin-depth interviews with key stakeholders from severalCanadian provinces, including Quebec (QC), NovaScotia (NS), Ontario (ON), British Columbia (BC), andAlberta (AB).ParticipantsWe recruited a convenience sample of frail seniors, care-givers, healthcare providers (HCP), and administrators/decision makers from nursing homes, hospices, hospi-tals, and home care agencies (DM). We recruited DMand HCP through the networks of the research teammembers. Patients and caregivers were recruited throughthe participating HCPs or through posters in geriatricclinics where the participating HCP worked. Seniorswere eligible to participate if they were 65 years of ageor older, and considered frail according to the ClinicalFrailty Scale [11] or the Edmonton Frail Scale [12]. Frailseniors with cognitive impairments were also eligible toparticipate if their caregiver accompanied them, and iftheir caregiver agreed to participate and answer the inter-view questions if the frail senior was unable to do so.Data collectionSix members of the research team conducted the inter-views from June to October 2015, to explore the partici-pants’ views and experiences with healthcare andservices for frail seniors, and to solicit their perspectivesabout potential opportunities for improvements. The50-min interviews followed a semi-structured guide(Table 1), which we adapted for frail seniors and theircaregivers to avoid jargon. We conducted phone inter-views with DM and HCP, and in-person interviews withfrail seniors and caregivers. The interviews were audiorecorded, and transcribed verbatim. One participant re-fused recording but agreed to note taking as analternative.Data analysesThe thematic data analyses combined deductive and in-ductive approaches. The Square-of-Care conceptualframework [13] initially guided the deductive analysis.This framework guides palliative care and describes acomprehensive set of care processes (e.g. assessment, in-formation sharing, decision making) and issues associatedwith illness and bereavement (e.g. social, psychological,Table 1 Interview guide1. How are you interested/involved in the care of frail seniors?2. In your opinion, what, if anything, is different about the provisionof care to frail seniors compared to other patients?3. In your opinion, what are the most important components ofquality of care for frail seniors?Probe:– What components of healthcare services, resource utilization,models of care are especially important for this population?4. Do you know of any instances where frail seniors did not receivequality care? If so, why didn’t they receive quality care?Probes:– Were there particular things about their health problems thatmight help explain why they did not receive quality care?– Were there aspects of their psychological health or socialenvironment that might help explain why they did notreceive quality care?– Were there aspects of their family environment that might helpexplain why they did not receive quality care?– Were there things about the establishment in which theyreceived care that might help explain why they did notreceive quality care?5. Imagine a future ten years from now and that your province waswell organized to care adequately for frail seniors. What does thatfuture look like to you?Probes:– What would high quality care and services look like?– In contrast, what would poor quality care and services look like?Giguere et al. BMC Geriatrics          (2018) 18:290 Page 2 of 14physical, practical issues). An inductive analysis allowedincluding new emerging themes using the constant com-parative method of analysis [14]. Three researchers collab-orated for the analyses: one initially analysed the data(EB), another validated the findings (VC), and the thirdverified consistency between the themes and the contentof interviews (AMCG). The team met regularly to reviewcodes and resolve discrepancies through discussion. Aqualitative data analysis software (NVivo version 10, QSRInternational) facilitated the analyses.ResultsWe interviewed 42 participants: eight frail seniors and/or their caregivers, 18 HCP, and 16 DM (Tables 2, 3, 4and 5). In QC and BC, we recruited frail seniors or theircaregivers through participating HCPs. In the otherprovinces where we used posters in geriatric clinics, re-cruitment of frail seniors or their caregivers remainedunsuccessful despite all efforts. Most of the participat-ing HCP were physicians (n = 11), and more than halfspecialized in geriatric care. The other HCP werenurses (n = 4), and social workers (n = 3). The majorityof participating DM worked in provincial health sys-tems. We did not recruit any frail senior with cognitiveimpairment.The final qualitative analysis retained several of themesdescribing care processes in the Square-of-Care conceptualframework (assessment, information sharing, care planning,care delivery) [13]. After our analysis, the Square-of-Caretheme ‘Decision-making’ was renamed ‘Patient engagementin decision-making’, and we added a new theme, ‘Access’, tothe list of care processes proposed in the framework. Wealso added several other themes raised by study partici-pants, to propose a set of key features of the quality of careTable 2 Socio-demographic characteristics of participants(DM = decision maker, HCP = healthcare professionals)Characteristic DM (n = 16) HCP (n = 18) Frail senior (n = 5) Caregiver (n = 3)All participantsGenderFemale 13 11 1 2Male 3 7 4 1Age (years)25–34 135–44 1 545–59 15 6 260–64 465+ 265–74 175–84 285+ 2NA 1ProvinceAB 4 4BC 4 4 3 1NS 2 2ON 1 4QC 5 4 2 2Table 3 Socio-demographic characteristics of decision makers(DM)Characteristics Frequency(n = 16)Management experience (years)6–10 411–15 216–20 221–25 526–30 231–35 1Type of organizationProvincial health system 10University 1Hospital 1Senior Advocate 1Medical Association 2Regional Health Agency 1Level of organizationRegional 3Provincial 11National 2Role in the organizationOperations 5Planning 1Operations, planning and finances 2Other 8Educational backgroundMD 3MA public administration 2MD, CCFP 2RN, MN, BSN 2MBA 1M. Sc. Health Services Administration 1BScN 1BScPT, MSW, MBA 1FRCPC int.Medecine 1BA, MBA,,MSC 1B.Sc. Health promotion, M.Sc. Healthadministration, Certified health executive (CHE)1Giguere et al. BMC Geriatrics          (2018) 18:290 Page 3 of 14and services available to frail seniors (Fig. 1). We furthercategorized these themes into weaknesses (Table 6),strengths (Table 7), and opportunities for improvement. Amore detailed account of the subthemes is available in the(Additional file 1: Appendices 1–15).Care processesAccess to health care and servicesParticipants perceived that long wait times for accessingacute care and specialized services, and limited access toprimary care, often result in using emergency care. Es-sential services, which would prevent crises, often re-main inaccessible. There is also a mismatch betweenwhat frail patients qualify for, and what they truly need:“Because my father is over 65, he doesn’t get anyrehabilitation. And that kind of shocked us becausemy dad… one of his main hobbies is walking and wekind of thought that you’d want to focus on rehabto get him some level of capability, so he’s not sucha burden on the healthcare system. And we weretold no. There’s no money for that. He does notqualify.” (BC, Caregiver#2)An HCP explained that qualifying criteria for subsidizedassisted living are so narrow that they leave out manypatients who would have benefited from it:“I think that’s a real gap. Unfortunately, people then...don’t move when they might want to, waiting for acrisis to happen.” (BC, HCP#2)Participants also highlighted that levels of care often donot match the changing needs of frail seniors. Frail se-niors and their families find themselves in a ‘viciouscycle’, as they are waiting for a certain level of care,which, when they get it, does not match anymore theirneeds that have changed:“…once they are in the nursing home, we see people,you know, fall and break a hip, for example, and thenrequire higher level of care. But the nursing homedoesn't always allow for a gradual increase in the levelof care. They may have been on the waiting list to getin that nursing home for a lower level of care, andthen because of a health event that requires more care,Table 4 Socio-demographic characteristics of healthcareprofessionals (HCP)Characteristics Frequency(n = 18)ProfessionPhysician 11Nurse 4Social Worker 3Specialization in geriatric careYes 11No 7Practice experience (years)1–5 46–10 116–20 321–25 326–30 231–35 236–40 2N/A 1Language used at workEnglish 14French 4Table 5 Socio-demographic characteristics of patients andcaregiversCharacteristics Frequency (n = 8)Patient (n = 5) Caregiver (n = 3)Language at homeEnglish 3 1French 2 1Other 1Patient’s marital statusMarried or domestic partnership 4 2Single 1Widow 1Patient’s locationAt home 2Nursing home 1OtherRetirement home 1 2Extended care unit 1At home and in a hospice 1Caregiver living with patientNo 3Patient have a caregiverYes 3No 1N/A 1Patient’s health problemArthritis 2Parkinson 1Paralysis 1N/A 3 1Giguere et al. BMC Geriatrics          (2018) 18:290 Page 4 of 14they stay in the hospital. They can lose their spot inthe nursing home and have to wait for a new level ofcare…” (NS, HCP#2)The essential access of frail seniors to primary care ser-vices is also complicated by the retirement of family doc-tors, which often leaves frail seniors stranded.“A lot of the frail seniors cannot access primary care,Right now, a lot of the older physicians are retiringfrom their practice and they are not taking on newpatients; this is just what I’ve seen. As a result, olderpeople can’t find primary care physicians to take ontheir case because they are so frail.” (AB, HCP#2)AssessmentHalf the participants described assessments as inad-equate, as underlined by this decision maker:“There are plenty of people who do not have ananswer to their needs because they are not detectedquickly. More and more, our partners are sensitized tomonitor signs of loss of autonomy. I think that ourgeriatricians who practice in remote areas are verycooperative in supporting front-line physicians in iden-tifying this loss of independence.” (QC, DM#5)Participants also emphasized the importance of compre-hensive geriatric assessments to diagnose frailty, andFig. 1 Key features of the quality of care and services for frail seniors, as initially deduced from the Square-of-Care conceptual framework [13],and then induced by study participantsGiguere et al. BMC Geriatrics          (2018) 18:290 Page 5 of 14underlined difficulties accessing it. They also judgedmental health assessments, and time dedicated to assesspatients, as inadequate. Participants stressed the import-ance of improving investigations of falls, cognitive im-pairment, and polypharmacy:“An individual that I've seen recently presented withfalls. The person was seen by a fall's service and wasput into a balance training exercise program, butunfortunately, the person had a neurological problemfor their fall difficulty, which would have required asearch intervention. People assumed that all theperson needed was an exercise program, when theyactually needed a diagnostic evaluation. A newunrecognized problem was causing the presentation.No one stepped back to see if there might be somesomething new going on.” (AB, HCP#1)Information sharingThe sharing of health information among frail patients,their caregivers and HCP was reported as problematic. Par-ticipants reported that caregivers lacked access to healthinformation regarding the frail patient. They also reporteda lack of health information to facilitate interactions anddiscussions among patients, caregivers and HCP:“The system is configured on the assumption thatpeople can speak for themselves and have all theinformation, whereas when you’re dealing with seniors,often times you’re dealing with the family. They bringtheir own perspective; they also bring additionalinformation to the encounters, which isn’t alwaysrespected or considered.” (NS, HCP#1)Participants also underlined the lack of mechanismsallowing caregivers access to important health informa-tion, such as discharge instructions, as explained by thisdecision maker:“And then for many older people, especially with thosewho have cognitive impairment, there needs to be a lotof family involvement. Sometimes, I think that with allour privacy policies we forget to involve the family.Therefore we may give the individual the informationthat they would need, but that doesn't mean that theyTable 6 Frequency of participants who discussed weaknesses of the current healthcare services for frail seniors in Canada, by maintheme (and sub-theme), and by Canadian province (AB = Alberta, BC = British Columbia = Nova Scotia, ON = Ontario, QC = Quebec)Overall(n = 42)ProvinceAB (n = 8) BC (n = 12) NS (n = 4) ON (n = 5) QC (n = 13)Care processes1. Access to healthcare and services 19 3 5 3 3 52. Assessment 20 7 5 2 1 53. Information sharing 8 2 3 2 0 14. Patient engagement in decision-making 9 2 4 0 1 25. Care planning 3 1 0 1 0 16. Care delivery 29 6 10 4 2 7Social environmentSocial support 16 5 4 2 3 2Social isolation 8 2 2 1 2 1Culture 1 1 0 0 0 0Healthcare systemsModels of delivery of care 18 6 4 3 1 4Cost of care 17 4 3 2 2 6Continuity of careRelational continuity 10 0 2 0 1 7Informational continuity 6 1 3 0 1 1Management continuity 1 0 0 0 0 1Coordination of care 9 1 3 1 3 1Healthcare organizationsHealthcare staff management and professional development of HCP 19 5 7 0 3 4Material resources and environmental design of healthcare facilities 11 4 5 0 1 1Giguere et al. BMC Geriatrics          (2018) 18:290 Page 6 of 14can actually use what you have given them andactually apply it to their lives.” (NS, DM#1)Patient involvement in decision-makingParticipants also reported several weaknesses related tothe lack of engagement of patients in decision-making:“Because they are frail, [they] may be not treated asequal as citizens… not talked to directly. Their familiesmaybe talked to, or their caregivers, as opposed to them…They are not included in the conversation. […] They arenot involved and they want so desperately to beindependent, respected and included, of course, in theirhealthcare decisions.” (BC, HCP#2)Participants perceived that the lack of patient engage-ment in decision-making to be widespread:“At this time, frail older adults do not have manydecisions to make on their own. Healthcareestablishments make every decision for them along theirtrajectory… Essentially, frail people have no control, nonewhatsoever… not over their lives and care. […] If we wantto improve the quality of care, frail older adults must beempowered to partake in their care.” (QC, DM#4)Care planningParticipants reported the reluctance of caregivers andfamily members to engage in advanced care planning.They mentioned the need for well-developed proce-dures and resources to ensure that caregivers andfamilies are duly and timely informed and educated,to prepare them for decline and engage them inend-of-life care:“We need to be better equipped to have thesediscussions, and to help us, seniors and the caregiversmake informed decisions around a plan. […] Our olderadults and the family caregivers should be given theright information so they can make informeddecisions.” (AB, HCP#4)“I think end-of-life care discussions are an importantthing that are missed often. When you’re working in ge-riatrics, you are certainly facing end-of-life care deci-sions. I think it’s difficult for a lot of people to have thattalk. I think that it’s something that geriatrics does verywell. Otherwise, people don’t get to talk about theirhopes and plans for their end-of-life goals of care, whento end treatment. If somebody is on chemo dialysis andthey’re reaching the point where they just don’t want togo on anymore, and nobody has that conversation withTable 7 Frequency of participants who discussed strengths of the current healthcare services for frail seniors in Canada, by maintheme (and sub-theme), and by Canadian province (AB = Alberta, BC = British Columbia = Nova Scotia, ON = Ontario, QC = Quebec)Overall(n = 42)ProvinceAB (n = 8) BC (n = 12) NS (n = 4) ON (n = 5) QC (n = 13)Care processes1. Access to healthcare and services 3 0 2 0 0 12. Assessment 3 0 0 0 1 23. Information sharing 0 0 0 0 0 04. Patient engagement in decision-making 4 0 2 0 1 15.Care planning 1 0 0 0 0 16. Care delivery 8 1 2 0 1 4Social environmentSocial support 9 1 3 1 1 3Social isolation 4 2 1 0 0 1Healthcare systemsModels of delivery of care 4 2 1 0 1 0Cost of Care 1 1 0 0 0 0Continuity of careRelational continuity 2 0 1 0 0 1Management continuity 2 1 0 0 0 1Healthcare organizationsHealthcare staff management and professional development of HCP 6 2 0 1 2 1Material resources and environmental design of healthcare facilities 2 1 1 0 0 0Giguere et al. BMC Geriatrics          (2018) 18:290 Page 7 of 14them, then they don’t know that they can say, I’ve hadenough. I want to stop now and know what palliativecare looks like.”(ON, HCP#4)The participants also raised the issue of the lack of ad-herence to care plans, as underlined by a decision makerfrom Nova Scotia:“Sometimes when people are taken to emergency,even if they have some kind of a care plan thatmay have been made with their doctor or theirgeriatrician or some other kind of healthcareprovider around the limits of that care, which careplan isn’t always accessible or available at emerge.So the limits of that care plan may not always berespected.”(NS, DM#2)Patients and caregivers suggested that adherencemight be improved if patients and caregivers were in-cluded as formal members of the care team:“Sometimes, more players need to be engaged in theplanning for healthcare support. If the person has afamily care provider who will be assisting, either whenthey are in hospital or when discharged from hospital,we should engage that person into the team of care.”(AB, DM#4)Care deliveryParticipants also perceived care delivery as lacking sensi-tivity to frailty:“…the person had to wait four days before theyactually had the hip surgery. And every one of thosedays, the person wasn’t allowed to eat just in case theywould get the operation that day. So the family andthe individual, who was 90 years old, felt that this wasan example of a frail elder who was not given highpriority in our healthcare system.” (BC, DM#3)Some participants expressed concerns about thestigma and prejudices against frailty in healthcare set-tings, as discussed by this decision maker form Quebec:“The other thing that makes frail seniors different, Ithink, is stigma. I think there is a large stigma byus against older patients. And I find in thehealthcare system that, when a senior with acomplex medical profile doesn't fit in a box like thehospital box, or the family physician box, or thelong-term care box, then it's often the case that no-body wants them and they're... they're truly aban-doned by the system.” (QC, DM#1)The inappropriate use of medications, the designs ofacute care settings, and the management of mentalhealth issues also worried them:“So in residential care, one of the biggest problems isthe use of antipsychotics to help people sleep or be lessagitated, and they get in a cycle of alienation, really.”(BC, HCP#3)Participants emphasized the importance of the frail pa-tients’ quality of life:“My dad has zero quality of life. He talks regularlythat “can you just cremate me?” […] He’s graduallygetting a little bit of dementia… because for two years,no mental stimulation […] And he keeps asking: “whatare they doing to help me get better?” so he thinks thatthe physiotherapy is part of the hospital. He doesn’tknow that we’re paying separately. He thinks he’s thereto get better. Not to just die.” (BC, Caregiver#2)The participants also discussed some positive experi-ences with the delivery of care, notably the presence ofgeriatric programs in some acute care settings, and theavailability of home care services:“My father was able to stay home for the last five years,because we have had support from our system. Untillast March, he was at home and had, five times a week,twice a day, people who came to help him at home. Ifthis support had not been there, it would not have beenpossible for him to stay home” (QC, Caregiver#4)Social environmentParticipants discussed how social isolation might in-crease the risks of later development of frailty. As statedby an HCP:“Lonely patients are more vulnerable and have agreater demand for acute care services.” (AB, HCP#2)Participants emphasized that HCP and the system mustbecome ‘vigilant’ to identify and support patients at riskof social isolation, and prevent it by increasing publicawareness, strengthening ties to the community, and im-proving relational continuity between family physiciansand caregivers (Tables 6 and 7).While family and friends represent significant sourcesof social support for frail seniors, caregiver burden re-mains unaddressed in our healthcare systems:“The family caregivers are the shadow work force. […]we recognize they are being burned out. They are beingGiguere et al. BMC Geriatrics          (2018) 18:290 Page 8 of 14stressed out (…). We are realizing that a lot of thecaregiving will fall onto one person in the family. […]when it’s all the spouses looking after the older adult,looking after an older adult can turn into a full-timejob.” (AB, HCP#4)Participants emphasized that care for frail seniors can-not be effectively improved unless caregiver supports areimproved.“I think there is too much reliance on public agenciesfor something as personal as your own care. I thinkcare should be built around family resources, whereverpossible. Any resources should be in terms of supportto the caregivers, whether they are financial, from thepublic agencies, or otherwise. The family lies at thecenter of the healthcare model that I see, with supportfrom outside, whether it’s private or public, tax, orservices from the government.”(BC, frail senior#1)Moreover, with an aging immigrant population, there is agreater need than before for cultural cohesiveness to addresslanguage barriers, cultural beliefs, and expectations of familymembers and caregivers, especially in end-of-life care.“It can be a cultural norm for a family to rally aroundand take care of their elderly, even if they need a lot ofcare at home. The staff might then think that it is toounsafe to discharge a patient home. But the familymay be adamant that this is what they want to do,even if they know there’s a risk taking them home. Butthe care team is still hesitant because they want what’sbest physically for the patient. Some social sensitivitiesdon’t get the attention they deserve.” (AB, DM#3)Healthcare systemsModels of Healthcare Delivery.Overall, participants shared that the current organizationand delivery of healthcare services are system-driven andinappropriate for frail patients:“[…] our responses tend to be system driven, and notnecessarily patient or family driven. And that’s wherewe can have problems and gaps in the care thatpeople receive for quality of life.” (BC, HCP#2)According to the participants, the division between in-curable and curable conditions is inappropriate in thecontext of frailty. There is a need for holistic,person-centred care that caters to the needs of patients:“A person-centred approach helps identify what is im-portant and meaningful for them [frail patients]. It isan interdisciplinary approach where you are includingthe client and the family, the family physicians, andany other consulting physician, as well as the nurse…and other team members who are needed to supportthe individual successfully.” (AB, DM#2)Improvements in the delivery of healthcare for frail pa-tients should focus on integration of medical and socialcare, and on improving primary care while facilitatingaccess to other levels of care. Participants identified sev-eral promising models suitable for frail patients, notablythose to prevent delirium by creation of senior-friendlyacute care settings, and the model aiming to improvecare integration by delivering primary care services ingeriatric clinics. One participant also discussed how thepalliative approach fits frail seniors:“[…] If you have a terminal diagnosis and you want tostay at home, palliative care is very good and verycomprehensive. They have teams of doctors, a partnershipwith home care, coordinators who are knowledgeableabout palliative care, and RNs or nurse practitioners whoalso have expertise in palliative care. For frailty, it isn’tthe same network of teams, but it’s robust. So I think thatwould be a model to which to aspire to.” (ON, HCP#2)Cost of careParticipants perceived that while the cost of frail seniorscare is high, it still does not meet the needs of frail se-niors. The participating HCP mentioned that the fund-ing programs supporting this population are limited,and that fee-for-service limits the delivery of propercare. Services that are deemed useful to frail patientsare largely inaccessible and unaffordable to them.Although home care has been successful in supportingfrail patients, it is simply insufficient. Thus, new fundingmodels should consider frailty and support of informalcaregivers:“There needs to be some recognition for the role,whether it’s a tax system approach where you get areimbursement and have a paid leave when yousupport someone to the end of life, […] or rest services,which could include things like day programs, or homecare support. That type of thing would enable peoplewho are supporting someone who’s frail to have abreak.” (AB, DM#2)Continuity of careCare transitions can seriously challenge relational con-tinuity and the therapeutic relationship between a pa-tient and the HCP. Participants reported communicationGiguere et al. BMC Geriatrics          (2018) 18:290 Page 9 of 14breakdowns occurring during care transitions (betweendifferent facilities and between floors of the same facil-ity) which can result in serious aggravations for frailpatients:“Just last week, they sent a patient who could notmove out of his chair, home. The note said ‘dischargeto long-term care’, but they did not understand... andso, he went home and had a fall. This is within 24hours of being sent home. So he ended up back in hos-pital. It’s really about communication. It’s not aboutmedical care.” (ON, HCP#2)Transfers from home to residential settings were de-scribed as particularly problematic because they couldprecipitate the onset of mental health issues and rapiddecline. The involvement of family physicians or socialworkers was viewed as essential to prevent worseningand ensure continuity of care. Overall, the predominantperception was that care transitions are not designednor coordinated to meet the needs of frail patients:“We need a sort of a one-stop approach to supportfrail people when they need to go for a diagnostic test-ing like blood tests and X-rays, anything like that.Right now, if there’s any kind of investigation that hap-pens… there are probably three or four or five appoint-ments that they have to make on different days, andthat just increases the complexity of navigating andgetting to an appointment.” (AB, DM#1)Coordination of careParticipants perceived an important fragmentation incare and services:“…having access to appropriate support in home… andthe coordination of those services if they are availablewith healthcare planning and service delivery ofprimary care... The coordination or all of that isbroken, it’s just... it’s embarrassing to explain to mypatients... I can’t help them.” (BC, HCP#1)Referrals are generally not built into the process of care. Par-ticipants underlined how the lack of communication amongproviders is a recurring issue across the continuum of care.“[Note from the author: the participant is discussing thecase of an older patient discharged home after beinghospitalized for a vertebral fracture] I was unable tocontact the people who had discharged her. I called thelocal community services center, left messages twice, and Iwas unable to speak to a person to ask questions and havea minimum of information, namely: Was someone incharge of this file? What services had been planned? This,for me, is an important gap. It takes a mechanism toquickly transmit information that a patient has beenhospitalized, what she is suffering from, that we arepreparing to discharge her, the services that we intend toput in place, the professional to be contacted. The otherthing is the connection between family physicians andhome care. Even when calling a hot line at the localcommunity services center, access is not easy. These peopleare having trouble joining us and we are having troublegetting in touch with them. We have to think more aboutthose processes. Effective modes of communication shouldbe established.” (QC, HeCP#4)Suggestions for improvement included the use of appro-priate communication technology, redesign of care path-ways and promotion of patient navigator roles, as discussedby this healthcare provider from British Columbia:“Sometimes it’s very confusing to patients and theirfamilies who is in charge, who’s involved, who shouldthey be talking to. Maybe a case manager or someonecould guide patients and give them more support.Right now, case managers in the community have hugecaseloads, so that something might be considered to tryto lower the caseloads so that patients and familieshave a person to turn to give them more time helpingthem, find the right resources and find the rightsupports and navigate the system.” (BC, HCP #2)Healthcare organizationsStaff management and professional developmentParticipants stated that staff management influences thequality of frail patient care. They mentioned issues with hav-ing the right staff and sufficient staff to attend to the needs:“…geriatricians can put all the comorbidities togetherand come up with a goal of care and plan for thefamily, and then a plan for the future. I think thefamily physician is very busy... I don’t think they havetime to do it and maybe not the skill set and theexpertise at that point. So, I think we need to hire lotsof geriatricians.” (AB, HCP#2)Participants recommended getting staff more downtimesto prevent burnouts. Other suggestions for improvementfocused on the recruitment of geriatricians in primarycare and residential facilities and allied healthcareworkers to assist with activities of daily living.“And I think we need more care workers who areinterested in providing care for elders. Not just doctors,but allied health as well.” (ON, HCP#1)Giguere et al. BMC Geriatrics          (2018) 18:290 Page 10 of 14Many participants felt that HCP lacked training to carefor frail patients, yet training was not uniformly availableat every healthcare organization:“The front line staff has no training (…) yet they maybe the clinical assistants, they may be sitting with thepatient, they may be caring for the patient, but theyhave zero education… I think all medical studentsshould go through geriatrics as part of their education.Definitely. […] Nurses too. Everybody.” (ON, HCP#4)Participants recommended that training curriculuminclude topics such as care for dementia, end of life, andguidance for appropriate level of care. They underlinethe importance for primary care providers to becomemore aware of supports for frail patients in the commu-nity and to improve their skills to identify and care forfrail patients.“I think all family physicians will be seeing more andmore frail elders. So we need to create some capacityfor people to take on those patients, both at home andin ambulatory setting, and to feel more competent totake care of them and to be knowledgeable aboutresources available. I think many family doctors don’tknow a lot of resources other than the hospital and theoffice. So, we need to make them aware ofrehabilitation facilities or day treatment programs,respite programs, and all those resources I think aren’ton the radar of most family doctors.” (ON, HCP#2).Design of Healthcare Facilities and Material ResourcesThere is a need for senior-friendly environments in allfacilities and organizations caring for frail patients:“We need to be more aware of senior-friendly environ-ments that will support older adults (…): appropriatesignage, appropriate ways of speaking with people whomight be hard of hearing, environments that are un-threatening and low in stimulations that exacerbatecognitive behaviours.” (AB, DM#1)Overall, there is also a lack of resources (beds, re-sources for bathing and daily activities) in patient homesand residential facilities.Comparisons between types of participantsParticipants of any type converged in their interest forcare processes, which they all discussed extensively.However, some themes were mentioned exclusively bythe DM and HCP, including models of care, educationand training of HCP, healthcare staff management, andinformation sharing. On the other hand, patients andcaregivers criticized several aspects of care delivery thatwere not discussed by HCP and DM, such as bereave-ment care in hospital settings, the invasion of their in-timacy by HCP at home, and the lack of adaptation oflong-term care facilities to senior needs. They alsobrought their unique perspective on assessment, by criti-cizing the fact that diagnoses are not integrated. Regard-ing relocalization, they were the only ones among alltypes of participants to discuss the pressure felt by FS inselecting a residential facility, the failure of transfer plansin meeting FS needs, and the difficult adjustment experi-enced by FS after transfer. They also mentioned the lackof information sharing between caregivers and patient.Comparisons between provincesSeveral of the weaknesses and strengths of the currenthealthcare services were discussed by participants fromevery province (Tables 6 and 7). On the other hand, sev-eral of these themes were raised by participants frommultiple provinces, but not from every province, includ-ing: information sharing, patient engagement indecision-making, care planning, continuity of care, andmaterial resources and environmental design of health-care facilities. Within the social environment theme, asingle decision maker from Alberta discussed culture,whereas participants from every province discussed so-cial support and social isolation.Regarding areas of improvement of care processes, theparticipants from Alberta discussed all sub-themes, butprimarily the delivery of care, and care planning and as-sessment (Additional file 1: Appendix 2). In BritishColumbia, more participants discussed how to improvethe delivery of care and patient involvement indecision-making compared to other sub-themes. Themain area of improvement discussed by Nova Scotia par-ticipants was delivery of care. Three of the five partici-pants from Ontario made suggestions to improve careprocesses, specifically assessment, delivery of care, careplanning and patient involvement in decision-making.Major areas of improvement discussed in Quebec wereassessment, information-sharing and patient engagementin decision-making.Participants from every province discussed potentialimprovements to the current social environment, modelsof delivery of care, and coordination of care. On theother hand, participants from multiple provinces, butnot all of the provinces, discussed potential improve-ments of the other features of the quality of care andservices for frail seniors.DiscussionWe described the perspectives of frail seniors, caregivers,healthcare providers and decision makers from five Can-adian provinces on the current state of healthcare andGiguere et al. BMC Geriatrics          (2018) 18:290 Page 11 of 14social services for frail seniors. The study participantshighlighted needs and care trajectories of frail seniorswhich are different from those of the general population,and for which the current system is inappropriate. Inter-pretation of our findings suggest redesigning five mainaspects of care and services to meet the specific needs offrail seniors better: access, assessment, communicationwith frail people and their caregivers, targeted care andservices, and integrated care.Participants highlighted that frail seniors need better ac-cess to preventative care and services, and to primary care,in order to avoid functional decline. A scoping literaturereview concluded that access to community-based pri-mary healthcare can be improved for vulnerable popula-tions by a formal integration of services, while alsoreducing hospitalizations, emergency department admis-sions, and unmet healthcare needs [15]. Another recentreview concluded that integrated care improved access tocare for older people, and quality of care [16].Study participants also discussed assessment, whichthey found inadequate for frail seniors. They proposedbroader implementation of comprehensive geriatric as-sessment, and an earlier assessment of geriatric syn-dromes and frailty in primary care. Hence, a redesign ofthe healthcare and services systems to meet their specificneeds would firstly identify earlier those who are frail.Comprehensive geriatric assessment is the evidence-basedprocess to detect and grade frailty, but is resource-intensive[17]. Ongoing research is trying to improve frailty identifi-cation and integrate it into clinical practice for older surgi-cal patients [18], older adults in the emergency department[19] and community-dwelling seniors [20].Study participants also pointed to specific weaknessesin communication and decision-making processes in thecare of frail seniors. They highlighted inadequate sharingof information among patients, caregivers, and health-care providers, and the lack of involvement of frail se-niors and their caregivers in decision-making. Thesefindings are consistent with other studies, which con-cluded that the routine identification of frailty shouldtrigger important discussions between the interprofes-sional team, caregivers, and the frail seniors to identifytheir goals of care and preferences, and choose the careplan that best meet these goals [21]. Despite being lessused to an active role in decision-making compared toyounger patients there are several examples that, withencouragement, older adults can participate in shareddecision-making [22, 23]. Older patients’ active engage-ment in their healthcare is associated with high-qualityand cost-effective healthcare [24, 25]. Identification offrailty, and engagement of seniors in decision-makingcan in turn offer opportunities for targeted care and ser-vices meeting their specific needs [26]. For example,physical and occupational therapy should be offered toimprove strength and functioning, and enhancehome-based care to help older adults who wish to re-main at home [27]. Our findings, however, also suggestthat more personalized care requires strengthening HCPcapacity to care for seniors with frailty. Study partici-pants indeed discussed the lack of training of healthcareproviders to care for frail patients, especially those livingwith cognitive impairment. HCP training might be chal-lenging as residents and newly graduated family physiciansreport little interest in caring for seniors afflicted withcomplex or chronic diseases, especially in home caresettings [28]. New training models, such as clinical place-ments in long-term care settings [29], and interprofes-sional faculty development programs in geriatrics [30, 31]show promise to improve the autonomy of HCP in theirclinical assessment and decision-making with vulnerableolder adults.We also found that the key stakeholders whom weinterviewed perceived a need for a more comprehensive,integrated, and interprofessional approach in caring forfrail seniors. This suggests that the various healthcareand social services should work together better to ad-dress the complex needs of frail patients and their care-givers. Experts in the care of frail seniors suggest thatcare of the frail seniors should be integrated by balan-cing medical and non-medical factors, such as nutrition,living situation, function, severity of symptoms, survivaland other patient-reported outcomes measures [27]. In-terpretation of our findings suggest that achieving thisbalance requires coordination of a variety of services be-yond healthcare, specialized training of providers andfamilies, caregiver support, and information technologyand protocols that facilitate effective communicationamong healthcare providers, patients and their care-givers. Integration of healthcare and social services forfrail patients with complex needs has been attemptedsuccessfully in health systems around the world [32].These models were successful in reducing caregiver bur-den, rates of hospital admission, and delays in caretransfer, while limiting overall costs [32]. Integratedfunding for healthcare and social services can also po-tentially improve frail seniors’ access to care, coordin-ation of care, quality of care and health outcomes, whilelimiting costs of care [33].LimitationsBecause we used a qualitative approach, our findings arenot generalizable to all frail patients, their caregivers,providers and decision makers. The sample also com-prised a limited proportion of patients and caregiversamong the study participants (8/42), all of whom fromQC and BC. Recruiting frail seniors using posters ingeriatric clinics proved inefficient in the current study.This might be ascribed to difficulties reading the posterGiguere et al. BMC Geriatrics          (2018) 18:290 Page 12 of 14due to vision problems, lack of understanding, or poorhealth [34]. Recruitment of members of this populationthrough their HCPs, although more efficient, did not ei-ther allow recruiting enough participants to ensure sat-uration within this population. This report might thusnot fully represent the perspectives of patients and care-givers, which were often complementary to the perspec-tives of other types of participants. We, however,gathered the perspectives of stakeholders from five prov-inces, thus ensuring transferability of our findings to di-verse areas of Canada. The majority of our participantswere women; however, our findings relate to issues thatare similarly experienced by men. We used a conveni-ence sample, so the participants who accepted to partici-pate may be different from the general population.ConclusionsStudy participants discussed more the weaknesses thanthe strengths of the current healthcare and social servicesavailable to frail seniors. Overall, our findings suggest thatfrail people require comprehensive assessments, care incontinuous relation with various care and service pro-viders, and away from acute care settings. Our findingsalso stress the importance of integrating care across caresettings and over time, of supporting the engagement ofpatients and caregivers in decision-making so that careand services are adapted to the specific needs and prior-ities of frail seniors, and of training our workforce to adoptpractices that meet the needs of this vulnerable popula-tion. Our findings could help redesign healthcare systemsmore sensitive to the needs and values of frail seniors.Additional fileAdditional file 1: Detailed themes and subthemes from the qualitativedata analyses. Tables (Appendices 1–15) with the count of themes andsub-themes, and for each province. (DOCX 70 kb)AbbreviationsAB: Alberta; BC: British Columbia; DM: Decision makers from nursing homes,hospices, hospitals, and home care agencies; HCP: Healthcare provider;NS: Nova Scotia; ON: Ontario; QC: QuebecAcknowledgementsWe thank all participants for their candor and the time taken to participatein the study. We also thank Valerie Carnovale, Selma Chipenda Dansoko,Danielle Caron, Rhada Sayal and Cynthia Kendell for their contributions todata collection and/or analysis.FundingThis work was funded by the Canadian Frailty Network, supported by theGovernment of Canada through the Networks of Centers of Excellenceprogram, and by the Quebec Centre for Excellence on Aging, and from LavalUniversity (Quebec City). AMCG is funded by a Research Scholar Junior 2Career Development Award by the Fonds de Recherche du Quebec—Santé.The funding body had not role in in the design of the study and collection,analysis, and interpretation of data and in writing the manuscript.Availability of data and materialsThe datasets analysed during the current study are available from thecorresponding author on reasonable request.Authors’ contributionsAMCG, JMH-L, SES, RU, PJD, AFT, FL, and MA contributed to the studyconception and design. AMCG planned data collection with RU, JMH-L andSS. AMCG, VC, EB, SG and NM participated to data collection and analyses.AMCG and EF prepared the manuscript. All the authors critically revised andapproved the final manuscript. All the authors take public responsibility andare accountable for this work.Ethics approval and consent to participateThe participants provided a written consent to participate. Frail seniorswith cognitive impairments were also eligible to participate if theircaregiver accompanied them, and if their caregiver agreed to participateand answer the interview questions if the frail senior was unable to do so.The study was approved by the Comité d’éthique de la recherche duCentre de santé et de services sociaux de la Vieille-Capitale, the Comitéd’éthique de la recherche du CHU de Québec, the Conjoint HealthResearch Ethics Board of the University of Calgary, the Behavioral ResearchEthics Board of UBC, the St. Michael’s Hospital Research Ethics Board, andthe Nova Scotia Health Authority Research Ethics Board.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Department of Family Medicine and Emergency Medicine, Laval University,Pavillon Ferdinand-Vandry, room 2881-C, 1050 avenue de la Médecine,Quebec, QC G1V 0A6, Canada. 2Quebec Centre for Excellence in Aging, St.Sacrement Hospital, Quebec, QC, Canada. 3Laval University Research Centreon Primary healthcare and services, Quebec, QC, Canada. 4Laval UniversityResearch Centre of the CHU de Quebec, Population Health and OptimalHealth Practices Unit, Quebec, QC, Canada. 5Section of Geriatric Medicine,Departments of Medicine and CHS, University of Calgary, Calgary, AB,Canada. 6Department of Medicine, University of Toronto, Toronto, ON,Canada. 7Department of Surgery, Dalhousie University, Halifax, NS, Canada.8School of Population and Public Health, University of British Columbia,Vancouver, BC, Canada. 9Department of Social and Preventive Medicine,Laval University, Quebec, QC, Canada. 10Department of Anesthesiology andIntensive Care, Division of Critical Care Medicine Laval University, Quebec,QC, Canada.Received: 1 December 2017 Accepted: 30 October 2018References1. 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