A Randomized Controlled Trial Using the Health TAPESTRY Approach to Care for Older Adults

Health Teams Advancing Patient Experience: Strengthening Quality (TAPESTRY): A Randomized Controlled Trial Using the Health TAPESTRY Approach to Care for Older Adults

Health TAPESTRY is a delayed intervention pragmatic randomized control trial promoting interprofessional team collaboration, facilitating connection to the community through system navigation and trained community volunteers, enhancing communication and improving care through the use of technology to better understand and assist older adult patients in achieving their health goals and to enable them to have optimal aging.

The overarching aim of the integrated multicomponent Health TAPESTRY approach is to promote optimal aging. Optimal aging within the Health TAPESTRY program means supporting people to move through life with good health in the best possible way: Being Alive Well. Health TAPESTRY is a health and social care approach that centres on meeting a person's health goals with the support of technology, trained community volunteers, an interprofessional team, system navigation, and better links between primary care and community organizations. The Health TAPESTRY intervention takes a complex, multilevel approach to integration, from both system level and individual level perspectives. The Health TAPESTRY program will provide processes and tools to activate and support individuals to access and use the broad range of available primary health care, social and community services to achieve their personal health goals and strategies to better integrate care at the system level. More specifically Health TAPESTRY will promote optimal aging:

• through intentional, proactive conversations about a person's life, health and care goals within the primary healthcare setting;
• through improved connections between inter-professional primary care teams, community service providers and informal caregivers;
• by training volunteers to serve as a link between the primary care team and a person in their home;
• by using technology from the home to link directly with the primary health care team which includes
• the tablet-based Health TAPESTRY app for volunteers to use;
• the Personal Health Record (PHR) and
• innovative resources (i.e. Optimal Aging Portal).

It is anticipated that together these will enable transformation of how primary healthcare and interprofessional teams provide care to older adults in a manner that provides value for resources used and meets needs and goals of older adults.

Inclusion Criteria:

• Any community-dwelling patient of McMaster Family Health Team over the age of 70

Exclusion Criteria:

• Patient is palliative or receiving end-of-life care
• Patient is deceased
• Has explicitly stated that they do not want to be part of a research project
• Patient resides in long-term care
• Patient has indicated that they do not want to receive a home visit from trained community volunteers.
• Patient or family member does not speak English
• Patient will be out of the country for more than 50% of trial duration