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Planning for future

Coordination of outpatient, inpatient and geriatric care in

the community of New Tecumseth

Dr. Izabella Kogan, MD Ph.D CCFPAlliston Family Health Team

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Sky is the limit

SMH

Town of New Tecumseth

AFHT- Ambulatory care/Medical ArtBuilding

Nautical Land Group

KInsgmere village/Geriatric Center

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Central LHIN is the most populated out of 14Ontario LHINs : 1,7 million

Central LHIN will experience greater-than-averagepopulation aging over the next 10 years, with the65+ age category projected to grow from 204,139

to 285,555.Thats an additional 81,416 seniors,

Central LHIN Statistics:

LHINs are the only organizations in Ontario that bring

together health care partners from the following sectors

hospitals, community care, community support services,community mental health, long-term care to developcollaborative solutions leading to more timely access to high-quality services for the residents of Ontario

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Central LHIN resources:

7,292 LTC beds - 1400 beds are deficient

102 Rehab beds - ? Are deficient1380 GPs

1000 Specialists

8 Geriatricians about 1 per 35 000seniors

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Aging at home

Each LHIN is required to allocate a minimum of 20 percent of the funding throughout the three years to deliverinnovative approaches, and new preventive and wellnessservice approaches within Aging at home

Measures:Reduction of ALS in the hospitalReduce avoidable emergency department visitsSupport reduction in provincial ER wait time targets

Delayed or diverted application for long-term care homeadmission

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Central LHIN , AGE at Home

Transitional Beds (Convalescent, Rehab ,Respite)For Nautical Land consideration

Assisted leaving beds (Kingsmere RH) Supportive Housing (Kingsmere Village) Adult day Programs (Geriatric Centre) Weekend admissions (Kingsmere RH) At home Palliative care (CCAC, Geriatric Centre)

Geriatric assessment clinic (Geriatric Centre) Geriatric outreach teams (Geriatric Centre) Enhanced homecare programs

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ADP objectives:

Will enable seniors to maintain their health andlevel of functioning and avoid unnecessary ERvisits and hospital

Services provided should support caregivers ofcommunity-living seniors by providing caregiverrespite and support.

Proposals should reflect an integratedmultidisciplinary support to clients (e.g. formallinkages to primary care and other serviceproviders).

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Kingsmere medical Center

Location: Industrial rd, Size: 30 000 SFFirst floor:

Urgent care clinic, will provide same day appointments for patientswho are not FHT clients or unable to get to AFHT

X ray

Specialty clinics:Geriatric assessment clinic + memory clinic,Urology/urogynecologyDermatology - ? Dr. Katz

Psychiatry - ? Dr.DanielsPain/RheumatologyNurse Practitioner clinic (wound, skin integrity, pessary)

Mobility clinic/ physiotherapy Pharmacy Home care store

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Kingsmere medical Center

Second floor: Audiology, Chiropody Optometry Dentist/ dental hygienist/ denturist

Medical cosmetic/anti-aging CCAC treatment room Board room/ patient education/ office for CDM brunch

Chronic disease management brunch ( COPD, DM, OA) in collaborationwith SLRH , Sandra Mierdel , manager

Geriatric outreach program brunch in collaboration with SLRH , Dr.Bida( RN, PT, OT, SLP do home visits after GP referrals re

dementia, malnutrition, depression, incontinence, mobility, falls, pain,polypharmacy)

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Adult Day Program

(respite for caregivers + restoration of function for seniors) Health Promotion (medications check, BP/BS check, dental checks, foot care) Nutritious Snacks and Meals Personal Care Physical Activity Cognitively stimulating games/activities Musical Entertainment

Community Outings

Currently there is one ADP in New TecumsethLocation: Simcoe MannorCapacity: 10-18 patients a day

ADP staff Registered Nurse (RN)

Physiotherapist (PT) Occupational Therapist (OT) Social Worker (SW) Recreation Therapist Rehabilitation Assistant Secretary

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Alliston Family Health Team

Young and growing, established 2006

Reliable (MDs cover for each other in case ofvacation/ absence

All MDs work in the hospital can helpcoordinate the care

Wide spectrum of services (regular assessment +cardiac work up+ lung function monitoring)

Internet based patient chart AFHT is the most attractive for new graduates

Group in the area

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Current home of AFHT- best example of restoration work in Southern Ontario

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Boyne River Edge Treatment &

Parking Re-organization Plan

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Alliston Medical Art Building

Location: 106 Victoria st west , UCC zoning

Existing building: 8000 SF

- Home care store

- Medical fitness

- AFHT admin offices + board room

- space for 4 physicians upstairs

Proximity to the Hospital (attract hospital services,

Convenience for physicians and patients)

Municipal parking lot

Will help to revive downtown

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Alliston Medical Art Building

Able to build 6200 SF x 4 (22 m height restriction)

Ground floor: Lab, DI, Physiomed, Vital air

First floor: pharmacy ,Echo, spirometry,

stress test, FHT services (SW, RD, RT,breastfeeding, pharmacist)

Second floor: FHT MDs+ NPs offices

Third floor: specialists/ ambulatory careGen Surgery, pediatrics, ENT, GI,cardiologist , dentistry , mental health

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AFHT/Kingsmere village/GeriatricCenter/ Hospital collaboration

Primary care access for senior residentsChronic disease management: COPD, DM, Cognitive

impairment

Interdisciplinary approach: GPs, NPs, RN, RD, SW,Pharmacist, RT24/7 Telephone Health AdvisoryContinuity of care: same group of doctors working ER/Hospital/ AFHT/Geriatric Center- same EMR sharedReduced number of unnecessary hospital visits due toDisease prevention, medications vigilance, early access tocare provider

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ER wait time reduction/ ALC projectanother LHIN priority

Because moving people through theemergency department depends, in part,on the ability to either admit patients to

acute care beds, or to discharge patientsto appropriate destinations, reducing waittimes cannot be solved by focusing on the

emergency department alone.

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A patient who cannot be

discharged home but no longerrequires hospital care is

designated ALC

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ALC floor

Alliston Medical Art will accommodate/ provideturn key operation for the specialists currentlyoccupying 2 nd floor of SMH:

SMH will be able to create an ALC floor

(RPN, PSW, PT assistant)Acute beds will have higher turnover therefore

helping to reach Ministry targets:- Reduce ER wait

- Reduce ALS- Improve financial health (pay for results strategy,

acute care finding> ALC bed )

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Geriatric Center and Kinsgmerevillage / Hospital collaboration

Urgent care

Outreach programs

Specialists care

Respite/ADP

Transitional beds

Objectives and measurements:

= reducing demand in unnecessary Hospital use

(Failure to thrive, caregiver burnout, respite)

= Reduce ALS by Accepting ALC patients for supportivehousing/transitional beds

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Coordination of outpatient, inpatient and geriatriccare in the community of New Tecumseth

AFHT Geriatric Center

Hospital

Senior

Reducing Demand (CDM) Increasing Supply (Age at home)

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New Tecumseth CommunityGeriatric Care Network

ER GEM

CCAC

Inpatient D/C planner

AFHT Geriatric Center

Geriatric Outreach

LTC

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Happy2012

Thankyou !