Patients are at the heart of primary care research initiative

“When was the last time your family doctor came over to your house and had tea and really understood what was important to you?”

David Price, chair of the department of family medicine, is well aware that family doctors simply can’t do that. “But it’s great to have that kind of information from our patients.”

So he helped create Health TAPESTRY, a program that allows people to share what matters to them with community volunteers, who pass the information along to their health-care team.

The program is one of many innovative research projects led by the family medicine department under the David Braley Primary Care Research Collaborative. It brings together the research, education and clinical care expertise of a strong network of primary care leaders.

The research collaborative launched in September through a $4 million investment — seeded by a $1 million contribution by philanthropist David Braley.

Here are some of the projects that the collaborative supports:

1. Community Paramedicine at Clinic (CP@Clinic), led by Gina Agarwal

What it is: A program for low-income older adults, with the goal of preventing chronic disease, reducing 911 calls and improving seniors’ quality of life and health outcomes.

How it works: Specially trained paramedics hold regular drop-in sessions where seniors live. The paramedics assess health risks and provide tailored education, connecting older adults with their primary care team and community resources.

“Community paramedics were seen as approachable and accessible health care providers who could bridge the gap between emergency departments and family practice,” Agarwal says.

Why it matters: Two randomized controlled trials found CP@clinic to be effective in reducing 911 calls by as much as 20 per cent. The program has also shown to improve quality of life, reduce chronic disease risk and improve connections to primary care.

Impact: After an initial pilot study in Hamilton, and a successful multi-site randomized controlled trial in Ontario, CP@clinic has expanded across Ontario. In 2019, the program received funding from Health Canada to scale up across Canada.

“My hope for CP@clinic is that it will continue to fill the gap for low-income seniors living in social housing so they can lead more empowered and fulfilling lives,” said Agarwal.

2. Health TAPESTRY, led by David Price, Doug Oliver and Dee Mangin

What it is: A community-based program that connects health-care providers with older adults to enhance the timeliness and quality of care they receive.

How it works: Community volunteers conduct in-home visits where they learn what matters most to a client and track their health and life goals with customized software. This information is then passed on to the client’s primary health care team, allowing care providers to learn more about their patients, so they can help them stay healthy.

“We usually start our health visits by asking ‘what’s the matter with you?’” said Doug Oliver, family physician and associate professor in the department of family medicine. “Health TAPESTRY asks ‘What matters to you?’ and those are the gaps we’re trying to fill.”

Why it matters: “We need to stop thinking about aging as a disease and start thinking about it as a success in Canada,” says Oliver, “by allowing adults to be in charge of their own care, when their care is delivered, where it is delivered, and how it is delivered.”

Impact: In the first trial of Health TAPESTRY, older adults visited their primary care team more and went to the hospital less. They also spent more time walking. The program has expanded into six Ontario communities, to test whether the TAPESTRY approach could be adapted to other communities.

Team Approach to Polypharmacy Evaluation and Reduction Program (TAPER), led by Dee Mangin, professor and family physician

What it is: A patient-centred program that aims to safely lower the number of medications the individual takes.

How it works: TAPER involves the patient, their family doctor, a pharmacist and an online tool to record information and identify possible drugs to “pause and monitor.” The patient and their preferences, priorities, and goals for treatment are at the core of this decision-making process.

Why it matters: Many older Canadians take five or more medications every day — known as polypharmacy. Unfortunately, it often causes unintended adverse effects, resulting in an estimated 70,000 preventable hospital admissions per year.

Impact: In Canada, the impact of TAPER is being measured through a large randomized controlled trial in several provinces. The program is also being adapted and tested in long-term care homes, community pharmacies, and hospitals in Canada, Australia and New Zealand.

“I see this as one of the best opportunities we have for improving health care and the life of older adults in the next 30 years,” Mangin says.

Prison Health Research Program, led by Fiona Kouyoumdjian

What it is: Research on the rates and causes of death in people who experience incarceration, and on ways to improve their health. The goal is to prevent incarceration, improve health care in prisons, and support health and community reintegration for people at the time of prison release.

How it works: Kouyoumdjian, a physician at a provincial jail and an assistant professor of family medicine, leads the research that examines the personal experiences of people who are incarcerated, and what their ideas are for ways to improve their health and health-care.

Why it matters: More than 40,000 people are incarcerated in Ontario’s jails and prisons each year, many with significant medical and psychiatric conditions. Many of the social determinants of health — including race, gender and socio-economic status — directly overlap with the social determinants of incarceration. Access to health care during incarceration is a human right, better treatment can help them lead fuller, healthier lives, and will reduce the strain on the health-care and prison systems.

Impact: This research has contributed to the decision to implement overdose prevention training in prisons and to distribute naloxone kits to people at the time of release from prison.

“My hope is that the research I work on leads to improved care for people who experience incarceration, and also imagining and building a world where we don’t have prisons and people are not incarcerated,” says physician Claire Bodkin, who works with Kouyoumdjian.