Innovations in Community Based Care of the Elderly

1. Innovations in Community Based Care of the Elderly Family Medicine Forum 2010 Kerstin Mossman, MD, CCFP Andrea L Moser, MD, MSc, CCFP Focus practices in care of the elderly

2. Disclosures • None for Dr.Moser • None for Dr. Mossman

3. The Oldest-Old Boomsource: Stats Can 2002 Seniors Health Teams, June 2010

4. Projected Prevalence of Dementia 850 750 650 550 450 350 250 150 0 300,000 Today - Over 750,000 Projected in 1 Generation 750 500 000’s 300 2031 2000 2011 Canadian Study of Health & Aging Working Group. CMAJ 1994; 150:899-913 Seniors Health Teams, June 2010

5. Seniors and acute care • 15-20% of Emerg Dept visits are by seniors • More life threatening or urgent medical condition • More than 1 issue and functional impairment • Higher rates of confusion • Increased use of diagnostic tests and resources • Increased adverse outcomes, death • More ambulance transportation (30%) • More repeat ED visits • Higher admission rate • 40% of acute care admissions Seniors Health Teams, June 2010

6. Health care challenges facing seniors Seniors Health Teams, June 2010 • Dementia • Increasing by 37% over next 10 years in NSM • Impact on individual and caregiver • Delirium – (acute confusion) • Death if undetected, falls, hospitalization, LTC • Falls • Serious injury, hospitalization, death • Fear of falling • Medication management issues – 10-17% of hospital admission • Chronic medical conditions • Arthritis, diabetes, hypertension, COPD, etc….

7. Geriatric Services Aging is complex and poorly understood, it: • Is NOT a disease in itself • Is NOT invariably deterioration, in health or function • Items leading to deterioration in health and function are complex, and modifiable • Affects the manifestation of disease • Interventions can help • modify risk factors • improve function • increase quality of life Campion E. NEJM 2002 Seniors Health Teams, June 2010

9. Goal of Geriatric Services • Increased independence and quality of life for seniors and their caregivers. • Improved patient outcomes: • Reduce functional decline associated with hospitalization • Increased likelihood of discharges home / reduced institutionalization. • Reduced mortality • Increased clinical efficiencies in acute care • Reduced lengths of stay and readmission rates • Decreased ALC days • Enhanced capacity of physicians and other care providers to assess and treat health problems of the elderly. Seniors Health Teams, June 2010

10. A Model for Specialized Geriatric Services MUSKOKA Seniors’ Health Team NORTH EAST (Orillia and Area) NORTH WEST (Midland/Penetanguishene and Area) CENTRALIZED SERVICES Seniors’ Health Team Seniors’ Health Team CENTRAL CORE Advocacy & Political Action Research & Ethics Central Inpatient & Specialty Support Services Central Intake & Triage Leadership & Resources Education, Mentorship & Knowledge Transfer CENTRAL WEST (Collingwood/ Wasaga Beach and Area) CENTRAL EAST (Barrie and Area) Seniors’ Health Team Seniors’ Health Team

11. Huntsville • Northern tip of LHIN 12 • Population 19,000 year round – 20% seniors • Increases by 50% + seasonally + tourists • Population growth highest for seniors • Health care resources • 24 family physicians, 4 internists, 3 surgeons. • Local hospital - 40 inpatient beds, no rehab or GAU • 24 hour emergency dept • 160 LTC beds • 150 retirement home beds and growing • Limited access to formal specialized geriatric services

12. Geriatric Care Team • 0.5 FTE Care of the Elderly physician • Alternate funding program, MOHLTC/OMA • Geriatric Outreach Team • Family health team funding • 1.4 FTE RN • 0.4 FTE Clinical Pharmacist • Integrated Intensive Case Management • Aging at Home – CCAC, hospital, Family health team • 1.5 FTE RN • Shared office for specialized teams

13. Geriatric Care Team - referral Physician referral – community, hospital, LTC Single point of access – joint referral with community mental health Criteria for referral Age >65 (or with an age related illness). Having one or more of the following: Recent onset of functional, physical, and /or cognitive decline Increased use of health care services. Major change in support needs e.g. caregiver stress, change in living arrangements. Presence of geriatric syndrome – i.e. Polypharmacy, falls, delirium, etc. 13

14. Cognitive impairment Delirium, dementia, MCI Mood and behaviours Functional decline IADL/ADL impairment Falls (osteoporosis) Pain Nutrition Chronic disease mgt Medication mgt Polypharm, compliance Safety Home safety, driving Caregiver issues Advanced Care Plan Community Resources Areas of Focus

15. Geriatric outreach team • Triage for urgency – same day if required • In home assessments – home, LTC, RH • Hospital consults – inpatient, ED • Interdisciplinary report • Comprehensive geriatric nursing assessment • Pharmacy review • Focused Care of the Elderly consultation • Interdisciplinary case conference • Monthly and as required • Problem lists with targeted outcomes

16. GCT outreach team cont’d • In-home consultation by interdisciplinary team (also hospital, ED, LTC) • Nursing, physician, pharmacist • Clarify diagnosis, identify problems that can be improved, refer to community supports • Education of client and caregivers • Follow with family physician until service no longer needed

17. GCT – Integrated Intensive Case Management • Community case management for at risk seniors • Case managers with ‘geriatric eyes’ • Caseload 40-50 • Education of client and caregiver • More frequent reassessment in home • Case conference once monthly all clients • Home visits once monthly with care of the elderly physician.

18. Outcomes • Increased ability to care for frail seniors • Support to primary care • Increased use of existing community resources • Decrease in unneeded visits to Emergency Department • Decreased admission to Alternate Level of Care beds • Transition to retirement home, LTC if needed Seniors Health Teams, June 2010

19. Projected Growth of Planning Areas in NSM LHIN 400,000 Barrie and Area are driving the growth of the NSM LHIN 350,000 Barrie and Area 300,000 250,000 Barrie Population 200,000 150,000 100,000 Collingwood Muskoka Midland 50,000 Orillia 0 2001 2006 2011 2016 2021 2026 2031 Time Period Source: Population Estimates Table : IntelliHealth Tool (PHPDB) MOHLTC 2010: MOF Population Estimates

20. North Innisfil Health Services

21. North Innisfil Senior Service summary • Comprehensive Geriatric Primary Health Care including care for housebound, frail seniors, palliative care and follow up for patients admitted to local nursing homes. • MD also provides consultation re senior patients to MD colleagues at Barrie office as needed. • Expansion of service to include Aging at Home funding in 2009. • About 400 senior patients at present for regular case load • 100 new patients through Aging at Home initiative, focusing on housebound, frail seniors

22. History of North Innisfil Health Services • 2000 – BCHC took over care from 2 PT GP’s • Approached by NIHS Advisory Community Group • 270 patients , Age 60-80 • RN(EC), 20 Hours onsite care per week • GP, 8 hours per week onsite • No On-call support or House calls • No hospital follow up • No access to inter-disciplinary team • Little or no co-ordination/integration of care/linkages to community • Reactive bio-medical model of care

23. North Innisfil Health Services • March, 2002 – closed due to inadequate funding • Community advocacy and BCHC advocacy • Funding restored, fall 2002 by MOHLTC • FT RN(EC), PT MD-2 half days per week • Beginning involvement of interdisciplinary team, mostly MD/RN(EC) acute bio-medical care • August, 2005 – FT MD with focused practice in care of the elderly • 2006, increased case load to 435 • Added 24 hr. on call support, hospital follow up, home visits, and palliative care • Continuity of care to patients entering long term care facilities

24. Staffing resources • FTE MD, Care of the Elderly trained, salary funded through BCHC • FTE RN(EC), funded through BCHC • FTE RN(EC), funded through Aging at Home • FTE administrative support, funded through BCHC • 0.2 FTE administrative support, funded through Aging at Home • Team utilizes BCHC additional resources at main office in Barrie, this includes: physiotherapy, RD, SW, Diabetes team, chronic disease management courses including an arthritis pool program, COPD/Asthma program, smoking cessation, Stanford Chronic Disease Self Management Program, Good Food Box, etc. • Team has access to an outreach Diabetes team (comes to NI office q3mos) and also provides Chronic Disease Self Management Program in local community • Team also has access to CCAC designated case coordinator who will assist with management of patients or addressing service needs as required

25. Linkage with community partners • SMART exercise program • First Link • CCAC • Simcoe Hospice • Mental Health Services through Penetanguishene • Others as per patient needs

26. Educational initiatives • No formal program until 2010, now part of geriatric rotation for FM residency program at University of Toronto, Barrie site • FM residents from McMaster through ROMP program • RN EC students from many locations

27. Indicators • BCHC required indicators are as per LHIN Accountability Agreement (MSAA) including patient encounters per provider, preventative care, etc. Balanced Scorecard Indicators as per 2009-12 Strategic Priorities/Strategy Map information can be provided if requested. • Aging at Home indicators are as per LHIN and include ER admissions, LTC admissions, Crisis LTC admissions and % of patients maintained in community. Currently the team is meeting the defined targets every quarter. • Additional indicators include yearly patient satisfaction surveys, chart audits including administrative chart audits and peer reviewed chart audits as required for Accreditation.

28. Aging at Home • A commitment to maintain the dignity, independence and respect of our seniors in Ontario • An investment of $1.1 Billion over 4 years across Ontario for the purpose of allowing seniors to stay in their homes as long as possible • Recognizes the importance of local planning and senior-driven responses • Places great emphasis on innovation and prevention

29. $13M $7.4M

30. Indicators for Aging at Home case load – LHIN specific