Older and Better: Living Well at Home or in the Community
annual-report_2006_english
1. Those working to improve the health
of seniors cannot have escaped the occa
sional moment of frustration as we have
witnessed a series of policy changes over
the past 10 years that have served to
increase the dependencies associated
with growing old in Ontario. These include
the elimination of secondary health pro
motion programs in public health, the
Integrated Homemaker Program, and
continued inequities in community and
geriatric funding that were originally
intended to enhance the health and inde
pendence of seniors in order that they
might remain living in their own homes
as long as possible.
Over the past year, in collaboration
with seniors and our many partners
across the region, we have undertaken a
new phase of strategic planning and we
have reflected on how to evolve seniors’
health in the changing context of our
emerging health system. Seniors and
their caregivers told us what they want
and need, and we heard from providers
about the challenges and opportunities
to enhance the health and independence
of seniors in our community. During the
past year we have also worked closely
with the Champlain Local Health Inte
gration Network to contribute to their
Integrated Health Services Plan. And, like
everyone involved with health services in
our region, we reflected upon the results
of an inadequate system of care that has
resulted in premature placement and
growing pressures on our acute hospitals,
relating to the need for alternate levels
of care. The result of this work is a new
strategic plan for the RGP of Eastern
Ontario and our partners within the
Regional Geriatric Advisory Committee
for the period 2007-2010.
The three key result areas we will be
focusing our collective resources on are:
Maximize the Health Potential❚❚
of Seniors;
Increased System Capacity and❚❚
Responsiveness; and
Coordinated Access and Service❚❚
Delivery Systems.
As a key partner in the delivery of
seniors’ health services across Champlain
Region, it has been tremendously reward
ing to be able to support a number of
important programs over the past year,
that are designed to improve seniors
health and the services they need to
stay living at home.
Maximize the Health Potential
of Seniors:
Our program has placed a strong
focus on further integrating community
support services across the continuum of
care. We have been actively involved in
developing new models of service that,
while optimizing seniors’ health and
independence, have been shown to reduce
dependence upon both hospital and insti
tutional care. Under the leadership of the
United Way of Ottawa, we supported a
forum of local providers with experts on
supportive housing and community support
from across the country to review the
latest evidence in community-based care.
The results of this forum have been inte
grated into a framework for supportive
housing to be used by the Champlain
LHIN, the City of Ottawa and both com
munity and housing providers for years
to come, that will support seniors to age
in place across the region. It has been
most rewarding to see the lessons learned
from this effort being so rapidly applied
to new services and supports, including
the re-birth of the ‘Aging in Place’
A Year of Partnerships, Planning & Transitions:
T
hrough our interdisciplinary expertise and leadership in clinical care, education, program development and
evaluation, the Regional Geriatric Program of Eastern Ontario has remained wholly committed to optimize
seniors’ health.
Annual
ReporT
rgpeo.com
2006
continued on page 2
Regional Geriatric Program
of Eastern Ontario
Programme gériatrique régional
de l’Est de l’Ontario
2. Annual Report 2006
2
supportive housing program that was
developed in the 1980s by the Council on
Aging. We have also continued to expand
access to health screening for seniors
across the region through our existing
Geriatric Assessment Outreach Teams.
More than 30 external geriatric assessors
have been trained to work in centres
across Champlain region over the past
year. Additionally, as part of the consoli
dation of the Long Term Care Physician
Education Network, we were proud to host
the first regional interdisciplinary long
term care education forum, with more
than 150 physicians and health care
professionals working in long-term care
across the region.
Through the Regional Geriatric Pro
grams of Ontario, and other provincial
partners, we have continued to advocate
for and contribute to public policies that
will ultimately enhance the health of older
Ontarians, in domains from community
support through to more integrated and
specialised geriatric care. We are hopeful
that a more balanced approach to investing
in the health of seniors will emerge.
Increased System Capacity
The Regional Geriatric Program main
tains a strong focus on enhancing
age-appropriate care in communities
from hospital to home, and continues to
serve as a resource to seniors and care
providers alike. We have built on the
notion that local communities know best
by continuing to support and collaborate
with the Rural Geriatric Networks within
Champlain region, and we hosted our
second Rural Geriatric Forum earlier in
the year. The recommendations of this
forum are being used to guide the devel
opment of seniors’ health services in
the small urban and rural areas of
Champlain region.
We recognize the tremendous potential
for seniors and their caregivers to adapt
to and manage the impact of the diseases
associated with aging. We are therefore
proud of the research that has been under
taken over the past year relating to the
disclosure of diagnoses, and of our close
partnership with the Alzheimer’s’ Society
and the Champlain Dementia Network in
promoting the First Link program with
seniors and family physicians. It is our
hope that the knowledge gained from
these studies will empower seniors and
their caregivers to become more informed
and active participants in their care.
We have also seen steady progress in
the development of more age-appropriate
acute care across our region over the past
year. Most notable, was the decision of
the Board of Directors of the Queensway-
Carleton Hospital to approve a plan and
begin the process to become a Senior
Friendly Hospital, endorsing the model
initiated by the RGP. Additionally, for the
first time we have been able to extend
geriatrician support to the Montfort
Hospital. Winchester and District Memorial
Hospital has hired their first Geriatric
Nurse Specialist, and we have worked
with Pembroke Regional Hospital to
establish a geriatric unit intended to
support safe and sustainable discharges
home. Within our host hospital, The Ottawa
Hospital, as well as the Queensway-
Carleton Hospital and Cornwall Community
Hospital Geriatric Emergency Management
(GEM) nursing is being introduced into
the emergency departments. We are also
pleased to have been able to maintain
our strong partnership with SCO Health
Service, through a number of joint planning
initiatives, including improved access to
geriatric rehabilitation services.
Coordinated Access &
Service Delivery
Gaps in care and support for seniors
have resulted in inordinate pressure on
access to acute hospitals across the
region. The debate on Alternate Level of
Care Strategies has been at the forefront
of health planning over the past year.
Based upon sound geriatric principles of
care, the Regional Geriatric Program has
advocated for a balanced approach from
health promotion and prevention to com
munity and facility–based care that is
organized around comprehensive geriatric
assessment and planning. Together with
the Champlain Local Health Integration
Network and our many partners, a com
prehensive framework for Appropriate
Levels of Care was endorsed by the LHIN
and local providers. We are gratified that
this framework has had impact at the
provincial level, and that it has guided
recent provincial investments intended
to alleviate unnecessary pressures on
hospitals in our region. In recognition
of the leadership and expertise of the
Regional Geriatric Program, as well as
the strength of our many partners on the
Regional Geriatric Advisory Committee,
the Champlain Local Health Integration
Network has assigned us lead roles for
both the coordination and evaluation of
ALC strategies for our region.
Through the expertise of our staff, and
collectively our teams, and the commit
ment and dedication of our many partners,
it truly has been a year in which we have
served as a resource to seniors and our
regional health system alike.
Cal Martell,
Director, Regional Geriatric Program
of Eastern Ontario
We recognize the
tremendous potential
for seniors and their
caregivers to adapt to
and manage the impact
of the diseases associated
with aging.
continued from page 1
3. Regional Geriatric Program of Eastern Ontario
I
n his report, Cal Martell has described
the many exciting new initiatives of
the Regional Geriatric Program of
Eastern Ontario. These include a close
working relationship with the Champlain
LHIN to further develop services for
seniors throughout Eastern Ontario and
to maximize the health potential of all
seniors, not just frail seniors (one of
our primary mandates), but also health
promotion, disability prevention, and
screening in important areas such as
cognitive impairment.
You are all aware of the focus on ALC
“patients” in Eastern Ontario. I feel that
the real solution is not just more services;
either home care services or building
more long-term care beds. Instead, we
need to change “the system” to focus
on 6 safety nets between being healthy/
living at home and moving to long-term
care. The main initiatives include:
health promotion,1.
“unfrailing” the elderly in the com2.
munity (which is the main focus of
the Geriatric Outreach Teams and Day Hospitals),
screening and assessing high-risk elderly in the emergency room who are3.
going to be returning to home (the focus of the new GEM: Geriatric Emergency
Management program),
improving the care and outcomes for elderly patients admitted to hospital through4.
hospital consultation services, senior friendly hospitals, delirium recognition pro
grams, optimal utilization of the Geriatric Rehabilitation Unit at SCOHS etc. and
more specialized CCAC case management (i.e. high risk frail elderly (the RISC5.
program) or dementia specific case managers once dementia care becomes
more complex).
But in the end, the real focus is on individual health care professionals working with
an elderly person at the “bedside” whether the bedside is LTC, hospital, clinic or home.
Without optimizing the individual health care experience at the bedside, all the system
changes in the world (to paraphrase Humphrey Bogart in Casa Blanca) “don’t amount
to a hill of beans”.
I could lament that we need much more geriatric training in all disciplines at the
undergraduate, postgraduate and continuing education level, and that we need many
more trained specialists in Geriatric Medicine, Psychiatry and all the disciplines, but I
would rather focus on the excellence of all the people in Eastern Ontario who currently
work with the elderly.
Our commitment:
Health and
Independence
The Regional Geriatric Program of
Eastern Ontario (RGP of Eastern
Ontario) is a coordinated network
that includes a broad range of
specialized geriatric services,
from hospital to home. It was
established in 1985 as Ontario’s
first specialized health services
network for seniors.
Our clinical services, teaching and
research and committed to the
health and independence of seniors
in the Champlain region. Hosted
by The Ottawa Hospital, the RGP
is a partnership of hospitals and
community partners.
3
Patients, Professionals,
and Good Care
I feel that the real solution
is not just more services….
Instead, we need to
change “the system”…
Bill Dalziel, Chair, The Regional Geriatric
Program of Eastern Ontario
continued on page 4
4. Annual Report 2006
4
I salute all of you who bring your pro
fessional skills and your personal caring
to your work with the elderly. I would like
to end with a quote that has impressed
me more than anything else that I have
read in terms of working with the elderly.
It is from Margaret Laurence shortly
before her death giving the convocation
address at Trent University about what
messages she would give if it was her
final hour of life.
“Well, an acceptance of limitations
does not mean that one is not constantly
trying to extend the boundaries of knowl
edge and accomplishment and it certainly
does not mean an acceptance of defeat
in whatever fields our endeavours take
place. It is my feeling that as we grow
older, we should become not less radical
but more so…”. Mind must be the firmer,
heart the more fierce, courage the greater
as our strength diminishes”. I would not
claim to pass on any secret of life where
there is none, or any wisdom except the
passionate plea of caring…. Cultivate
in your work and your life the art of
patience, and come to terms with your
inevitable human limitations, while striv
ing also to extend the boundaries of your
understanding, your knowledge and your
compassion. These words are easily said;
they are not easily lived. Learn from those
who are older than you are; learn from
your contemporaries; and never cease to
learn from children. Try to feel in our
hearts’ core, the reality of others.
Bill Dalziel,
Chair, The Regional Geriatric Program
of Eastern Ontario
continued from page 3
I salute all of you who
bring your professional
skills and your personal
caring to your work with
the elderly.
Teamwork and
passion raise the level
of care for the elderly
in Hawkesbury
T
op-quality hospital geriatric services
are now a specialty of the Hawkesbury
and District General Hospital (HDGH),
thanks in no small measure to the efforts
of a talented and passionate group of
local health-care providers.
Two of those providers, registered
nurses Marielle Heuvelmans and Lise
McDonell, have been instrumental in
developing the program, which includes
geriatric assessments, senior-friendly
health initiatives, chronic-disease
management and rehabilitation.
Marielle is the hospi
tal’s Vice-President of
Clinical and Therapeutic
Programs. She is in
charge of the organiza
tion and administration
of patient care. Lise is
the Geriatric and Clinic
Nurse Counsellor. She
is immersed with the
patients themselves,
performing geriatric
assessments and plan
ning ongoing patient
care. She is also part
of the multidisciplinary
chronic-disease-
management team.
Neither of these experienced nurses
can imagine doing anything else. “Many
people talk about the emergency depart
ment as ‘the place to be’ for a nurse,”
says Marielle. “But I think there’s no more
clinically exciting area than geriatrics.”
“It’s a continually changing area,”
adds Lise. “You think of geriatrics and
you think old, but I think new and exciting
because things keep changing and evolv
ing with new therapies and medications.”
The HDGH geriatric-care program is
the outcome of their passionate pursuit
to address a lack of local, specialized
health-care services for the region’s
senior citizens.
In the 1990s, Marielle and Lise were
case managers for the Hawkesbury
Community Care Access Centre (CCAC),
which helps people to connect with the
long-term care and community-based
services they need.
At that time, geriatric
services were focused
largely on the man
agement of chronic
diseases, for example,
through regular mon
itoring of patients’
blood pressure.
But in the course
of their work, Marielle
and Lise were finding
that senior care was
becoming more com
plex. Often, patients
had more than one
serious condition
and required more in-depth attention.
Also, the nearest specialized geriatric
services were primarily in Ottawa—too
far away for most elderly people to take
advantage of on a regular basis.
Acting on these observations, the
women signed up to be trained as geriatric
assessors by the Regional Geriatric
Program (RGP) of Eastern Ontario.
“It’s a continually
changing area, …
You think of geriatrics
and you think old,
but I think new and
exciting because
things keep changing
and evolving with
new therapies and
medications.”
5. Regional Geriatric Program of Eastern Ontario
5
As two of the first geriatric assessors
in their community, they were eager to
apply their newfound expertise in home
health-care delivery.
However, it soon became obvious
that the community’s capacity to deliver
specialized geriatric services required
greater coordination. So, as players in a
larger team of like-minded people, the
two health-care champions set out to
develop a dedicated geriatric program
for Hawkesbury. “The geriatric program
in this area was built from the ground
up with the help of local champions,”
says Marielle.
Some of those champions were
physicians like Dr. Reneé Arnold, who
works in the hospital and community.
Dr. Arnold began endorsing the nurses’
geriatric-assessment reports, giving
them credibility with the patients’ family
doctors. And Marielle and Lise became
involved with geriatricians through
specialized services, such as the
memory-disorder clinic.
“Having that link with physicians,
it snowballed from there and we were
getting referrals from family doctors
asking us to please see this patient for
an assessment,” says Lise.
While CCAC organized community-
based elder care, Dr. Arnold worked to
establish a geriatric team and program
at the Hawkesbury and District General
Hospital. In 2003, Lise was hired as
the first geriatric nurse on staff to do
assessments. Marielle followed a year
later to join the hospital’s senior
management team.
Today, Lise takes care of front-line
patient needs, while Marielle ensures
that the hospital puts in place the
policies, resources and programs that
enable the patient-centered care her
colleague implements.
Marielle and Lise credit their colleagues
at the hospital and in the community for
the success of Hawkesbury’s specialized
geriatrics program. They also credit the
RGP of Eastern Ontario, which acted as a
mentor and resource in developing the
program. “This only works because of all
the good people behind it,” says Marielle.
“Without the RGP’s support from the
beginning, it would’ve been very difficult
for us to move forward,” adds Lise. Both
women continue to be involved in the RGP
through additional training and partici
pation in committees.
Modern geriatric care involves taking
a patient-centred, holistic approach that
is not fragmented by disease, such as a
singular focus on diabetes, stroke or car
diac disease. “Geriatrics doesn’t work
that way,” says Marielle. “It works across
all those areas and we cannot lose track
of that.”
The rewards of this patient-driven
vision for senior care are obvious, says
Marielle. “Geriatrics is an area that’s
underestimated in terms of the signifi
cant difference you can make and the
impact you can have, both on the patient
and on their family.”
Marielle Heuvelmans (left) and
Lise McDonell see caring for
elderly people as a privilege.
“It’s an extremely special
population,” says Marielle.
“We’re so privileged to
hear their stories,” adds
Lise. “I mean, we’re
meeting people who have
survived wars and the
Depression, just incredible
circumstances.”
