Concurrent Sessions

A3 Optimizing the Health of Older Adults with Multiple Chronic Conditions: The Development of KeepWell

Theme 3. Employing and empowering the patient and caregiver perspective

Presentation Details

  • Date: Wednesday, October 25, 2017
  • Concurrent Session A
  • Time: 2:30pm-3:15pm
  • Room:
  • Style: Presentation (information provided to audience, with opportunity for audience to ask question)
  • Focus: Balance between both (e.g. Presentation of a best-practice guideline that combines research evidence, policy issues and practical steps for implementation)
  • Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Representatives of stakeholder/partner organizations

Learning Objectives

On completion of this session, the participants should be able to:

  1. Understand the complexities of multimorbidity in older adults
  2. Understand how to involve patients in the co-design of interventions/tools.
  3. Learn how to apply knowledge translation science in the design of complex interventions and tools


Background: More than half of older adults have ≥ 2 chronic conditions. Clinical guidelines and tools are created mostly for a single disease, not created for older adults, and do not consider health priorities. Our objective was to develop a patient-centered, web-based knowledge transation (KT) tool called “KeepWell” with the potential to optimize self-management of older adults and to facilitate the clinical decision making of family physicians in the context of multimorbidity. Design and participants: Integrated KT strategy involving: older adults with multimorbidity (age ≥ 65 years), e-health and KT experts and providers; and the Knowledge-to-Action framework to create KeepWell. The tool (including its name, features and design) was co-designed by a working group of 10 older adults with multimorbidity in 7 informal focus groups. The prototype was iteratively created using input from: older adults; evidence-based clinical practice guidelines; family physicians, geriatricians, KT researchers; and literature on KT and behaviour change. Setting: KeepWell is a web-based application that can be used on any computer, tablet, or smartphone in the community and primary care. Significance: KeepWell is innovative as it integrates the care of any combination of 11 chronic conditions affecting older adults, has a clinical decision support component for providers, and responds to the complexities of disease concordance/discordance. KeepWell has great potential for scale and spread. It is a web-based platform, so it will be relatively inexpensive to deliver and no human resources will be required for its functioning in the community. It will need little more than the dissemination mechanisms to be scaled up, so it can be easily spread across Ontario primary care practices and teams.


  • Monika Kastner, Research Chair, Knowledge Translation and Implementation, North York General Hospital

Authors & Contributors

  • Leigh Hayden
  • Julie Makarski
  • Yonda Lai
  • Nate Gerber
  • Joyce Chan