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Canadian Coalition for Seniors’ Mental Health
The Southwestern Ontario Geriatric Assessment Network
Catherine GloverDr. Lisa VanBussel
September 24-25, 2007
Declaration
We are unaware of any apparentconflict(s) of interest that may have
a direct bearing on the subject matter
of this presentation.
SWOGAN
Network of specialized teams of clinicians located in the ten counties of Southwestern Ontario that provide specialized services to the frail seniors and their caregivers.
SWOGANFigure 1: Map of Southwestern Ontario
Table 1: Population 65 years of Age and Older in Southwestern Ontario
AreaPopulation 65+,
2001% 65+, 2001
% 65+, 2006
% 65+, 2010
% 65+, 2016
Bruce 11,100 17.4 18.0 20.0 24.4Chatham-Kent 16,210 15.1 15.3 16.0 18.4Elgin 11,195 13.7 13.8 14.7 14.4Essex 47,980 12.8 12.5 12.9 14.4Grey 16,035 18.0 18.4 20.0 23.3Huron 10,365 17.4 17.7 18.5 21.3Lambton 20,085 15.8 16.3 17.8 21.2Middlesex 52,570 13.0 13.2 14.1 16.2Oxford 14,910 15.0 15.0 15.8 18.0Perth 10,745 14.6 14.3 14.5 15.8
Note: 2001 information from 2001 Census data, Statistics Canada; 2006, 2010 and 2016 population projections from the Ministry of Finance
Vision
To lead and sustain a network of care in the Southwestern Ontario region that builds local capacity to care for older adults with multiple, complex needs.
Programs and Service Delivery
• Consultation• Education• Research• Evaluation
Implementation• Integration of programs and services:
local and specialized; Geriatric Mental Health and Geriatric Medicine
• Leadership• Infrastructure creation• Partnership • Implementation of education initiatives • Network-wide evaluation framework.
Service Delivery Model• Vision of the Network• Why a “Service Delivery Model”• Current function• Future opportunities• Breakthrough success
Reference: Making It Happen MOHLTC 1999
Partnership
LocalFamily Doctor with
Expertise in EldercareAlzheimer Society
Local Geriatric NurseHome Care
CommunityFamily Doctor
Long Term CareLocal Hospital
Specialized
Geriatric Psychiatry Geriatric Medicine
Collaborative Care
Service Delivery Model
• Development and implementation of network-wide service delivery model.
• This model is expected to support timely and consistent access to expertise in Geriatric and Psychogeriatric care throughout the Southwest.
Service Delivery Model
SWOGAN Evaluation FrameworkDevelopment of a Network Balanced
ScorecardConsensus approach
Framework Quadrant themes Indicator selection Data collection procedures
Feedback Local team meetings Leadership forum discussions
Education
• Build Capacity• Links with Academic Community
and Resources• Links with LHIN’s• Links with provincial and national
bodies
Innovation and LearningIndicators
• Number of educational opportunities delivered and received.
• SWOGAN Spring Team Exchange.• Research and Evaluation Inventory.
Challenges• Categories.
Process• Submitted annually.
Utilization and QualityIndicators
• # referrals, # consultations, # initial assessments, # follow-ups, wait times
Challenges• Definitions• Setting targets
Process• Collected throughout year• Data quality checks• Submitted quarterly• Summaries available within 1 month
Client SatisfactionIndicators
• Tool development.
Challenges• Some pre-existing tools / expectations.• Additional work.• Satisfaction of other stakeholders also
important.
Process• Clients seen in 1st & 3rd quarter sent
questionnaire in 2nd or 4th quarter.
Infrastructure
• Network Strategic Plan• Communication Mechanisms• Structures and processes for
clinical collaboration.• Provincial linkages
Staff: IndicatorsPercent of Time Allocated to Each Activity: SWOGAN
0
10
20
30
40
50
2002-03 20.0 30.0 5.0 10.0 9.0 5.0 20.0
2003-04 19.1 31.5 7.1 17.9 9.3 7.1 7.9
2004-05 22.5 28.4 8.4 12.8 8.6 3.5 15.8
2005-06 19.2 30.0 7.2 14.6 10.1 4.6 13.8
Direct Patient CareIndirect Patient
CareTravel Time
Educ Delivered & Received
Team Developmnt/ Admin
Linkages and Marketing
Vacation/Sick Time
Data CollectionChallenges
Staff burden.• Complexity of data entry.
Process• Four 1-week snapshots.• Face-to-face meetings with local teams
about data collection processes.• Ongoing support.
2002-2006 New and Follow up Assessments
1501
12441146
1673
1119
14861572
0
200
400
600
800
1000
1200
1400
1600
1800
New Assessment Follow up Assessment
# o
f P
ati
en
ts s
ee
n
2002-2003
2003-2004
2004-2005
2005-2006
ne
w a
nd
fo
llow
up
to
ge
the
r
Strategic Planning
• SWOGAN continues to grow and the commitment of Network partners to develop an evidence-based model of care is further reflection of its commitment to evidence-based practice, evaluation, and the full engagement of Network partners in planning.
Getting back to Vision• Increase in quality of care provided to
frail seniors in a large geographic area• Locally available with access to
specialized services when necessary• Influence on Public policy• Influence on Education of Health
providers• Collaborative care within communities
combined influencing methods of care delivery across the Region
Getting There
• Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed it’s the only thing that ever has”
Margaret Mead
Breakthrough Success
• Work of the task team• Discussion and Consensus process
today• Delivering on the strategic goals• Abstracts and publications• Service to clients: Blueprint• Local access –Regional access
Contacts
• Bonnie Kotnik, Director, Geriatric Psychiatry Program
• Maureen Vickers, Director, Specialized Geriatric Services
• Dr. Lisa Van Bussel, MD Physician Leader, Regional Psychogeriatric Program