Clinical Services Plan for Geriatric Medicine - HNHB LHIN · June 30th, 2009. Dear Sir/madam Re: Clinical Services Plan for Geriatric Medicine Please find enclosed the proposals from

June 30th, 2009

Dear Sir/madam

Re: Clinical Services Plan for Geriatric Medicine

Please find enclosed the proposals from the geriatric Planning Advisory Group.

We have had numerous meetings in large and small groups and in the end submit four different but

related proposals. We chose to submit like this because we do not feel that we have the resources to

provide comprehensive Geriatric Services LHIN wide at this point.

Background

To explain our situation we would like to provide some background. Geriatrics is a essentially a specialty

that deals with the care of frail older adults. Geriatricians provide comprehensive assessments of older

adults and assess medical problems, cognition, mood, function, supports and risk factors. Traditionally

geriatricians work in teams of health care professionals that would include nurses, occupational

therapists, physiotherapists, speech language pathologists, dietitians, pharmacists and social workers.

Comprehensive care plans are developed in consultation with these various health care professionals.

In Ontario, Geriatricians were funded thorough Regional Geriatric programs. There are five, each

attached to a Medical school. They were funded in this order Hamilton, Toronto, Ottawa, London and

Kingston. When they were funded, the monies were given to hospitals. So traditionally Geriatricians

were attached to hospitals and were seen as tertiary care services like cardiac surgery or burn units.

So, as a result, geriatricians worked almost exclusively in hospital in consult services, inpatient

assessment units and/or outpatient departments. Today we see the legacy of that funding situation. In

this LHIN 80% of Geriatricians are located in Hamilton, working in hospitals and for the most part they

are all attached to the university. There is currently no funding in place for community geriatricians.

There are some services given out side of Hamilton like Greater Niagara General Hospital because the

hospital has provided funding for this program.

Currently, Geriatricians work in these programs where resources are provided. They have no way of

expanding these programs to work with primary health teams, to increase outpatient clinics, to expand

outreach services or to provide specialty clinics like falls, dementia or continence clinics because they

have no resources. Geriatricians can only work where resources are provided and stop working if these

programs or services are withdrawn.

Geriatricians are anxious to provide services outside of Hamilton and outside the traditional silos where

they have been forced to work for decades now. Geriatricians have been communicating together for

months in anticipation of this proposal. In addition to inviting our own membership, we also invited key

stakeholders to help us with our planning. In collaboration with our partners we developed a Discussion

Document that addressed demographic, utilization and some preliminary ideas on specialized geriatric

service delivery models. We then used a Delphi consensus process to determine what areas we would

like to develop as a priority. Then we met for a day workshop with an external facilitator (Dr. C. Powell)

and developed four priority areas;

1. Family Health teams – shared care model 2. Outreach – “atHome” program 3. Transitional care program 4. Video conferencing (via OTN)

At the strategic workshop we divided into teams and developed proposals for each of these areas. We wanted to focus on programs that could be applied throughout the LHIN in cities, small towns and rural areas. We wanted to assess people in their own environment, in their own homes or in their family doctors’ offices. Unlike traditional tertiary care services that are located in large teaching hospitals, these services go to where the patient is, to provide services where the person is, when they need it and what they need. Rather then propose a centralized intake process, we recommend the best approach will be to have multiple access points for referrals. Each portal will employ a standardized approach using common care processes and common screening and assessment forms. This will facilitate improved overall communication across programs, reduce system redundancy and allow for data to be collected so evaluation and benchmarking activities can be initiated. These proposals do not replace existing services. They build on existing services and attempt to enrich them and provide a focus and integration of services that is currently lacking. Geriatricians want to work with CCAC, Family health teams and Community health Centres. These four proposals represent our efforts to expand specialty services throughout the LHIN. We have provided a common template for sections 2 for the four proposed areas. While we have provided four different proposals to expand specialty services we recognize more needs to be done and obviously we would be happy to meet with your staff to discuss an overall strategy for expanding specialty services throughout the LHIN. The main limitation to this right now is the lack of specialist geriatricians, nurses and allied health care professionals to work in these teams. No matter what the strategy, it will have to be gradual and incremental. So these proposals represent the strategies offered by the Regional Geriatric Program central to expand these specialty services throughout the LHIN. Sincerely Dr. W. Molloy Chair, Regional Geriatric Program central David Jewell Director, Regional Geriatric Program central

Re: Geriatric Clinical Services Delivery Model Diagram for HNBH LHIN

This diagram provides an overview of our current and future service models

Current Inpatient services – largely Hamilton based

Geriatric Consult Service

Geriatric Rehabilitation and Assessment

Current Outpatient Services – largely Hamilton based

Geriatric Outpatient Clinic

Geriatric Outreach

Geriatric Day Hospital

This new HNHB model links the acute care system with 4 new model enhancements:

1. Transitional care – expedited discharge with strong prevention of readmission program elements.

2. Primary Care – Development of a shared care model between primary care and geriatrics. This will provide increased assessment and treatment expertise among physicians and allied health in Family Health Teams. Transitional care will link with primary care.

3. atHome Program – This geriatric outreach service will be highly responsive to clients in emergency, identify those at risk in the home and put in place prevention measures to help improve independent living. This program will link closely with Transitional care and Primary – shared care model.

4. Video conferencing – will improve clinical access to services. Video conferencing will begin to address lack of access to clinical services in rural areas. A number of geriatricians have already begun to link with Family Health Teams and other sites.

Geriatric Clinical Services Delivery Model HNHB LHIN

EDUCATION ‐ TRAINING – CAPACITY BUILDING

LOW RISK

HIGH RISK

Admission to Acute Care

ACUTE CARE

Geriatric Inpatient Consultation

Geriatric Assessment & Rehabilitation

Units

Transitional Care

CCAC‐based APN

transitional coach to

provide patient/caregiver

self‐care training

Specialty Geriatric Community Services

atHome Program: Outreach Team

Home Visits

Inpatient & Outpatient Geriatric

Assessments

Training/Capacity Building

Video

Conferencing

Outpatient Geriatric Assessment clinics & Day Hospitals

PRIMARY CARE (FHTs & CHCs)

Shared Care Model

LOW Vulnerability HIGH Vulnerability Frailty Severity

Outpatient Geriatric Assessment & Consultation

Outreach Team Home Visits

HAMILTON NIAGARA HALDIMAND BRANT

LOCAL HEALTH INTEGRATION NETWORK

CLINICAL SERVICES PLANNING PROJECT

At Home Geriatric IP Outreach

PLANNING ADVISORY GROUP MEETING GUIDE

HNHB LHIN Clinical Services Planning Project, Planning Advisory Group Meeting Guide

1. Complete Template #1. Describe the strengths and challenges within the existing health care system in addressing population health care needs for the PAG’s patient/client population. Primers for discussion: ‘Summary of Community Values and Preferences’ (Appendix A), ‘Criteria for PAG Service Delivery Models’ (Appendix B) and ‘Guiding Principles for PAG Service Delivery Models’ (Appendix C).

Template #1: Strengths and Challenges within the Current System in Addressing Population Needs PAG Name:

At Home Program

Outreach Specialized Geriatric Services for Frail Older Adults

PAG Facilitator

Dr. W. Molloy, Mary‐Lou van der Horst

Strengths and Challenges

Introduction

This proposal describes a LHIN wide program that will provide quicker access to Geriatricians, geriatric assessments and coordinated specialized

geriatric services. The geriatric assessments use a risk‐based management model and standardized tools and processes. In addition, for frail older

adults who cannot attend geriatric assessments within the outpatient settings due to health and functional issues or who are at risk of maintaining

themselves/their health will be offered geriatric assessments within their own home.

Goal: The goal is to keep these frail older adults at home and help them maintain their independence, reduce unnecessary admissions to

acute care, and avoid premature admissions to long‐term care.

Innovative: The atHOme program is distinct from and complementary to current services like FHTs and CCACs operating in the community.

It offers timely and efficient access to complex services for complex patients. Highly skilled teams of health care professionals are trained to

deal with complex frail older adults. It can be accessed by doctors, CCACs and other community agencies who have health and functional

concerns about community‐dwelling frail older adults.

FINAL: At Home Geriatric Outreach 7 of 86


Urban and Rural Settings: The atHOme program is designed to work in urban and rural settings. It is an excellent model for rural settings

and small towns.

Comprehensive Geriatric Assessments: Evidence‐Based and Knowledge Informed

Comprehensive Geriatric Assessments that use standardized tools and processes have been shown to reduce mortality, morbidity and reduce costs

when used appropriately in the care of frail older adults. This program targets a specific group of older adults – those who are frail and vulnerable

to changes in their health ‐ which represent a substantial portion of people over the age of 85 and to a lesser degree those over the age of 65.

At Risk Frail Older Adults

Typically these patients will be frail, elderly, and have some of the following risk criteria:

Multiple admissions or ER visits (frequent users), falling, non‐compliant with medications/polypharmacy, poor nutritional status due to not eating/food selection/lack of food, refusing help in the home, poor ambulation, confusion, incontinent of bladder/bowels, and at risk of hospitalization and/or premature institutionalization (long‐term care).

In the Home Assessments

The first step is a telephone screening conversation by an advanced practice nurse to determine if this person meets the criteria for an in‐home

assessment. If the person fits the criteria, the urgency is assessed next. The urgency will be ranked from low to high and a home assessment

arranged based on this ranking. All Home Assessments will use standardized assessment measures including history, medications, systems review,

physical exam, psychosocial assessment, functional assessment, cognition, mood, home safety/environment, and risk assessments. The assessment

will be client‐focused and culturally sensitive. This assessment will be recorded electronically and will be part of a larger data base. The next step is

a Case Conference with the interprofessional/ interorganizational team and the Geriatrician. Less complex cases may not be seen by the

Geriatrician. More complex cases will be reviewed and a determination made if a home visits needed or if the person can be seen in the outpatient

setting.



The Inter‐professional and Inter‐organizational Team

This inter‐professional and inter‐organizational team will have nurses and other health care providers such as occupational therapists and physical

therapists. We would also include Community Care Access Centre (CCAC), Family Health Team (FHT) and Community Health Centre (CHC) staff on

the team to facilitate interorganizational collaboration and speed up turnaround times for home supports. The patient, family and caregivers are an

important and critical part of this team. We also will consult with speech language pathology, dietitians, pharmacists and other health care

providers based on the care needs. Technology will be used to promote interorganizationl collaborative care. For example, if there are geographical

barriers, primary care providers will be invited to attend care conferencences via videoconference.

Network of Geriatric Services

The atHome Program will be part of the Regional Geriatric Program‐Central which encompasses a wide range of geriatric services including

Geriatric Assessment Units, Geriatric Rehabilitation, consultation services, outreach teams, outpatient clinics, and day hospital programs. This

program will interface with existing programs such as Adult Day Programs, Community Support Services, various community associations and

governmental associations such as Veterans Affairs, Hospices, Palliative Care, and cultural groups.

Education

This program offers excellent opportunities for all health care providers to learn from each other and gain continued learning through the Regional

Geriatric Program – Central’s linkages with McMaster University.

Follow Up

Follow up will be done by CCAC and primary health teams. The atHome Team will remain available for consultation and follow‐up support.



2. Complete Template #2: Describe the leading factors that are most likely to increase or decrease the demand for health care by the PAG’s patient/client population by 2013. For each of these factors, indicate whether it will have a modest or significant impact on the future demand for health care. And, list factors that may influence the demand for care beyond 2013

At Home Geriatric Outreach Program

As of 2006, the HNHB LHIN was home to over 200,000 seniors aged 65 years and older; the largest number of seniors of all LHINs. In 2006,

seniors 65 years of age and older represented 15.8% of the total HNHB LHIN population, compared to 13.6% for all of Ontario.

Twenty‐nine percent (29%) of seniors aged 65+ live alone in HNHB communities, higher than the provincial average of 27%. Within HNHB the highest proportions of seniors living alone are found in St. Catharines (33%) and Brantford (33%) and the lowest proportion in Wainfleet (19%).

Seniors living alone may be at greater risk of social isolation. The lack of social support among the elderly contributes to poor health status and the need for formal and institutional care.

Approximately 27.7% of seniors in the HNHB LHIN live alone (See Table 2). Seniors living alone may be at greater risk of social isolation. The

lack of social support among the elderly contributes to poor health status and the need for formal and institutional care. i A recent Statistics

Canada studyii demonstrated that the vast majority of seniors remain in the community as their health care needs increase. Between 1981‐

2001 the proportion of Canadians aged 65+ living in health care institutions remained at about 7%; in 2001, approximately one‐third of

Canadians age 85+ lived in an institutional care setting. Among seniors living in the broader community, the Ministry of Health and Long‐

Term Care estimates that relatives, friends and volunteers provide about 80% of support to seniors with needs.

The majority of seniors that live in the HNHB LHIN live within Hamilton and Niagara (See Figure 1). In terms of absolute numbers, Hamilton

and Niagara are each home to over 74,000 seniors 65 years of age and older, and together represent 72% of the total HNHB LHIN population

over 65 years of age.

Significant impact

on future demand

for health care




Population aging presents significant challenges to the health care system in Ontario. Not the least of these is the fact that 82% of seniors

have one or more chronic health condition and 43% have three or more chronic conditions. This latter group is at risk of becoming frail.

Frailty, characterized by complex bio‐psycho‐social and functional problems, is associated with increased health system usage and puts

seniors at risk of loss of the capacity for independent living and lowered quality of life (Wolff et al, 2002). Within the aging demographic,

frailty may be the fastest growing issue across the province and particularly in northern regions and outside high‐density urban areas

(Manuel & Schultz, 2001).

The ageing of the Baby Boomers will be the main driver of the increased number of people who are 65 years and over. These numbers will

increase by 50% over the next 10‐15 years. Improved life expectancy will also see the numbers of people aged 80 years and over double

during the next two decades. As we live longer we are likely to see an increasing proportion of people with age related medical disorders

such as neurodegenerative disorders, depression and mental health problems (Hopkins & Hopkins, 2005).

A key contributor to the increase in severe disability experienced by those over 80 is growth of neurological conditions, which result in

disorders of memory, cognition, behaviour, motor and sensory functioning, mobility and balance. These neurodegenerative diseases are

often slowly progressive and they have not, so far, been amenable to prevention or delayed onset, as have other disorders such as heart

attacks and stroke. While there is no strong evidence that the incidence of these diseases is changing, their prevalence is rising rapidly as

more people are living longer. We can expect the systemic disorders to be overtaken by neurodegenerative diseases as the major cause of

death in older people during the coming decades and also the major cause of severe disability.

People will come out of hospital with the capacity to get better and it will be important that the health system has a strong focus on

restorative and preventative measures. The demand for rehabilitation and other services following these acute events will certainly increase.

In response to these trends we may benefit from a hospital sector that plays a greater role in preventing acute admissions to hospitals and

delivers more services in the community.




The Dementia Epidemic: In Ontario, dementia is the leading cause of disability for those over 60 years of age causing more years lived with disability than stroke, cardiovascular disease and all forms of cancer (Alzheimer Society of Ontario, 2007). It is expected that by 2010, 175,000 Ontarians will be living with dementia; this will increase by almost 127% by 2020 (Hopkins & Hopkins, 2005). Table 1 presents the estimated incidence of dementia in the HNHB LHIN for 2006. Ageing demographics will have a significant impact on human resource planning and development in all professions working in many health

care contexts across the circle of care (McKnight et al. 2003). Providing care to this expanding population of frail seniors requires both an

increase in the numbers of care providers, capacity building across various health care sectors, and restructuring of how and where we

deliver care. Our skill sets require expertise in three broad competencies ‐ geriatrics, inter‐professional practice and inter‐organizational

collaboration.

Table 1: Estimated Incidence of Dementia in the HNHB LHIN, by County and Age Group, 2006.

Age Group

Geography 60‐64 65‐69 70‐74 75‐79 80‐84 85+

Total

(60+)

Brant 31 50 93 173 291 533 1,171

Burlington 45 73 134 238 391 667 1,548

Haldimand‐Norfolk 31 48 86 148 242 438 994

Hamilton 125 207 386 742 1,242 1,968 4,670

Niagara 121 204 378 704 1,201 1,997 4,605

HNHB LHIN 353 583 1,077 2,005 3,367 5,603 12,988

Ontario 2,984 4,872 8,578 15,146 24,486 42,003 98,069

Source: Statistics Canada, 2006 Census; Dementia Age Relative risk: 60 1%; 65 2%; 70 4%; 75 8%; 80 16%; 85+ 32%. Source:

Significant impact

on future demand

for health care

Significant impact

on future demand

for health care




Competence in geriatrics is required because the clinical presentations of frail seniors are unique and include the ‘geriatric giants’ of

dementia, delirium, falls, continence and poly‐pharmacy. These often co‐exist in complex ways. Competence in inter‐professional practice is

required because the complexities of these clinical presentations are such that optimal care requires an interdisciplinary team. Inter‐

professional teamwork, as outlined in the recently published Health Force Ontario, Inter‐professional Care: Blueprint for Action (Oandasan &

Closson, 2007), is the care delivery method of choice in caring for frail seniors (Geriatrics Interdisciplinary Advisory Group, 2006). Finally,

competence in inter‐organizational collaboration is required because the management of frail seniors requires the sharing of care across

many organizational boundaries from primary and community based care to emergency and hospital‐based services.

Significant impact

on future demand

for health care

Advancement in technology and how we communicate with each other

Based on this aging population and HR challenges we need to develop e – health strategies such as video conferencing, maximize electronic

record sharing such as clinical connect, standardize all documentation processes to facilitate data collection, evaluation and reduce

redundant assessment practices that are a further burden on staff and patients and families. Common forms and tools will create more

effective practice and help different teams start communicating AS ONE. Common documentation will facilitate rapid and improved transfer

of information. Capacity building will be much easier and bench marking will be attainable.

Patients/clients need to assume more responsibility for their care. Work has been done using patient passports and best practice needs to

be implemented using principles from the chronic disease model, e.g., flag prevention measures, telephone follow up to reinforce messages

etc.

Video conferencing is now being tested by geriatricians and office space has been secured. Geriatricians will be among a very small group in

the province of Ontario to actually use video conferencing for clinical purposes. We are just beginning to understand the full ramifications of

this technology.

Significant impact

on future demand

for health care




How services are offered

As frail seniors decondition rapidly in hospitals e.g., loosing muscle mass, delirium, infections etc., it is imperative that services are designed

that prevent admission and re‐admission and help people live longer in their homes with a good quality of life. The specialty of geriatrics can

not tackle this problem single handedly. Using a collaborative model, we propose developing a shared care model with family health teams

and community health centres. Building expertise in geriatrics across the continuum with targeted specialist support will help multi‐

disciplinary groups identify seniors at risk. We need to equip primary care settings to be responsive to seniors at risk so they can provide

time sensitive support to hospital discharges or seniors presenting in emergency who can return home with expedited clinical support.

Having a flexible team that can provide outpatient and at home outreach services is critical. Many seniors in our LHIN live in isolated

situations and are at risk.

Best practice

We know that targeted care to frail seniors makes a difference in health outcomes. Evidence indicates that interdisciplinary teams on an

inpatient and outpatient basis is important. Comprehensive Geriatric Assessment targeted at frail seniors responds to immediate issues and

prevents other medical conditions from worsening. Home visits will improve overall functioning and help seniors live more independently.

Teaching seniors more about their health and how to manage their care more proactively is a integral part of the care process. Already, we

have positive results in the Transitional Care program through Dr. G. Heckman that shows teaching frail seniors is effective and helps them

stay out of hospital. Using communication strategies like providing patients a copy of their treatment plan, having them bring their patient

passport to all health care appointments is an important health information tool. This will introduce evidence based practice for meeting the

needs of aging population

Significant impact

on future demand

for health care

Significant impact

on future demand

for health care

Significant impact

on future demand

for health care




What factors are expected to influence the demand for health care beyond 2013?

Practice of geriatric care is clustered in urban centres, primarily Hamilton

Rapidly growing older adult population with shortage of geriatric specialty trained health care professionals across all sectors of health care including primary

care and community.

Movement of older adults to retirement communities, often smaller towns with poorly established geriatric health services and limited family and

transportation

Finite number of Long Term Care beds



Template #3: Components of an Ideal Service Delivery Model

PAG Name

Geriatric Outreach Service: At Home ‐ Home First.

Geriatric outreach team for Frail Elders

PAG Facilitator

Dr. W. Molloy, Mary‐Lou van der Horst

Component of service delivery

model

Services associated with this component of the

model

Clinical and non‐clinical interdependencies (e.g.,

DI, lab, other programs/services, other PAGs) Linkages to community services

Health Promotion/Disease

Prevention

The referral is triaged immediately and risk of not

managing at home is assessed. For an at home

visit, the assessment is comprehensive covering

physical, emotional, social, psychological and

functional aspects. Assess‐ ment in the home

setting provides unique information of the person’s

current health and functional status and risk.

Interorganizational collaboration is important to

helping maintain the older adults staying in their

home Health issues that may become problematic

in the future are addressed. At the same time this

program promotes family education. If a person

cannot or will not come to an out patient clinic,

they will qualify for an outreach visit.

Direct link to:

- CCAC including Placement Coordination Services, Home Care services, Adult Day care , community association such as Alzheimer Society, Diabetes Association; FHTs/CHCs and family doctors, Labs; Outpatient clinics, other services

The assessment will provide a blue print for

action. Working within an interprofessional

interorganizational network, decisions will be

made about which services are most appropriate

so services are offered in a more timely and more

efficient way. As much as possible, promote one

stop shopping for the patient and family.

The assessment is comprehensive

and provides a portal to

appropriate services. The atHome

Program will function much like a

“traffic controller” so the patient

can get the right care in the right

place at the right time and ideally

in the home…This is client‐

centered and needs based…The

care plan will be comprehensive

and recom‐mends where the

person can get needed services

e.g. FHT, Cardiology, Day

Care…We maximize links to all

community services;

Community Support agencies :

‐ MS, CNIB, Meals on Wheels, Life

line, Catholic Family Services,

Parkinson’s Society, faith‐based

organizations, etc



PAG Name

PAG Facilitator

Geriatric Outreach Service: At Home ‐ Home First. Dr. W. Molloy, Mary‐Lou van der Horst Geriatric outreach team for Frail Elders

Component of service delivery Services associated with this component of the Clinical and non‐clinical interdependencies (e.g.,

model model DI, lab, other programs/services, other PAGs) Linkages to community services

Primary Care/prehospital care

This program responds to primary care and keeps

the focus at the primary care level and out of

hospital. It aims to keep people in the community

and use community based services. If the person

does not have a family doctor, they can be referred

from a walk in clinic. It links directly with CCAC and

can take referrals from CCAC case managers

directly. In fact, the intent is to take referrals from a

variety of access points to maximize accessibility

such as family doctors, other programs, community

agencies, self‐referral for those who don’t have

family doctor, etc. Using a common triage and

screen ‐ing process and assessment tools, patients

can be referred from different programs – all using

the same documents and processes of care.

Patients have access to interdisciplinary teams (OT,

PT, SLP,) through family health teams and

Community Health Centers. Referrals will be

accepted for those who don’t have family doctor’s.

The people in the home (care‐giver network) now

become involved directly in the care planning

process.This program is linked to academics in

research and education. Should an admission occur

to hospital this info‐rmation is available in the

hospital data base.

The people in the home (caregiver network –

patient and family) now become involved directly

in the care planning process.

This program provides assessment in an

outpatient clinic for those who can access them

or in the home for those who can’t go to an

outpatient clinic. It promotes the interface of

community programs. It fosters inter‐

organizational collaboration with different

associations (Mental Heath, Veterans Affairs,

cultural organizations, Parkinson’s Society,

diabetes) so an integrated care plan can be

developed in the “home”. E Health transmits and

exchanges information with the different

programs and agencies. Each person in the circle

of care has access to this information.

In this program, the locus of care

is patient and family the home .

For patients receiving geriatric

assessments in their home, they

will have a chart in their home

listing the different care programs

and contact people in the care

team. If patients are receiving

home care and have a current

chart in the home, the atHome

Program will collaborate to ensure

they their information is part of

the cart. See non‐acute section

for further information.

This type of communication hub

creates home based linkage to

community services



PAG Name

PAG Facilitator




Hospital Care

– Acute and non‐acute

All of the information gained in the atHome

geriatric assessment and follow up in the

community will be available to the hospital. The

patient chart from the home will help facilitate

improved understanding of the assessment,

medications and overall community care plan. If

the patient needed elective surgery then a

comprehensive assessment would already be done

and it would be shared with the hospital staff. The

chart in the home would have the assessment data

in the chart and they can bring this with them to

the hospital if they are going for any assessment

e.g. Cardiology outpatients, ER visit. If the patient

arrives in the ER and has never been reviewed by

the outreach team, the ER doctors can connect

with the atHome team to get an urgent assessment

to allow for discharge thereby preventing

admission to ER. The atHome team will have the

capacity to do different levels of responses e.g. the

ER staff can do a trigger/urgent referral to allow

the atHome staff to organize an urgent referral

next day and prevent admission. If the person has

been seen, the ER team will contact the atHOme

team and arrange for immediate follow up. There

will be an urgent response in the home to prevent

The key is to have information to hospital staff

available so they are aware of all the assessment

data and the care plan.

“Share rather than duplicate”

Hospital staff:

The hospital staff can access a wealth of clinical

information so they will be aware of what was

happening in the community before the person

came to hospital. The broad network of

information is richer and more comprehensive

then the information that the CCAC alone can

currently provide. The atHome outreach team

will provide richer medical and health

information from dedicated specialist teams

directly to hospital staff. The hospital staff will

know what careproviders are involved in this

person’s care in the community. This will increase

linkages between the hospital team, transitional

care program and the community services.

The atHome Outreach Team is

available to the hospital staff to

provide support and information

about various geriatric and

community support services.

Because the CCAC and FHTs are

part of the atHome Team, they

can expedite such linkages and

work to assist the hospital to plan

for earlier return home. The

atHome Team is part of the larger

RGPc network of specialized

geriatric and related community

services.



PAG Name

PAG Facilitator




hospital admission.

The atHome outreach team

The atHome outreach team is the portal to

community services and a quick and easy access

point for patients to understand the geriatric and

community services. Linkage to CCAC for ongoing

care in the home is facilitated by the outreach

team. The team collaborates with the CCAC and

in hospital staff to provide the appropriate home

care services to facilitate discharge. Upon

discharge from the acute care setting the team

immediately follows up in the home to provide

for seamless transfer by enriching and

broadening the interface between the hospital

and community services. This will minimize the

risk of readmission to hospital and ER through

guidance on appropriate care approaches to frail

older adults and their geriatric syndrome and

chronic disease issues.



PAG Name

PAG Facilitator




Non‐acute Hospital Care

The team will link with in patient rehabilitation,

slow paced rehabilitation, complex continuing care,

palliative care, convalescent care, day hospital

programs when appropriate. Non acute services

available can also be accessed as appropriate.

People who have gone through these programs will

all be referred to this outreach team on discharge

to follow up in the community

The atHome Outreach Team is available to the

hospital staff to provide support and information

about various geriatric and community support

services that the patient has accessed and/or

currently using. Any Geriatric Assessment,

laboratory, test or services information that the

atHOme team has can be quickly accessed and

shared.

In this program the locus of care is

in the home so each person will

have a chart in their home listing

the different care programs and

contact people in the care team.

Teams members will use lap tops

in the home to fill out the

standardized assessment process

using reliable and validated

instruments. A copy of the

assessment and care plan is left in

the home to be accessed by family

and caregivers in the home. In this

way the information is directly

communicated.



PAG Name

PAG Facilitator




Post‐Hospital Care

If a person is discharged, then this team will have

access to hospital records to review the

investigations treatments etc. Nurses and

physicians on the teams will be able to determine

what happened during the hospital stay. A referral

to the Transitional Care program may be made.

If the older adult was a patient of the atHome

Program prior to admission and communication is

maintained during hospitalization/transition care,

care back to the community will be seamless and

simple.

If the older is newly referred to the atHome

Program, the Outreach Team will assist with

return home.


available to the hospital staff to

provide support and information

about various geriatric and

community support services.

Because the CCAC and FHTs are

part of the atHome Team, they

can expedite such linkages and

work to assist the hospital to plan

for the return home. The atHome

Team is part of the larger RGPc

network of specialized geriatric

and related community services.

The interorganizational

component of the team allows for

coordinated return home care and

services.



PAG Name

PAG Facilitator




Community‐based Acute Care

This team will triage assessments first over the

phone when the referral is made. The second step

is when the assessment is made in the home, the

team will determine if there is significant issues

that can be managed in the home with appropriate

assessment and treatment e.g. pneumonia,

congestive heart failure. cellulitis, to prevent

hospital admission. If necessary the person would

facilitate hospital admission to bypass emergency,

e.g., directly to the Geriatric Assessment unit or

palliative care or CCC. The team will determine the

level of urgency and develop an appropriate care

plan. For example, consider a person with

pneumonia. The physicians diagnoses, treats and

the person is followed by a nurse daily and may be

managed in the community. This program could

easily be integrated with the transitional care

program or assume responsibility for those patients

who finish with the transitional care program.

This service will link to community services as

appropriate and facilitate referrals to specialty

clinics. Ultimately we will determine which

patients can come to outpatients and which ones

will need in home assessment. This program

interfaces with all the other specialty Geriatric

services. This includes dementia clinics, falls

clinics, referrals to Osteo clinics etc


available to community

agencies/services to provide

support and information about

various geriatric and community

support services. Because the

CCAC and FHTs are part of the

atHome Team, they can also assist

with community linkages. The

atHome Team is part of the larger

RGPc network of specialized

geriatric and related community

services and knowledge about

these agencies.



PAG Name

PAG Facilitator




Community‐based Non‐Acute

Care

Please refer to information contained within the

following boxes above:

- Health promotion/disease prevention - Primary Care/prehospital care

Please refer to information contained within the

following boxes above:

- Health promotion/disease prevention - Primary Care/prehospital care

Please refer to information

contained within the following

boxes above:

- Health promotion/ disease prevention

- Primary Care/ prehospital care



Diagram of Ideal Service Delivery Model:









Template #4. Assess and Describe the PAG service delivery model using the HNHB LHIN Criteria PAG Name: Geriatric Outreach Service: At Home Geriatric Outreach Team for Frail Elders

Domain Criteria Assessment Description

Strategic Fit Alignment with LHIN priorities

for health improvement

- Promotes Aging in Place - Promotes better health management of complex health issues (chronic diseases) of frail older adults who

are the largest proportion of health care system users - Decreases unnecessary visits to ERs - Decreases unnecessary admissions to hospitals - Expedites discharges from transitional care - Averts premature admission to long‐term care homes

Alignment with trends in

health care needs and system

transformation

- Addresses the increasing usage demands being placed on the health care system by older adult consumers (increased life expectancy and diseases associated diseases of longevity)

- Provides greater access by more older adults to finite and often geographically distant geriatric expertise (geriatrician) and related specialty services

- Promotes more efficient use of finite geriatrics services - Promotes a standardized approach to geriatric assessment of frail older adults across the LHIN - Promotes use of evidence‐based best practices in geriatric care - Provides access to a network of established geriatric and related services

Population Health Health status (clinical

outcomes & QOL)

- Improved management of frail older adults chronic diseases and their related functional and cognitive consequences

- Promoting “at home” geriatric services and “remaining at home” care, life enhancing strategies becomes the focus of care, ensures it is client‐centred, and deals with health issues that ensure the older adult’s quality of life is recognized and maintained



PAG Name: Geriatric Outreach Service: At Home Geriatric Outreach Team for Frail Elders


Prevalence - Targeting frail older adults (25% of those older adults over 80) – largest consumers of health care - Burdened with diseases of longevity (chronic diseases and their debilating effects)

Health promotion & disease

prevention

- For frail older adults the focus is not so much on disease prevention or health promotion but rather on health maintenance (e.g, disease stabilization) and minimizing health declines (e.g, minimize functional losses)

- Promotes Aging in Place

Client‐focus - atHome has the client at the centre of its program model - all assessments are client‐focused and include the family/care givers - client, family and caregivers are included as part of the atHome Outreach Team - link with the Aging at Home Strategy

Partnerships - the atHome Program has an “interorganizational” focus and collaborates networks with existing community organizations and hospitals directly and through the Regional Geriatric Program Central

- FHTs and CCAC will be part of the core membership of the outreach team

System Values

Community Engagement

- the atHome Program has an “interorganizational” focus and collaborates with networks with existing community organizations and hospitals directly and through the Regional Geriatric Program Central

- FHTs and CCAC will be part of the core membership of the outreach team - Several atHome teams will be developed to serve a specific geographic area and will draw team

membership from the local area, connect with local organizations and resources





Innovation

- The atHOme program is distinct from and complementary to current services like FHTs and CCACs operating in the community.

- It offers timely and efficient access to complex services for complex patients. - Highly skilled teams of health care professionals across the LHIN are trained to deal with complex frail older

adults. - It can be accessed by doctors, CCACs and other community agencies who have health and functional

concerns about community‐dwelling frail older adults - The atHOme program is designed to work in urban and rural settings. - It is an excellent model for rural settings and small towns. - It is based on a highly successful pilot project in the Niagara area with Dr. W. Molloy and a team of geriatric

specialty trained health care professionals. It is not offered anywhere else in the LHIN and funding on the Niagara pilot project is due to end.

Equity

- Will be available to urban, small town and rural communities - All communities will have access to specialized geriatric services and geriatricians - All frail older adult can qualify especially those who cannot leave their homes but are able to stay within

them - Anyone or any agency can refer, no requirement to have a family doctor





Efficiency (operational) - Promoted through use of team format - Promoted through use of a triage decision‐making process - Promoted through case management and immediate handling of geriatric issues by the team and

appropriate referral of very complex cases to the Geriatrician (not all frail older adults need to see the Geriatrician but can benefit from the geriatric assessment provided by the team with appropriate referral to necessary services)

Access

- Improved access to Geriatricians and specialty trained geriatric health care professionals - Improved access for smaller towns and rural areas - Improved access through the use of technology such as video conferencing/assessments - Reach frail older adults within their homes who cannot go to a hospital outpatient clinic

Quality - Promote the use of standardized assessment tools and processes across the LHIN - Promote the use of evidence‐based and best practices in geriatric care - Hire only geriatric specialty trained health care providers - Timely service provision - Patient and family satisfaction

System Performance

Sustainability

- Able to implement very quickly due to the linkages within the system, knowledge of who and where the geriatric health care professionals are, linkages to the RGP and academia, linkages to FHTS and CCACs, linkages to many geriatric focused organizations

- Will require additional funding to sustain some of the roles within the atHome Outreach Team





Integration

- Focus is on interprofessional and interorganizational collaboration - Focus is on expansion of geriatrician and geriatric specialty services to more frail older adults but through

better model design and system efficiencies - Promote consistent approach to assessment and care coordination for frail older adults



3. Complete Template #5. Describe the pre‐requisites, enablers and challenges to implementation of the ideal service model.

Template #5: Description of Pre-requisites, Enablers and Challenges to Implementation: Category Pre‐requisites Enablers Challenges

Policy/legislation Frail older adults do not need a family

doctor to access atHome Outreach

Program

LHIN

Regional Geriatric Program Central

Specialized Geriatric Services

CCAC

FHTs

Resources (e.g., human, fiscal, capital,

etc.)

Geriatricians

Geriatric specialty trained health care

professionals

Funding support for new positions

within the atHome Program,

Geriatrician services funding via

teleconferencing

Community readiness

Partners have collaborated on various

geriatric care issues in the past

Established geriatric services network

Services

Enhancement of geriatric outreach

services

RGPCentral

FHT

CCAC

LHIN

Niagara is only area in this LHIN that

has piloted a similar model



Partnerships/linkages

Partnerships and networks are well

established

Formalize outreach partnership






Primary Care Family Health Team




Complete Template #1. Describe the strengths and challenges within the existing health care system in addressing population health care needs for the PAG’s patient/client population. Primers for discussion: ‘Summary of Community Values and Preferences’ (Appendix A), ‘Criteria for PAG Service Delivery Models’ (Appendix B) and ‘Guiding Principles for PAG Service Delivery Models’ (Appendix C).

Integrating specialty geriatric services in primary care:

Background

Seniors represent the fastest growing age group in the Haldimand Norfolk Hamilton Brant, Local Integrated Health Network (HNHB LIHN)1. Volume and complexity of care is increasing. Primary care practitioners will provide the majority of care.

Family physicians have identified inadequate training, lack of confidence to manage frail elderly and limitations with the primary care model as barriers to provision of comprehensive geriatric care 2, 3. Limitations with the traditional organization of primary care include; focus on acute problems that are managed in short (average 7 minutes) unprepared visits, without consistent planned follow up4.

Specialized geriatric services in the HNHB LIHN are largely hospital based, located in urban areas (Hamilton, Niagara, Brantford and St. Catharines). Continuity and accessibility of care is fragmented between community and hospital settings, limited to urban areas and fraught by referral delays up to six months with limited emphasis on capacity building in the community.

Objective

This project proposes a shared care model that integrates specialized geriatric services within primary care. The target population is community dwelling seniors

at risk of functional decline, institutionalization and or hospitalization. This complimentary interface between primary care and specialized geriatric medicine

addresses limitations of accessibility, capacity and system organization barriers to provide the most appropriate care, when needed, in a familiar and accessible

location to seniors.

Integrating specialized geriatric medicine within primary care distributes specialized geriatric services throughout the LIHN.

A shared care approach extends the traditional role of the consultant to include capacity building among primary care providers.



Case finding, consistent use of standardized tools for comprehensive geriatric assessment combined with planned follow up visits that focus on evidence based

interventions addresses current organization limitations with respect to provision of comprehensive geriatric care in primary care.

Goal

The goal of this project is to support community dwelling seniors to maintain independence in their ‘home’. It is anticipated that targeting this vulnerable

population prior to functional decline will improve home and driving safety, decrease emergency department visits, increase average age of long term care

admission and decrease alternate level of care placement. The ultimate goal is to provide comprehensive geriatric care to all frail seniors in the HNHB LIHN.

Plan

The initial phase of this project focuses on multidisciplinary family health teams (FHTs) that are poised to provide inter‐professional, comprehensive team based

geriatric care for community dwelling frail elderly. This represents an innovative shift in family health team focus by integrating chronic disease management

into a population approach The next step will be to adapt the model to community health centres as well as non‐FHT group and solo practices according to

expertise and resources in these settings. The ultimate goal is to integrate and extend specialty geriatric services into all models of primary care throughout the

LIHN.

This project builds on the experience of a pilot study funded by the Department of Family Medicine, McMaster University5 in collaboration with the Hamilton

Family Health Team, Division of Geriatric Medicine, McMaster University, Alzheimer’s Society of Hamilton and Halton and the HNHB Community Care Access

Centre.

The goal of this pilot project is to: provide comprehensive geriatric care for frail elderly patients attending McMaster Family Health Team, Stone church Family

Health Centre, enhance expertise among primary care providers and family medicine residents, foster interprofessional collaboration among allied health care

providers and strengthen inter‐organizational partnerships with community resources.

Implications

Data gathered from this initiative will inform future programming and resource distribution based on the needs d. For example

References

1. Hospital Discharge data. Population Health Planning Database. Ontario Ministry of Health and Long-Term Care 2. Rueben DB et al. Restructuring primary care practices to manage geriatric syndromes. The ACOVE-2 intervention. Journal of American

Geriatric Society 2003; 51: 1787-1793.



3. Grimshaw JM, Shirran L, Thomas R et al. Changing provider behaviour. An overview of systematic review of interventions. Med Care 2001: 39:2-45

4. Kates N. Shared mental health care. The way ahead. Canadian Family Physician 2002; 48: 853-855 5. Feasibility of a collaborative care intervention between specialized geriatric medicine and family health team providers. 2008. Department of

Family Medicine. McMaster University. Project n progress

Template #1: Strengths and Challenges within the Current System in Addressing Population Needs Integration of specialty geriatric medicine services within primary care

PAG Facilitator: Dr. A. Moore, Dr. D. Cowan

Strengths Challenges

Strengths within the primary care system to facilitate this project include:

The target group of this proposal is frail older adults living in the community who are at risk of functional decline, hospitalization, and institutionalization in long term care homes.

This project proposes collaboration between specialized geriatric services (SGS)

and primary care. The initial phase proposes a shared care model with family

health teams. Subsequent stages will extend to community health centres, non

FHT group and solo practices with the ultimate goal of integrating SGS in

primary care across the LIHN.

A comprehensive and accessible primary care network in the HNHB LHIN. More than 95% of residents over 65 years of age have family doctors (significantly higher than the Ontario Average).

Concentrated core of FHT’s with multidisciplinary teams poised to provide appropriate care for the complex needs of community dwelling frail elderly (about 25% of family doctors work in family health teams).

Challenges within the primary care system to facilitate this project include: Volume

200,000 seniors, fastest growing age group, largest number of seniors in all 14

LIHN populations in Ontario.

Complexity

Seniors living with more than one chronic condition is increasing. 55% of

Ontarians suffer from two or more chronic conditions

Primary care challenges

Primary care practitioners provide the majority of care for elderly living in the

community. Family physicians have identified inadequate training, lack of

confidence and resources to manage complex frail elderly.

The traditional organization of primary care which emphasizes triage and



Minimal wait times to see Family Doctors vs specialized geriatric services

Family doctors provide the majority of care for the aged.

Relationship between geriatric medicine specialists and family doctors is an

opportunity for capacity building.

Highly dedicated staff

Patient satisfaction

Academic affiliations (some providers)

Opportunity for early intervention, health promotion, disease prevention, risk

reduction (eg vitamin D, exercise program, prevention of falls and social

isolation – risk of depression, medication management, driving and home

safety assessment) potentially leading to decreased emergency department

visits, alternate level of care placement and increased average age at

admission to long term care.

Opportunities for advanced planning (health, shelter, finances)

Early experience with shared care model integration of specialized geriatric

medicine in primary care (collaboration project between the Department of

Family Medicine, McMaster University, Hamilton Family Health Team,

Alzheimer’s Society, Community Care Access Centre).

patient flow, focuses on acute problems that are managed in short (average 7

minutes) unprepared visits without consistent after care. This practice is

incongruent with the needs of frail elderly.

Advanced care planning is minimally addressed in primary care and represents

the ideal opportunity for these discussions.

Wide variety of primary care models (family health teams, community health

centres, family health groups, fee for service, solo and group practices).

Delayed access to consultant services (geriatric medicine, rehabilitation

services, orthopedics, internal medicine).

Access to MRIs

Communication delays and gaps with specialists – Lack of shared health

electronic record

Access to marginalized immigrant, aboriginal, socially isolated and

disadvantaged seniors



Strengths within specialized Geriatric Medicine system to facilitate this

project include:

Highly dedicated staff

Academic affiliations (education and training health care professionals)

History of relationships with Family doctors

Hospital based services – full scope of medical programs available

Existence of partnerships; i.e., (HHSC, SJH, etc…)

Linkages and collaboration with community resources (CCAC, DVA, AS)

Challenges within the specialized geriatric medicine system to facilitate this

project include:

Inconsistent access to specialized geriatric medicine services

Largely hospital based, urban centred

Prolonged wait times to access specialized geriatric medicine services (up to 6

months)

High ALC rates

Lack of access to alternatives to hospital admission

Delayed access to consultant services (geriatric medicine, rehabilitation

services, orthopedics, internal medicine)

Access to MRIs

Communication delays and gaps – Lack of shared health electronic record




Template #2: Factors Most Likely to Increase or Decrease the Future Demand for Health Care:

Same as previous information in template 2



5. Complete Template #3. Describe the key components of an ideal service delivery model for the PAG’s target population.

Template #3: Components of an Ideal Service Delivery Model PAG Name

Integration of specialty geriatric medicine services within primary care

PAG Facilitator

Component of service

delivery model


model

Clinical and non‐clinical interdependencies

(e.g., DI, lab, other programs/services, other

PAGs) Linkages to community services


Prevention

- Patient and family educational materials

Collaboration with case manager at CCAC regarded self efficacy for client in the home. Capacity building‐Educational events for the Family Health Teams

Patient Passport

Public Education

Professional Continuing Education - Resource specialists/CCAC case

managers on site - Needs assessment from clients and

families related to gaps in knowledge

- Referrals from outpatient and Home visits assessments to specialists, organizations and CCAC

- Case finding – Referrals from Health Team to specialists, continence advisors, bone density testing

- University Education

- Links to community groups e.g. Alzheimer Society

– First Link program,

counseling and

education, respite care,

CCAC, legal services,

seniors Drop‐In

centres



PAG Name PAG Facilitator



delivery model


model




Primary Care /

Pre‐hospital Care

- This program provides service in the persons local community (FD office, CHC or home) care is locally accessible in a familiar setting.

- Supports self care and independent living at home as long as possible by treating medical social, psychological and functional needs

- Efficiency is maximized by working with local resource network (CCAC, Alzheimer Society, DVA, meals on wheels) no duplication of services, engagement of appropriate services.

- Given comprehensiveness of assessment this responds to diverse needs and individual client characteristics.

- Specialized Geriatric Services (e.g., newly proposed atHome Program’s geriatric outreach team to assist with diversion from hospital, ER admission) response to primary care request for

- Similar to out patient visit

- Links to current community services, back to the referrer and to new community support organizations

- e.g. other consultants, Alzheimer Society

CCAC (home care,

day care, LTC)






delivery model

Services component of the

model




associated with this

clinic or home visit - Referrers are family physicians, CCAC,

etc. - Add mechanism to deal with patients

who do not have a family physician - Consult note has an educational

component and is shared with patient and family

Tele health is starting in some areas and will be expanded

Local geriatric clinics

Case management model so clients have a primary worker who is accountable for overall coordination of care

Visiting specialists - Eventual incorporation of physician

assistants

Acute Hospital Care

- Prevent admission to acute hospital care by increasing resources in the community

- Link with Transitional Care and proposed atHome geriatric outreach program to prevent readmission. Handoff from the transitional program

- Similar to out patient visit - Link with CCAC or other CHC services

- Link to RGPc network of geriatric service providers

- Link to proposal/atHome






delivery model

Services

model



PAGs) Linkages services

associated with this component of the

to community

to primary care will be very important - Increase access to Specialized Geriatric

Services via multiple clinic settings across the LHIN

- Referral to appropriate geriatric inpatient services such as rehabilitation as required.

Pre operative Comprehensive Geriatric Assessment eg elective hip will help reduce LOS to acute hospital care. If surgery is required hospital admission can be delayed by increasing resources in the community - Improved two‐way communication –

automatic notification of admission to hospital to family health team, pharmacist etc

geriatric outreach program






delivery model


model





- Increase referrals to CCAC and community support programs to help people manage at home

- Hospital admission to rehab, geriatric assessment unit, day hospital, OT, PT, SLP, physiatrist

- Similar to out patient visit

- Discharge planning - Need for expedited

follow up on frail seniors

- Linkage with outreach/outpt programs/day hospitals


- Support for “precarious discharge” patients (e.g. transitional care).

- Shared care model will offer a variety of clinical settings. High risk patients will be seen promptly. This will help reduce hospital and LTC admissions. This will also provide a discharge location as hospital teams will have more confidence that referrals will be picked up quickly for frail clients.

- Having multiple teams in various primary care settings is an enhancement of the current outreach program

- CCAC - Community support

services - Transitional care - Primary care






delivery model


model




Community‐based Acute

Care / Community‐based

Non‐Acute Care

Patient Passport

Transitional care coach

Reintroduce links between family health team and CCAC case management

Enhanced community rehabilitation services

Inpatient assessment to identify patients who

need rapid follow‐up assessment

- CCAC and community support services



Diagram of Ideal Service Delivery Model: Integrated Specialty Geriatric Services Within Primary Care



Template #4. Assess and Describe the PAG service delivery model using the HNHB LHIN Criteria PAG Name – Integration of specialty geriatric medicine services within primary care


Strategic Fit Alignment with LHIN

priorities for health

improvement in response

to the demographic

imperative

- Decrease readmissions to hospital and visits to Emergency Departments - Improve Aging in Place - Improve access to services - Aligned with Chronic Disease Management model (self efficacy, self care, education) - Health promotion and prevention – target specific interventions such as memory loss,

depression, falls risk, confusion re: polypharmacy


health care needs and

system transformation

- System of services, standard assessment forms and common care path approaches - Connecting individuals to services and improving collaboration amongst service providers - Will build on Best Practice - Use of shared care models - Access to other team resources

Health status (clinical

outcomes & QOL)

- Improved health and quality of life

Prevalence - targeting of frail older adults eg 25% of over 80’s

Population Health

Health promotion &

disease prevention

- Will target those at risk of falls, declining functional status, memory loss etc. Will build in strategies to help people learn more about their health so they take on more responsibility

-



PAG Name – Integration of specialty geriatric medicine services within primary care


Client‐focus - Yes, bringing service to the client at home. Link with “aging at home” services - Use of circle of care approach, drawing in extended family, church and significant others - Will reach those who are marginalized due to physical disability or lack of transportation - Will have improved access to staff who speak different languages and will promote cultural

sensitivity based on client population characteristics

Partnerships - Pts, families and informal supporters - Multiple partnerships; - Community organizations – e.g. formal (CCAC) and informal (Alzheimer Society) - Sectors (primary care, acute care, community care) - Professions (OT, PT, SLP)

System Values

Community Engagement - Will be responsive to diverse needs and in corporate approaches to care and education that is appropriate

- Will improve proximity to care as lack of transportation will not exclude people from expert care - Teams in rural areas may need to be made up of a different mix of disciplines compared to

urban/academic centres. Rural areas will collaborate with a smaller set of organizations. We will be sensitive to the needs and strengths nested in each “community” area

- Resources will be more efficient if a “shared care” approach is used. Tremendous capacity building

- Ongoing focus groups will be required with senior citizens to help develop age friendly health promotion and prevention strategies and a review of how each “communities” constellation of services are working together. Care issues will be addressed through this ongoing feedback loop from consumers. The Hamilton Council on Aging (HCOA) is very diverse and has agreed to help develop this form of engagement with consumers of health care. The HCOA will help us link with other seniors groups in other areas of the LHIN



PAG Name – Integration of specialty geriatric medicine services within primary care


Innovation - Enhancement of current service with outreach workers using a shared care model - This service will be responsive using different interventions such as telephone reminders,

assessing priority visits for those screened at high risk, assessing self efficacy skills etc -

Equity - Reach frail seniors who cannot travel to current service sites - Address travel/transit challenges (particularly in rural regions of the LHIN) -

Efficiency (operational) - Yes – shared care models - Screening by trained staff will allow specialists to see those at high risk while other patient

referrals may be managed by team members or referred to other community programs. This model will ensure those most at need will be seen by the specialist. This will also allow the specialist to see more patients at clinics when team members have already completed a battery of tests with a preliminary assessment in place

Access ‐ improved access through multiple clinic sites and home visits

Quality - Quality assurance component - Patient and family satisfaction

Sustainability

‐ This model can be implemented very quickly. All that is required is clinic space, access to appropriate

staff and basic infrastructure needs

System Performance

Integration

‐ This outreach model will promote more consistency of care with common approaches, common

assessment documentation and linkage with transitional care and primary care settings. Continuity of

care is known to improve overall patient care





Policy/legislation Policy will address access variation to

specialized geriatric services LHIN

wide

Agreements accountability, locus of

care

Criteria for intake

Model evaluation, definition of

outcome measures

Standardized assessment tools to

allow evaluation/audit LHIN wide

Developed –Hamilton Family Health

care mental health policy agreements

in alignment with current legislation

(Seniors health initiative in family

health team)

Large resource of evidence based

quality indicators (some tools

developed locally)

Adaptation to models of primary care

delivery across LHIN


etc.)

Distribution of specialized geriatric

team based expertise from hospital

(urban) to community (urban and

rural)

Recruitment / Training physician and

allied health.

Financial and human resources

Interprofessional communication

Inter‐organizational communication

Well established hospital based

multidisciplinary geriatric teams

Highly skilled providers

Expertise in collaboration

CCAC

FHTs

Hospitals

Experience community based geriatric

multidisciplinary medicine teams (role

definition, scope of practice,

communication, electronic medical

records, remuneration)



Co‐located team based care facilitates

communication

enhances continuity of care between

specialist, and community providers

(family doctors, allied

Community readiness

Ongoing communication will be

required with all stakeholders

patients, family, care givers, primary

care providers, specialized geriatric

medicine providers, community

resource organizations, community

partners (Hamilton Family Health

Team),

Recognition of need has been

identified, preliminary experience

Familiarity with shared care model

(mental health shared care model

HFHT)

History of collaboration between

stakeholdes; patients, primary care,

specialized geriatric providers,

community organizations and

partners)

Current initiatives:

Shared care model with specialized

geriatric medicine in primary care

(Collaboration between Hamilton

Family Health Team, Department of

Family Medicine, McMaster

University, AS, CCAC)

Patient health passport

Widely variable models of primary

care delivery across the LHIN

(variation in resources of space,

human, remuneration)

development of patient health

passport



Services

Survey and identify process for

linkages between services (eg.acute

care, LTC primary care, community

resources, transitional care, ‘at home'

program,

Clinical services with established

efficacy

Under utilization, duplication of

services, variable awareness of

resources and services

Coordination of services will require

communication, accountability.


Engage, communicate build on

current linkages among

stekeholders/partners (CCAC AS DVA

CNIB meals on wheels etc),

survey needs and identify strategies

to maximize resources and linkages to

avoid under utilization and

duplication of resources and services

Well established relationships

collaborative partnerships among

stakeholders (patients family, care

givers, primary care providers

specialized geriatric providers,

community partners)






Transitional Care




Complete Template #1. Describe the strengths and challenges within the existing health care system in addressing population health care needs for the

PAG’s patient/client population. Primers for discussion: ‘Summary of Community Values and Preferences’ (Appendix A), ‘Criteria for PAG Service Delivery

Models’ (Appendix B) and ‘Guiding Principles for PAG Service Delivery Models’ (Appendix C).

Template #1: Strengths and Challenges within the Current System in Addressing Population Needs PAG Name Transitional Care PAG Facilitator Dr. George Heckman

Strengths and Challenges

Introduction PAG – Geriatrics (frailty and chronic disease)

Almost 15% of Canadians are aged 65 years or over, and the greatest proportional population increase is occurring among octogenarians (StatsCan 01). The

rising numbers of older persons is expected to cause a significant strain on health care budgets, as the burden of chronic disease increases with age (Rapoport et

al, 2004). Chronic disease management (CDM) approaches have focused on improving outcomes for persons with major chronic illnesses such as diabetes

mellitus, heart failure or chronic obstructive pulmonary disease. However, such approaches perpetuate a system of care silos that focus on individual conditions

as if they occur in isolation, a model that is unsuitable to the growing number of seniors who suffer from multiple concurrent comorbidities. In Canada, over 40%

of persons aged 80 years and over report three or more chronic illnesses (Rapoport et al, 2004). In addition to these chronic illnesses, increasing numbers of

seniors are also afflicted by age‐associated disabilities and geriatric syndromes such as frailty, functional decline, disability, falls, incontinence, and

psychogeriatric disorders such as cognitive impairment, depression and anxiety. In the 2003 Canadian Community Health Survey of 28617 adults aged 65 years

and over, 4% of men and 4% of women aged 65 to 74 years required assistance in at least one basic activity of daily living (BADL), and 9% of men and 18% of

women required assistance in at least one instrumental activity of daily living (IADL) (Gilmour 05). Among men and women aged 85 years and over, these figures

rose to 20% and 23% for BADLs and 46% and 65% for IADLs, respectively.The economic impact of these geriatric syndromes is equivalent to that of major chronic

illnesses (Gilmour & Park, 2005; Cigolle et al, 2007; Levy & Muller, 2006; Rubenstein, 2006; Fillit & Hill, 2005; AHA 2002; Szczech & Lazar, 2004).



Introduction to Geriatrics – Frailty and chronic disease management model

Frailty can be understood as a state of increased vulnerability to adverse health outcomes due to age‐related decreases in physiologic reserve, and is most often,

but not exclusively, found in older persons (Bergman 2007). Frailty bears many similarities to major chronic diseases, as it is more common with age, and leads

to disability, increased health resource utilization, and mortality. Perhaps less widely appreciated is that frailty can be a direct consequence of poorly managed

chronic diseases such as heart failure, COPD, or diabetes. Moreover, just like these chronic diseases, frailty can be successfully managed. Numerous randomized

clinical trials demonstrate that comprehensive geriatric care can reduce mortality, improve function, cognition and quality of life, and prevent hospitalization

and institutionalization into long‐term care facilities, in a manner that can be cost‐effective. Yet, despite this evidence, the management of frailty in our current

health care system remains disjointed and inadequate.

In this submission, we propose an integrated system of clinical services to manage frailty at all levels of our health care system. These services will

complement existing inpatient consultation services and the regional Geriatric Assessment and Rehabilitation Unit at the Henderson General Hospital, by

enhancing the care of frail seniors in the community. The proposed clinical services are based upon the Chronic Disease Model, in which the majority of care

provided to seniors is at a primary care level, appropriately supported by multiple disciplines, including advanced practice nursing and other allied health

professions. In this model, specialty services, such as geriatric medicine or geriatric psychiatry, play two important roles:

1. Direct patient consultation: patients identified at the primary care level being at greatest risk of adverse events, such as institutionalization, due to

complex medical problems and / or geriatric or psychogeriatric syndromes, will undergo comprehensive geriatric assessments delivered by specialized

multidisciplinary teams that include a specialist in geriatric medicine or geriatric psychiatry.

2. Capacity building: For most patients to be cared for at the primary care level, specialists in geriatric medicine or psychiatry, as well as specialized allied

health professionals will be available to provide primary care providers educational opportunities designed to enhance their capacity to provide care to

seniors with mild to moderate frailty.



Introduction to Transitional Care

Over the last several decades, the average length of stay of older patients admitted to acute care hospitals with exacerbations of chronic diseases such as heart

failure or COPD has declined significantly. This trend has been associated with a parallel rise in the number of patients discharged with a particular diagnosis and

who are shortly thereafter rehospitalized with the same diagnosis. Risk factors for readmission include:

multiple functional deficits

polypharmacy, 2+ chronic health conditions

limited social support system

2+ hospitalizations in last 6 months

poor chronic disease knowledge (Naylor J Cardiovasc Nurs 00, Bowles JAGS 02, Wright Eur J Heart Fail 03; Riegel Nurs Res 07) These patients are essentially frail seniors.

In order to reduce the risk of readmissions, transitional care initiatives, based on the chronic disease management model, have been developed and evaluated.

Transitional care denotes a series of processes or actions to ensure / enhance continuity of care and collaboration between health care professionals, and thus

facilitate the safe and timely transfer of patients from one level of care (e.g., hospital) to another (e.g., primary care physician).

The core of transitional care is focused on enhancing the capacity of patients, often with the assistance of their primary informal caregivers (e.g. spouse, child),

for self‐care. The two primary components of self‐care include:

1. Self‐Maintenance: adherence to treatment and positive health practices 2. Self‐Management: active process that involves recognizing and responding to symptoms:

– recognize subtle changes in status; – evaluate their significance; – take appropriate action to avert further clinical deterioration; – evaluate effects of the action taken, and take further action is required.

Educating patients and caregivers on how to assertive and effectively navigate the health care system is a key desired outcome.

A number of randomized controlled trials have demonstrated the clinical benefits and cost effectiveness of this approach. A randomized controlled trial of 239

patients hospitalized with heart failure, aged on average 76 years and with 6 active comorbidities, evaluated an Advanced Practice Nurse (APN)‐led Self‐Care

intervention in which individualized plans of care addressing comorbidities and social issues were developed for each patient (Naylor MD J Am Geriatr Soc 04). In

addition to hospital visits, the APN visited the patient the day after discharge, and up to 7 more times during the 3 subsequent months. After a follow‐up of 1

year, the intervention results in substantially fewer heart failure deaths and rehospitalizations, as well as in fewer rehospitalizations for comorbid illnesses, at a



cost‐saving of $4845 per patient.

A second trial enrolled 750 pts aged on average 76 years, with various diagnoses including heart failure, stroke, coronary artery disease, arrhythmia, COPD,

diabetes mellitus, spinal stenosis, hip fracture, peripheral vascular disease, and venous thromboembolic disease (Coleman Arch Intern Med 06). The intervention

also focused on self‐care, including assistance with medications, development and maintenance of a patient‐centred and owned medical record (passport),

timely follow up with primary or specialty care, and development of a list of red flags to detect early illness decompensation and plans for response to avert a

readmission. An APN performed one home visit as well as 3 follow‐up phone calls during the subsequent 28 days. The intervention resulted in a reduction in

readmission for the index diagnosis at 6 months, and saved $500 per patient.

Finally, a randomized controlled trial enrolled 2370 pts, median age 80 and with various diagnoses including fractures, neurological disorder, cardiorespiratory

disease, and cognitive impairment (Cunliffe Age Ageing 2004; Miller Age Ageing 2005). The intervention was provided by a multidisciplinary team of allied health

professionals who provided patients and their caregivers with self‐care education, therapy and personal support following hospital discharge. The intervention

resulted in fewer total hospital days for up to one year, as well as improved performance of instrumental activities of daily living at one year, and reduced

caregiver burden during the first 3 months after hospital discharge. The intervention was associated with a savings of £1727 per patient.

Reflecting the strength of the evidence from these clinical trials, the Canadian Cardiovascular Society Heart Failure guidelines endorse the role of transitional

care programs in preventing hospital readmissions among frail older persons with heart failure (Arnold et al, Can J Cardiol 2008).

In response to this recommendation, a Transitional Care Team funded through the Aging at Home strategy, was established in Hamilton in the fall of 2008. This

team consists of Acute Care Nurse Practitioners, working in conjunction with the Hamilton Niagara Haldimand Brant Community Care Access Centre (Hamilton

branch), and targets frail older patients with heart failure or COPD and who are hospitalized at the General and McMaster sites of Hamilton Health Sciences.

Thus far, over 110 patients have been enrolled. The effect of the program on patient self‐care knowledge, functional ability, quality of life, and readmissions, as

well as on caregiver burden and quality of life, is being evaluated in a study approved by the McMaster University Research Ethics Board. Preliminary data

presented at the Annual Meeting of the Canadian Geriatrics Society in April 2009 demonstrate significant increases in patient self‐care knowledge, with no

significant decline in patient function, as well as no increase in caregiver burden. The readmission rate for both COPD and heart failure at 3 months was 18%,

which compares favourably to rates of readmission for heart failure alone reported in the literature (Phillips et al JAMA 2004).

Proposed Enhanced Program Model

This proposal builds upon the Transitional Care Model described above that has been funded through AAH. Once fully implemented, all older hospitalized

patients with mild to moderate frailty will be eligible for Transitional Care support upon discharge from hospital. Currently, patients with heart failure and COPD

are eligible. Eligible diagnoses will be expanded to include, among others, diabetes mellitus, pain, neurological disorders (e.g. Parkinson’s disease, stroke),



coronary artery disease, as well as the other diagnoses noted in the introduction above. Patients will be identified early during the course of hospitalization and

assessed and followed by a specially trained nurse. Upon discharge, patients will be seen within 48 hours, whereupon the self‐care education will begin. Patients

will be enrolled for at least 4 weeks, and for up to 3 months as required.

It is important to recognize that no more than half of clients served by the CCAC are referred from hospital, with the other half referred directly from primary

care or from other outpatient sources (personal communication from Dr. Jeff Poss, University of Waterloo). It is expected that a substantial proportion of these

patients will also suffer from multiple chronic diseases, and will thus also be able to benefit from the self‐care education delivered by the Transitional Care

Approach. As long‐stay CCAC clients are regularly assessed by CCAC case managers using the RAI‐HC suite of instruments, we will be able to utilize these

instruments to identify clients eligible for Transitional Care, this time with the additional aim of preventing an admission to hospital.

The RN Role

Currently in Hamilton, consistent with the literature, the RN role is provided by an Acute Care Nurse Practitioner trained in adult education as well as adult

medicine. Ultimately, the role of the ACNP will be to become a resource for the program and to train registered nurses to perform the self‐care role.

Input from Geriatric Specialists

The Transitional Care Model is essentially a primary care model for complex patients, consistent with the Chronic Disease Management approach. A certain

proportion of patients (approximately 20%) will be particularly complex and will benefit from the input of specialists in Geriatric Medicine or Geriatric Psychiatry.

Therefore, part of the initial and ongoing assessment of patients by the RN will include the use of standardized instruments to assess individual patients’ degree

of frailty and risk for subsequent adverse health outcomes. Patients at high risk will be seen in consultation by a Geriatric Medicine or Psychiatry specialist.

Please refer to the “athome outreach” and “primary care shared model” descriptions for a better understanding of how these programs relate to each other.

In addition to a direct consultative role, specialists in Geriatric Medicine and Psychiatry will assist primary care in developing the capacity to manage frail older

patients through ongoing clinical education activities, journal clubs, and workshops.

Data collection and evaluation

Data shall be collected in order to evaluate the effectiveness of the program. In addition to RAI‐HC data (as the program will run as an enhanced CCAC service),

we will utilize standardized instruments to collect data on patient self‐care knowledge, quality of life and caregiver burden. The RAI‐HC data may assist us in the

comparing the effectiveness of the program with historical control groups, as well as with other Ontario LHINs.





Same as template 2 in section above



8. Complete Template #3. Describe the key components of an ideal service delivery model for the PAG’s target population.

Template #3: Components of an Ideal Service Delivery Model PAG Name Transitional Care PAG Facilitator Dr. George Heckman


model


model




Prevention

Enhancing self management

Targeted towards secondary prevention e.g

hospital admissions for indexed and other

diagnosis, adverse reactions

Pharmacy support re: medication

management, linkages to

programs to help maintain

function – falls, memory, diabetic,

continence advisors. Take actions

early on to prevent further

deterioration in health. Increase

confidence and knowledge



PAG Facilitator Dr. George Heckman PAG Name Transitional Care



Primary Care

Identify population CHF COPD and refer

Screening to prevent from getting to the point to

be admitted to hospital

Some can be managed by primary health

Geriatrician build capacity in FHT/family physicians

–through consult and provide advice

Chronic disease management model

CCAC FHT attachments

Geriatrician

Linkages with Alzheimer’s Society

– First Link, Diabetic Management

Programs

Pharmacy home visit or med

review program

Pre‐hospital Care






Acute Hospital Care

Identify population requiring program – CHF, COPD

upon ED admission or inpatient and refer

Those with dementia and Diabetic Management

programs

Case finding – daily team rounds

Need electronic system to flag potential referrals

Frailty scales can assist in case finding

Need champions and key individuals to identify –

OT SW PT

Linkages with Alzheimer’s Society

– First Link

Diabetic Management Programs



NP assess in the hospital and in the community

CCAC. Contracting out as required to Physio to

help senior improve independence at home


review program

Community‐based

Acute Care







Care

CCAC and NP – teaching self management ,

monitoring of symptoms, strategies to circumvent

exacerbation

Clinic and in home where appropriate

NP could build capacity of other personnel e.g. RNs

Education to non regulated personnel in client’s

home

Case finding

Multidisciplinary

RN complete teaching, NP LHIN wide ‐ lead building

capacity

Support to primary care

Services developed in conjunction with

clients/families, their goals and self management

needs – Client centred not service centred

Flexible duration of service e.g. longer for those

with hidden cognitive impairment,

Supportive housing project or wellness centres

Community Home to Stay programs

CCAC attachments to supportive housing settings.

Primary Care

Geriatrician

Interdependencies with informal and formal

systems of support – consistency of approach

CHCs for Francophone, aboriginal population for

shared service delivery

Potential Enhancement – linkage

to LTC NPs to manage in the LTCH


review program

Heart Failure clinics/diabetes

programs

Academic linkages to maintain

evidence based practice

End of Life Care

Primary care, hospitals






System navigation

Follows national heart failure guidelines

Quality indicators – readmissions, ACOVE (quality

indicators for frail seniors)

Patients/families taught to self navigate the care

continuum, use of care passport



Diagram of Ideal Service Delivery

Hospital ‐ frail senior

with complex illness –

CHF, COPD,

DM, Atrial Fib,

dementia/cognitive

impairment with co

morbidities

CCAC

Transitional Care Program

(Readmission Prevention)

Self management to

patient and caregiver

Multidisciplinary – RN

does most education re

self management

Primary Care: FHT,

Family Dr

Specialist/specialty

clinic

Supportive

housing/community

settings

Lead NP to build capacity in other

personnel

To build capacity in community

Geriatrician consultation on high risk

patients

Capacity Building/Knowledge Transfer

Need good screening and champions

to identify – especially upfront until

part of the culture

Geriatrician consultation on high risk

patients

Electronic solutions/CAPS

Streamline referral process

Supported by Geriatrician to build

capacity

Electronic triggers to identify

Geriatrician consultation for highest risk

Capacity Building/Knowledge Transfer

Common identification Tool across



Template #4. Assess and Describe the PAG service delivery model using the HNHB LHIN Criteria PAG Name: Transitional Care




ALC alleviation

DM using CDM model as part of optimal management of co‐morbidities or primary index condition

Emergency Department Diversion

CCAC able to service rural communities

Could use e‐heath solutions



transformation

Primary care reform

Addresses growing senior, frail population

Integrated approach

LHIN wide access (not limited by catchment area)

Shorter Hospital LOS – shift to community

Continuity of care

Holistic

Self efficacy/self management approach

Capacity building

Strategic partnerships



PAG Name: Transitional Care



outcomes & QOL)

Reduced hospitalizations and shorter LOS

Reduce risk of adverse events

Increased self management skills

Prevalence Will reduce prevalence of hospital admissions and acute decompensation of chronic illness in frail seniors

Population Health


prevention

Addresses secondary prevention

Client‐focus Involves client in their own care

Flexibility – tailored – duration, teaching etc to meet client need

Consideration of linkages with CHCs re: populations – cultural and linguistic minorities

Flexibility – initially focused on CHF but can later consider including other populations

Partnerships educe duplication

CHCs, Other community partners such Alzheimers – First Link,

Hospitals, CCAC, primary care,

System Values

Community Engagement Want to engage with Hamilton Council of Aging and other groups to keep consumer/patient focused

Satisfaction surveys completed in pilot – feedback received





Innovation Evidence based

Could include telehealth technology in transitional model

Equity Can be LHIN wide – not reliant upon patient transportation

Can be facilitated by e‐health

Efficiency (operational) Reduced costs

Move to training nurses rather than using NPs

Access Can be LHIN wide – not reliant upon patient transportation

Portable across LHIN – common approach

Quality Best practice established by local evidence and national guidelines, as well as randomized controlled trials

Local evidence from pilot that clients’ experience very high satisfaction and improvement in self care knowledge

System Performance

Sustainability

Reduced costs so should pay for itself

Move to training nurses rather than using NPs

Capacity building in primary care

Builds on current infrastructure, Integration with existing delivery systems

Future training for health care professionals





Integration

By definition; supports continuity care across the system. Essential core nature of the intervention.





Policy/legislation Appropriate funding levels

Supported by national policy re:

Chronic Disease Management for

Heart Disease “Canadian Heart Health

Strategy Action Plan”


etc.)

Human Resource investment

Funding model for Geriatrician

Consultation e.g. clinic space and

supporting resources

Need family physician

Using rich RAI HC data to risk

stratifying

Care Connectors

Sharing of electronic care passport eg.

Memory sticks

Limited clinic space for Geriatrician

clinics

Long waiting lists for Geriatricians

No family physician

Community readiness

Community champions to promote

uptake of new service

Seniors Education to target the at risk

population

CCAC support already in place for

many of these individuals

Linkages with retirement homes and

supportive housing settings

Fear from some seniors – perception

that it may complicate their care

Support from family medicine



Services

Community Based Geriatrician

consults e.g. CCAC branches, other

Community Agencies.

Co location agreements

Supporting infrastructure already in

place re; hospital, primary care, CCAC,

geriatric consults


Hospitals need to invest in what

happens in the community after

patient discharge.

CCAC has established linkages with

FHTs and Hospitals

Hospitals need to invest in what

happens in the community after

patient discharge






Video Conferencing Geriatrics




Complete Template #1. Describe the strengths and challenges within the existing health care system in addressing population health care needs for the

PAG’s patient/client population. Primers for discussion: ‘Summary of Community Values and Preferences’ (Appendix A), ‘Criteria for PAG Service Delivery

Models’ (Appendix B) and ‘Guiding Principles for PAG Service Delivery Models’ (Appendix C).

Template #1: Strengths and Challenges within the Current System in Addressing Population Needs PAG Name Geriatrics ‐

Video conferencing

PAG Facilitator

Dr. D. Cowan

Strengths Challenges

Can be used across multiple sites and for a variety of purposes;

educational and clinical.

Increased access to specialized geriatric services

Cuts out need for transportation in some instances. Links well with

screening and assessment by outreach teams to assess risk. People who

cannot travel may be able to access a video conferencing site and with a

nurse get access to a geriatrician via video link





Same as template 2 from the previous section



Complete Template #3. Describe the key components of an ideal service delivery model for the PAG’s target population.

Template #3: Components of an Ideal Service Delivery Model PAG Name

Videoconferencing Geriatric Consultation and Out‐reach Service PAG facilitator: Dr. D. Cowan


model


model




Prevention

Health promotion and disease prevention is an

integral part of comprehensive geriatric

consultation. We focus upon the person as a whole

routinely assessing and screening or many

preventable diseases/problems such as cognitive

impairment, depression,

polypharmacy/inappropriate prescribing,

osteoporosis, falls and fragility fractures,

deconditioning, and malnutrition, amongst others.

These disease prevention interventions can now be

provided to clients in outlying areas who would not

receive such services. There is also an important

“learning by seeing” function whereby general

practitioners/allied healthcare workers adopt these

practices and apply them to others in their practice.

Videoconferencing can also serve as an important

direct educational tool for rural health care teams

which can take of case conferences surrounding

their individual patients, or educational sessions

with health care teams.

The major partner in this initiative

is the Ontario Telemedicine

Network whose mandate is to

provide equitable and timely access

to health care services, and medical

education, to those in outlying

areas using videoconferencing

technology. Underutilized

videoconferencing technology is

already available to all hospitals in

Ontario, as well as Family Health

Teams. The Ontario telemedicine

network has a goal to increase

direct patient services using

videoconferencing by 30% annually

and is committed to partnering

with geriatricians in LHIN’s 4.

Our service will be closely aligned

with other community partners

such as the Alzheimer's Society and

the Community Care Access

Centers. This will provide local



PAG Name



model


model



support to the frail elderly as well

as a means to follow up with

specific recommendations and care

plans for each patient.

Other linkages would include Meals

on Wheels, Lifeline, DVA, There is

excellent evidence suggesting that

community education and support

prevents/delays

institutionalization.



PAG Name



model


model



Primary Care

This is likely the most important aspect of

telemedicine consultations services. While we are a

consultation model, it is also blended with primary

care in so far as a consultation process directly

involves the primary care team as they will be with

the patient during the clinical encounter. This

serves the referring team will benefit from direct

communication with the geriatrician, moreover,

the patient can receive specialized services within

their primary care setting which is a much more

patient centered approach (i.e. preventing travel

over long distances and allowing them to the

setting and a setting which is more familiar and

comfortable.) . This model also provides a more

equitable distribution of services to rural

communities, as well as increasing efficiencies in so

far as physicians do not have to travel long

distances to see patients. Wasted travel time can

be directed toward seeing multiple patients in

multiple communities on the same day.

As above.



PAG Name



model


model



Pre‐hospital Care

Comprehensive geriatric consultation has been

shown to reduce hospitalizations. These benefits

could now be extended to clients in rural areas who

otherwise would not receive such services..

Linkages will be made with services

that can help to prevent

hospitalization such as respite care

(benefiting overburdened

caregivers), day programs, CCAC

(providing nurse monitoring, OT,P)

and the Alzheimer's Society.

Acute Hospital Care

Although it would be difficult to see patients

directly in acute care hospitals, each hospital in

Ontario is equipped with telemedicine services.

Thus, geriatricians could act as an invaluable

resource by case conferencing specific clients with

the health care team in an effort to assist with the

management of complex problems to help assure

discharge into the community where ever possible.

Education



PAG Name



model


model




A backlog of ALC patients is one of the greatest

challenges facing acute care hospitals. As in the

case with Acute care Hospital, individual clients

could be case conferenced to ensure care is

optimized thereby increasing the probability

patients can be discharged to the community. For

patients who cannot reliably be discharged, this

often neglected group with multiple co‐morbidities

will receive care that otherwise would not have.


Early follow‐up following discharge has been shown

to reduce hospitalizations in the elderly. It would

not be practical to have these patients assessed by

geriatricians were not in the immediate geographic

area. Telemedicine services would provide a means

for geriatric input following hospitalization in a

timely manner to hopefully maintain patients in the

community and prevent re‐admission.

Community‐based Acute Care


Care



Diagram of Ideal Service Delivery Model:

+++++ Please refer to overall Specialized Geriatric Services Model diagram



Template #4. Assess and Describe the PAG service delivery model using the HNHB LHIN Criteria PAG Name: Videoconferencing PAG facilitator – Dr. D. Cowan




Geriatric consultation and outreach service via video teleconferencing supports many LHIN priorities including

focusing on geriatric services, mental health and e‐health. Successful geriatric interventions can reduce

hospitalizations, reduce lengths of stay (for example HELP programmes),



transformation

This intervention helps to address the impending crisis in health care involving the aging population. It is also an

innovative model utilizing videoconferencing technology to provide these services in an efficient and equitable

manner to patients and healthcare providers alike.


outcomes & QOL)

A videoconferencing model of geriatric consultation will provide a proven means of intervention to elderly

populations who would not otherwise enjoy the benefits of these services. Outcomes that geriatric consultation

have been shown to achieve include reduced hospitalizations, delay to institutionalization with compression of

morbidity, prevention of outcomes such as falls, and reduced caregiver burden.

Prevalence Prevent measures employed in geriatric consultation have been shown to prevent many negative outcomes

including falls, fractures, frailty and institutionalization, thus reducing the prevalence of these conditions in the

community. Videoconferencing also provides an effective and efficient means of spreading best practices to primary

care physicians and allied healthcare professionals.

Population Health


prevention

As above

System Values Client‐focus Videoconferencing consultation services are extremely client focused in so far as they allow the individual to be

seen closer to their home in a more familiar setting. Client satisfaction data collected by the Ontario Telemedicine

Network indicates that individuals would rather receive teleconference services as opposed to traveling longer

distances to meet with a specialist if they are given the choice.



PAG Name: Videoconferencing PAG facilitator – Dr. D. Cowan


Partnerships The application videoconferencing Geriatric Consultation takes advantage of a multimillion dollar infrastructure that

is already in place via OTN. Thus there would be little additional cost to take advantage of this valuable resource.

Moreover, OTN is a dedicated partner searching to promote clinical opportunities with an intention of delivering an

additional 30% per year of direct patient services. Geriatricians already have close partnerships with existing

services such as the Alzheimer Society.

Community Engagement Seek local sites to host technology

Innovation This is an innovative approach in so far as videoconferencing consultation is in its infancy and underutilized in this

geographic area. There is only one other person in Ontario providing geriatric consultation by this means. There is

tremendous potential for growth.

Equity The shortage of geriatricians in Ontario is a problem that is not going to be solved quickly. (There are only 45

geriatricians in all of Ontario compared to much larger specialty groups such as cardiology. In fact, demographic

data suggests that the number of geriatricians may even decline given that new graduates are fewer than those

nearing retirement. It is self evident that videoconferencing will greatly improve equity of access to the scarce

resource, particulate particularly for patients in rural and urban under serviced areas.

Efficiency (operational) This PAG model is extremely efficient insofar as it utilizes existing resources that are being some optimally employed

such as the OTN network and other community service providers such as the Alzheimer's Society, CCAC etc

Access Not only will this provide timely access and a more efficient use of geriatrician time by eliminating the need for

travel, this will provide access to geriatric services for clients who would have had none at all.

Quality

System Performance

Sustainability

This is a highly sustainable intervention. The MOHLTC and OTN both have a substantial commitment to providing

videoconferencing consultation services. The infrastructure is in place already. The model is simple, and could be

implemented within a matter of two or three months at any given site. We are presently piloting the feasibility at

one community site already.



PAG Name: Videoconferencing PAG facilitator – Dr. D. Cowan


Integration

Videoconferencing technology can be used to deliver geriatric services both in terms of education and patient care

in primary care settings, acute care hospitals. The infrastructure is now available in all hospitals in Ontario and 70

Family Health Teams with the goal being to grow further In the primary care setting.






Policy/legislation Funding for geriatricians Funding for geriatricians


etc.)

Equipment

Community readiness

Host sites

Services


Host sites

Documents

Clinical Services Plan for Geriatric Medicine - HNHB LHIN · June 30th, 2009. Dear Sir/madam Re: Clinical Services Plan for Geriatric Medicine Please find enclosed the proposals from