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Designing a More Seniors-friendly Health Care System
 

Designing a More Seniors-friendly Health Care System

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Designing a More Seniors-friendly Health Care System was the second in a Seniors Summit series produced by Health Sciences North. This event was held at the United Steelworkers Hall on Brady St. in ...

Designing a More Seniors-friendly Health Care System was the second in a Seniors Summit series produced by Health Sciences North. This event was held at the United Steelworkers Hall on Brady St. in Sudbury on Monday June 3, 2013. This presentation is a combination of the three presentations made by our keynote speakers: Sholom Glouberman, President of the Patients Association of Canada and Philosopher-in-Residence at the Baycrest Centre For Geriatric Care; Dr. Janet McElhaney, HSN Volunteer Association Chair in Geriatric Research, Medical Lead of Seniors Care at HSN and Senior Scientist at AMRIC and Dr. Jo-Anne Clarke, Geriatrician, Northeast Specialized Geriatric Services

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  • 17th Century: everyone over 40 had at least one chronic condition or other20th Century: everyone over 65 has at least one chronic condition or other In general 50% of people with chronic conditions have more than one – good reason for speaking of complex chronic diseases2004Cancer 29.5%, heart disease 22.9% Statistics Canada, Catalogue no. 82-003-XPE • Health Reports, Vol. 20, no. 1, March 20091Medication use among senior Canadians • Health Matters Pamela L. Ramage-Morin
  • OPTIONAL SLIDESimple:The recipe is critical to success Recipes are tested to assure replicability of later effortsNo particular expertise; knowing how to cook increases successRecipes produce standard productsCertainty of same results every timeOptimism re resultsComplicated:Formulae are critical and necessarySending one rocket increases assurance that next will be okHigh level of expertise in many specialized fields + coordination Rockets similar in critical ways High degree of certainty of outcomeOptimism re results Complex:Formulae have a use. But not aloneRaising one child gives no assurance of success with the nextExpertise however multi-disciplined can help but is not sufficient Every child is unique in critical waysUncertainty of outcome remains Optimism re results
  • With complicated acute diseaseA diseased body to be diagnosed and treatedAn autonomous individual with no relevant links to othersFocus on the disease or organ to be repairedCompliance to Prescribed treatmentThe person named on the OHIP card Complex chronic conditionA person with a particular history and personalityA group of people including the person and those close to themA resource for changing how health and healthcare is providedn of 1 trials Anyone who has had a significant healthcare experience themselves or is close to them
  • I think the 2 blues that don’t match are a little much on the eyes – can we use white as per the original here?
  • Previously unimagined numbers of people are living over the age of 65. Just after the turn of the century, in Canada, just under 5% lived to >65, and now 14%, projected to reach 23% by 2041. Largest growth in the >85 group.
  • 1500 hundred pediatricians, 125 geriatricians in OntarioIn the last year 2012 – none of the graduating residents in orthopedic surgery was able to find a job.
  • In the medical model, it is disease specific. 1 disease – that presents with many symptoms – 1 form of treatment to treat the disease.For example – the disease is pneumonia – the lungs are infected the following symptoms present: fever, cough, shortness of breath, chills, muscles aches, increased respiratory rate… once diagnosed the pneumonia is treated with antibiotics and resolves.
  • Delirium – is a medical emergency which is characterized by an acute and fluctuating onset of confusion, disturbances in attention, disorganized thinking and/or decline in level of consciousness. Delirium results in many serious complications: prolonged hospital stays, increased discharge mortality, progressive physical and cognitive decline, persistence of delirium symptoms, admission to LTC, experience recollection of delirium experience…Multifactorial intervention: Reduced incidence of delirium: 15% vs 9.9% (ARR 5.1%, NNT 20) at day 7 Reduce the number of episodes of delirium (62 vs 90, p=0.03) Reduced the duration of delirium episodes (105 days vs 160 days, p=0.02)
  • The HRS study: Survey administered in 2000 to > 11 000 adults aged 65 or older living in the community and nursing homesOf adults aged 65 or odler, 49.9% had 1 or more geraitric conditions (cognitive impariment, falls, incontinence, low BMI, dizziness, vision and hearing impairment,): Looked at 3 chronic disease (CHF, CAD and DM) and 2 GS (falls and incontinence)
  • The HRS study: Survey administered in 2000 to > 11 000 adults aged 65 or older living in the community and nursing homesOf adults aged 65 or odler, 49.9% had 1 or more geraitric conditions (cognitive impariment, falls, incontinence, low BMI, dizziness, vision and hearing impairment,): Looked at 3 chronic disease (CHF, CAD and DM) and 2 GS (falls and incontinence)If you look at its ability to predict functional decline and disability, The HRS study: Survey administered in 2000 to > 11 000 adults aged 65 or older living in the community and nursing homesOf adults ageDisability = 1 ADL dependency
  • activity is a key component of frailty management, and has been shown to be beneficial at almostany stage of frailty. It should be available to those who wish or need to participate. Furthermore,the promotion of healthy aging requires a healthy senior friendly environment, proper nutrition,and attention to community supports and connections. Socially connected and active seniors arehealthier. Poor social support is a health stressor, and in a frail individual may tip the balancefrom relative independence to institutionalization [12]. The optimal management of frailtytherefore requires the integration of the “medical” and of the “psychosocial” approaches to care
  • LHIN strategies related to Aging at Home, Alternate Level of Care, and Emergency Department wait times are particularly impacted by the capacity to provide care and support to older patients. This suggests significant potential for targeted interventions with the frail elderly to achieve positive health outcomes for patients, as well as significant reductions in health care utilization. In recognition of both the imperative and the opportunity for more effective and efficient approaches to the care of the frail elderly, Ontario has recently made a commitment to the development of Ontario’s Seniors Care Strategy. This, in combination with the renewal of the Integrated Health Services Plan for the North East LHIN, which is also currently underway, presents significant potential for the review of the governance and sponsorship of NESGS to further align the role of specialised geriatric services in the context of system-wide planning. 3 Commission on the Reform of Ontario’s Public Services, Queen’s Printer for Ontario, 2012. 4 C. Preyra, “Realizing the Health Based Allocation Model,” PowerPoint deck provided by Mr. Preyra, 2010, p. 37.
  • City of Greater Sudbury demonstrated a long-standing commitment to respond to the needs of the aging population in the North.CGS lead to the funding and recruitment of the first geriatrician in the North EastSupport and collaboration with the North East LHINNESGS established as a regional geriatric program in 2009Recognized affiliate program of the Regional Geriatric Programs of Ontario
  • Now fully supported by the North East LHIN, the NESGS regional geriatric team includes two physicians, 7 interdisciplinary clinicians and five academic and administrative staff for a total of 14 FTEs, and an operating budget of approximately $1.3M. Notwithstanding this recent progress in the emergence of specialised geriatric services in the North East, a draft report applying population-based benchmarks to geriatrician human resource planning11indicated a shortfall of 12 geriatricians, reinforcing the need for a dramatic increase in access to specialised geriatric services in the North East. In response to these unmet needs, and in recognition of the geographic limitations for a single regional geriatric team, planning has been undertaken to support the development of local geriatric teams to function in coordination with NESGS, in the communities of Sault Ste. Marie and North Bay. Health Sciences North has also moved forward with its development of specialised geriatric services which include both inpatient and outpatient services. They have recently recruited an additional geriatrician for Health Sciences North with a dual academic and clinical role.
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Designing a More Seniors-friendly Health Care System Designing a More Seniors-friendly Health Care System Presentation Transcript

  • patientsassociation.ca4-Jun-13An Introduction 1
  • What Do Patients Want?Designing a More Seniors-friendlyHealthcare SystemHealth Sciences NorthJune 3rd, 2013
  • patientsassociation.caDisclosureThe Patients’ Association of Canada hasreceived funding from the OMA, the CMA,CIHR, CIHI, CHSRF, CFHI, Infoway, theHealth Council, the Change Foundation,the Trillium Foundation, a large number ofhospitals, and some individual benefactors.It is not our policy to accept funds frompharmaceutical companies.
  • patientsassociation.caA Brief History4-Jun-13An Introduction 4
  • patientsassociation.caA Brief History of Our Health SystemBefore 1850 Longevity = 35-40oLeading causes of death – infectious diseaseso Cholera, tuberculosis, small pox, typhoid fever, etc.Major Innovations 1850-1880o 1850 – Use of Ether as Anaesthetico 1867 – Joseph Lister & carbolic acido 1880-81 Robert Koch and Louis Pasteur discover causeand vaccine for anthrax and other infectious diseasesOur Healthcare System Beginso Hospitals, Medical Schools, Laboratories, Professionals4-Jun-13An Introduction 5
  • patientsassociation.caBetween 1880 and 1960Rapid decline of % of death by acute infectiousdiseases – success!o Hospitals growo Doctors specializeo Penicillin begins to save lives in WWII (1940-45)o New surgeries are performedo Medical science promises silver bulletso Cures all around!4-Jun-13An Introduction 6
  • patientsassociation.caCanadian Medicare:o 1947 Saskatchewan Hospital Ins. Programo 1957 A National Hospital Insurance Programo 1962 Saskatchewan Hospital & Doctor careo 1966 Medicare : A national program coverso hospital careo doctorso 1984 Canada Health Act: Coverage for whatis medically necessary4-Jun-13An Introduction 7
  • patientsassociation.caOur Current SystemoCovers hospital careoCovers Doctors feesoDoes not cover drugsoDoes not cover much non-medical treatmentoIt is:o Highly specializedo Body-part focusedo Very instrumentalo Increasingly Fragmented4-Jun-13An Introduction 8
  • patientsassociation.caAttempts to Link Silos Create Moreo 1950s Quality (Shroud waving for Quality)o 1960s Ethics (Because Clinicians need help to be ethical?)o 1970s Clinical Directorates (Drs are not managers)o 1980s Program Management (Sewer pipes for silos)o 1990s KT ( Applying knowledge to particular cases)o 2000s IPE (A new specialty in its own right)o 2010s Lean (Industrial Methods for Human Systems)
  • patientsassociation.caThe 20th Century Healthcare SystemoDoes amazing things to patientsoDoes wonderful things for patientsoDoes almost nothing WITH patients (to saynothing about their families and caregivers)4-Jun-13An Introduction 10
  • patientsassociation.caDisease Shifts: Acute > ChronicCanada 2012•89% of deaths due to chronic diseases• Cancer , Heart Disease, Lung Disease, Diabetes•<3% deaths due to acute infectious diseases•49% of the population is on long term medication•Everyone over 65 has at least 1 chronic condition•2005 76% of people 65+ had taken medicationwithin 2 days•More than 30% with chronic conditions have 2+4-Jun-13An Introduction to the Patients’ Association of Canada 11
  • patientsassociation.caAcute / Chronic ComparisonAcute diseases are simple or complicatedhave clear diagnoses, can be “conquered”with vaccines and respond well toestablished procedures without much patientparticipationhowever…Chronic conditions are complex, with manycauses & need patient & family collaboration
  • patientsassociation.caTypes of Problems - Examples4-Jun-13An Introduction to the Patients’ Association of Canada 13Simple Complicated ComplexStep by Step Recipe Building a Bridge Raising a SecondChildSteps are critical Formulae are critical Formulae useful butnot aloneSteps are tested sothey work each timeBuilding 1 bridgehelps make sure thenext will be okRaising 1 child is noassurance of successwith the 2ndNo particularexpertise neededExpertise in manyfields required +coordinationExpertise helpful butnot aloneSame results everytimeHigh certainty ofoutcomeOptimism despiteuncertain outcome
  • patientsassociation.caHow Patients and Families are Seen4-Jun-13An Introduction to the Patients’ Association of Canada 14With Acute Disease With Chronic ConditionComplicated ComplexBody to be treated Person with historyIndividual – not linked to others Person with people close to themFocus on disease or organ repair Resource on the health teamTry prescribed treatment Try different approaches oroptionsOHIP card name Person with healthcareexperience as patient or caregiver
  • patientsassociation.caThe System is beginning to Respondo “Patient centred care” is the current flavouro McGill U Med School - more family docso Hospitals - patient and family adviserso CIHR is including patients on its boardso Cancer is recognized as a chronic diseaseo Disease Charities “help now, hope later”o St Mike’s “Hospital at Home”o Mount Sinai and sexy geriatrics4-Jun-13An Introduction 15
  • patientsassociation.caWho Are We at the Patient’s Assoc?We bring a distinct patient and familycaregiver perspective to healthcare• All providers have their own perspectives.• They also speak on behalf of patients.• As a result they do not always agree with eachother about what patients want.• We are beginning to speak for ourselves and webelieve that this will make it easier for doctorsand other providers.4-Jun-13An Introduction 16
  • We promotepatients and familycaregiversas partners inCanada’shealthcare system4-Jun-13An Introduction 17Our Mission
  • patientsassociation.caOur Vision4-Jun-13An Introduction 18
  • patientsassociation.caOur VisionCanadian patients and families will activelyparticipate in the transformation of theCanadian healthcare system.4-Jun-13An Introduction 19
  • patientsassociation.caMaking Patient Experience CountoAll our work is based on patients’ experiencesoPublic Meetings to Receive Experienceso Experimental methods to hear what patients have to sayoPatients’ Choice Awards (with OMA)o Patients Nominate, Patient Jury SelectsoBring Patient Perspective to Advisory Boardso Cancer Care Ontario, Infoway, OMHARN, CCPCRN, KTGRB
  • patientsassociation.caOur Process (ROKS)1. Review from a patient & family perspectiveo Your plans, achievements so far, current patient place2. Orient Organization to Patient-FamilyPartnerships3. Help set Goals with experience based KeyPerformance Indicators (KPIs)4. Support participating patients & familiesand staff groups4-Jun-13An Introduction 21
  • patientsassociation.caReviewoWhere are you in the process of partneringwith patients?o Our experience with Patient Rightso Focus groupso Partial participationso Areas of partnership4-Jun-13An Introduction 22
  • patientsassociation.caOrient Organization to Partnershipso Orientation to Current Situationo Partner with change championso Educational Sessions for Everyoneo Identify Opportunities for Changeo Surface Apprehensions and Difficultieso Work with anxietieso Develop a balanced approacho Mediate difficult caseso Institute local self development4-Jun-13An Introduction 23
  • patientsassociation.caKey Performance Indicators of PFCCo In ERs triage nurses are excellent atdistinguishing very sick from not very sicko 90% of patients are not very sick, but mostare quite anxiouso Almost no triage nurses are trained to dealwith patient anxietyo A KPI for ERs is that front line staff istrained to respond better to worried people4-Jun-13An Introduction 24
  • patientsassociation.caKPIso Information Based KPIso Review of Primary are KPIso Review of Accreditation KPIso Review of System Performance KPIso Hospital Audit for KPIso KPIs for Chronic Careo KPIs for Long Term Careo KPIs for End of Life Careo 4-Jun-13An Introduction 25
  • patientsassociation.caSupportoSupport patients and familieso Conferenceso Peer supporto Help lineo Support local championso Learning seto Meet others facing similar issueso Providing peer supportoSupport Organizationso Problem solvingo Customized programso 4-Jun-13An Introduction 26
  • patientsassociation.caPatients Redesign Service DeliveryoAt BaycrestoRedesign the Admission Processo Especially the day of moving ino Introduction of Family Member Mentors for New familieso Recognize and reduce anxiety of families as they move ino Why patients and family caregivers are necessaryoAt Northumberland PATHo Better transitions for older people in Northumberlando Collaboration among 12 providers and patients and familieso We are responsible for preparing and helping bring the patientperspective4-Jun-13An Introduction 27
  • patientsassociation.caPatients Can Work with ProvidersoAs AdvisersTo bring the patient and family perspective to planning and policymaking.oAs MentorsTo bring their experience to new patients and families and helpsupport them through difficult experiencesoAs EducatorsTo prepare organizations and individuals to create partnershipswith patients and their family caregiversoAs ResearchersTo bring a patient and family perspective to research4-Jun-13An Introduction 28
  • patientsassociation.caMake Your Experience Count!Join the Patients’ Association!oHelp transform the Canadian healthcare systemo Become a Volunteer at the Patients’ Associationo Tell us your experiences as providers and patientso Help us gain better insight into the provider perspectiveoLearn to work with Patientso Help train patients and family members to participate4-Jun-13An Introduction 29
  • Join us!It’s FreeGo to our websitepatientsassociation.caTHANK YOU!W patientsassociation.caT @PatientsAssocCaFacebook Patients Association of CanadaMake Your Experience Count
  • patientsassociation.ca4-Jun-13An Introduction 31
  • patientsassociation.ca4-Jun-13An Introduction 32
  • patientsassociation.ca4-Jun-13An Introduction 33
  • Aging with Vitality:Partners in CareJanet E. McElhaney, MD, FRCPC, FACPHSN Volunteer Association Chair in Geriatric ResearchProfessor of Medicine, Northern Ontario School of MedicineHealth Sciences North andAdvanced Medical Research Institute of CanadaSudbury, ON
  • Seniors’ Health: Adding Life To Years60 70 80 90Age2000’s1990’s1980’s
  • CompetenceConfidenceConnectionDeterminants of Health
  • Risks Associated with Hospitalization:United States 1993-199765+ population are hospitalized 3X more often than younger adults;37% of discharges, 50% of inpatient days, and 60% of expenditures65+ population – 80% have one chronic disease; 50% have twoAt discharge, 33% are more disabled and one half never recover5% die in hospital, 20-30% die in the year after hospitalizationElixhauser A et al; AHRQ Pub. No. 00-0031, HCUP Fact Book No. 1, 2000Covinksy KE et al; J Am Geriatr Soc; 51:451, 2003
  • Ageing and Hospital Use in the 70+ Only a small proportion of older adults are consistentlyextensive users of hospital services (Wolinsky, 1995)42.6%6.8%4.8%24.6%Consistently Low Users No Hospital EpisodesConsistently High UsersInconsistently High UsersSeniors StrategyAgeing and Hospital Use in the 70+With Permission: Dr. Samir Sinha, MD, DPhil, FRCPC,Provincial Lead Ontario’s Seniors Strategy
  • Changes in Level of Frailty:Can we “see” it and what does it mean?45678 9321When reserve capacity isdecreased to a cruciallevel, adaptive mechanisms tostressors can no longer bemobilized, leading to a breakdownof homeostasis and crossing thethreshold to clinically manifestedfrailty syndrome.
  • Acute Illness: Prevent or Minimize Disability80 80 80 80 80AgeCardiovascular DiseaseDiabetesOsteoporosisChronic Lung DiseaseCognitive ImpairmentDynamicFrailtyUsualAgingIADLFrailtyADLFrailty
  • One presentation of dynamic frailtyPicture an 82 year old woman who presents in the ED with a possiblefracture from a fall while walking with her 3 K-a-day Club.
  • Dynamic frailty can be a maskthat limits our view of possible outcomesPicture an 82 year old woman who presents in the ED with a possiblefracture from a fall while walking with her 3 K-a-day Club.
  • Learn to look behind the mask …
  • The Care Pathway: “48/5”• Starts within 48 hours of hospital admission andfocuses on evidence-informed decisions about:– Medication reconciliation/appropriateness– Delirium / Cognition– Functional mobility – “Every day is an activation day”– Nutrition / Hydration– Bowel / Bladder• Interprofessional collaborative practice• Mobility is the “fifth vital sign”
  • Acute Illness: Prevent or Minimize Disability80 80 80 80 80AgeCardiovascular DiseaseDiabetesOsteoporosisChronic Lung DiseaseCognitive ImpairmentDynamicFrailtyUsualAgingIADLFrailtyADLFrailty
  • Summary Holistic care integrates evidence with a person’s goals andvalues Optimize prevention strategies to maintain independence Goals of care: what would it mean if the quality of life werethe determinant of value in healthcare decision-making?
  • Improving Community-BasedSenior’s CareDr. Jo-Anne ClarkeGeriatrician
  • 14.6% of Canadians are 65 and older, yet account fornearly half of all health and social care spending(Census, 2011).Canada’s older population is set to double over thenext twenty years, while its 85 and older population isset to quadruple (Sinha, HealthcarePapers 2011).Health care system developed when average of age ofa Canadian is 27 years of age1500 hundred pediatricians, 125 geriatricians in OntarioHealth care system poorly adapted to the complexity ofmanaging and treating chronic disease, frailty anddependence in an aging populationDecreased availability of family and caregivers
  • Amount of health care seniors receive is largelydriven by the number of chronic conditionsthey have, not their age.Seniors with 3 or more CCs have nearly 3x thenumber of health care visits than those with noreported conditionsSeniors with 3 or more CCs account for 24% ofthe senior population, but account for 40% ofhealth care use
  • Older persons accumulate chronic illness asthey age51Age Number of chronic conditions0 1 2 3+40-59 44% 30% 14% 12%60-79 20% 25% 25% 30%80+ 12% 24% 22% 41%
  • Its more than Chronic DiseaseUnderstanding GeriatricSyndromes & Frailty
  • 531 Disease Many Symptoms 1 treatmentPneumoniaTroublebreathingFeverShort OBCoughMyalgiasAntibiotics
  • 54Many Factors One Syndrome Multiple InterventionsDeliriumInouye, NEJM 2006
  • As prevalent as chronic diseaseIn the HRS, 50 % of people > 65 had 1 or moregeriatric conditionsCommonly co-occur with chronic diseasemore than 25% of older adults with chronicdisease have at least one geriatric syndromeStrongly associated with functional declineand disabilityMore likely than stroke to cause disailityTop 3 predictors of “why cannot go home”from hospital (mobility, incontinence,cognitive impairment)IncontinencePressure ulcersFallsFrailtyDeliriumCognitiveimpairment….Examples
  • HRS Study - Association btw disease, geriatricsyndromes, and disabilityCondition Risk of disabilityNumber of geriatric conditions123+2.13.66.6StrokeDiabetesHeart diseaseCancer3.01.31.21.0Ann Intern Med 2007;147:156-64
  • One disease model does not workEarly identification, and management ofcontributing and accumulating deficitsRequires integration of medical and social aspectsof care Medical and chronic disease management Strong primary care essential Enhancing physical activity, make it accessible andavailable Senior friendly environment, proper nutrition Community supports and connections Formal and informal supports essential
  • Objective Target Population Initiatives Responsibilities1Maintain independenceprevent functional lossHEALTHPROMOTIONPrimaryCare (1o Care)2Restore independence/Reverse functional lossReview and InterveneUNFRAIL:DiseasesDrugsDeconditioningRehabCCAC+ Primary Care+ Specialized GeriatricServices(SGS):OP3Identify and manageconditions contributing tofrailty and functional lossScreening for high risk toreturn to EDED GEM, CCAC RISC1o Care, and SGS4Identify and manageconditions contributing tofrailty and functional loss(10%)ADMIT TO HOSPITALScreen for high risk by 48hrs Prevent deconditioning/IatrogenesisGeriatric consult unlessclear D/C plan Hospital Care Team5Return home or to lowerlevel of care (10%)ASSESSMENTPrior to ALC designation toensure NO reversibility6Reduce demand forplacement by optimizingfunction for patientsreferred (17%)ACTIVATION and time (stillsome “recoveries” possible)6 Safety NetsALC UNITLTC PLACEMENTALCPatientFRAIL & NOWSICKELDERLY IN EDFRAIL & NOW SICK ELDERLY IN EDFRAIL ELDERLYHEALTHY ELDERLYChanging the trajectory to Long term care: The keyto start early, target and treatBEINGADMITTEDSENT HOME
  • Prolonging LifeOptimizing quality of lifeand functionAGEA B C DOsterweil D. 2007
  • Increasedprimary carecoordinationEnhance carecoordinationand transitionsMental Healthand AddictionsAccessCulturaldiversityNorth East Local Health Integration NetworkSeniorsremain in theirown homelongerIntegratedCareGeneratingKnowledgeSpecialized Geriatric ProgramsIndependence & Quality of Life•Increased likelihood of living at home•Improved physical & mental health•Improved continuity of careClinical Efficiencies•Reduced Hospital Days•Reduced LTC Placement•Cost SavingsPatient Outcomes•Improved diagnosis•Reduced loss of function in hospital•Improved patient satisfactionGeriatric Capabilities•Improved Clinical Decision-Making
  • Program GoalsTo provide specialized geriatricassessment and treatment tomedically complex, frail elderly.To provide education andknowledge transfer promotingbest practices for geriatric care.To increase capacity in geriatriccare throughout NortheasternOntario.To be responsive to the needsof the communities ofNortheastern Ontario
  • NESGS Clinical Team:GeriatricianCare of the Elderly PhysicianNurse PractitionerGeriatric Nurse CliniciansOccupational TherapistPhysiotherapist64Interdisciplinary:• Cross trained in completingcomprehensive geriatricassessments and supportingtreatment plansMultidisciplinary:• Providing professional specificassessment and treatment
  • 6526 Hospitals1 CCAC1 NEMHC53 Long TermCare Facilities1,896 RetirementBeds+ communitysupport services,FHT, CHC’sReferrals Received toDate: 2909► clinics► in-patient consults► LTC consults► Ontario Telemedicine(OTN)► Home visitsCochrane14%Algoma = 3%Cochrane 13%Sudbury =67%Timiskaming =3%Nipissing = 2%Parry Sound =12%DEMOGRAPHICS
  • 66GeriatricianCare of theElderlyPhysicianNursePractitionerGeriatric NurseClinicianOccupationalTherapistPhysiotherapistComprehensive Geriatric Assessment&Support ClinicPhysician Assessment&TreatmentReferral to multidisciplinary teamIntensive Case ManagementMonitoring of side effects/conditionsComprehensive Cognitive TestingFunctional AssessmentHome ModificationsExerciseGaitMobility AidsContinence ClinicBone Health ClinicFrail to Fit Falls PreventionProgram
  • Geriatric Interprofessional and interorganizational collaboration(GiiC)Mini GiiCNorthern Geriatric Care Conference (biennial)Next conference: September 18-20, 2013Weekly calendar to all partners in care advising of educationalopportunities (OTN, rounds etc.)WebsitePhysician educationTrainingMedical students, medical residents, nursing students, allied healthstudentsPGY 3 – now availablePost secondary institutions/students
  • Development of Geriatric ProgramsGeriatric Network in Sault Ste. MarieDr McElhany HSN STAT program, COACH teamsGEM programs (HSN, Parry sound, SSM)Memory Clinic Training ProgramFunded the involvement of 4 FHT across theNortheast as well as research/evaluationGeriatric Medicine Certificate ProgramDevelopment of a curriculum & evaluation
  • Integrated care model with CCAC Geriatric/Complex Care CoordinatorsCreate standards of practice for all programssupporting older adults i.e. GEM Nurses, DayHospitalsWork in partnership with NE LHIN, partnersin care, and our patients, to develop aRegional Seniors StrategySupport local communities to developGeriatric Networks and specializedGeriatric Services along the continuum ofcare
  • Ministry of Health and Long-Term Care and its LHINs should establish aprovincial working group of geriatricians, care of the elderly family physiciansand specialist nurses, allied health professionals, and others to help developa common provincial vision for the delivery of geriatric services and aprioritization plan to guide local staffing and funding of care models asresources become available.
  • Increase home careMore exercise classes andfalls preventionHousing and supportsConnect every senior to aDoctorBetter coordinationHospital at home modelsImprove transitions of careOntario wide geriatric careImproved assessmentsImproved training in geriatricsStrengthen PSW work force
  • Improvedaccess toprimary careOnecommonassessmentOne point ofaccessSharedinformationBettertransitionfromhospital tocommunityAccessible,timelyservices inthe homeCommunitysupportworkers withgeriatricexpertise
  • 4-Jun-13An Introduction 73
  • 4-Jun-13An Introduction 74