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Enhancing Senior Care: GAIN Geriatric Clinic Services

Learn about the Geriatric Assessment & Intervention Network and its goal to improve outcomes for frail seniors, reducing hospital stays and emergency visits. Discover the collaborative effort focusing on senior care in the community.

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Enhancing Senior Care: GAIN Geriatric Clinic Services

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  1. RGP GEM 7th NetworkSenior Friendly Emergency Departments Emerging Services in Interface Geriatrics September 21, 2011 1500 – 1600 Holiday Inn Markham

  2. GAIN Geriatric ClinicsGeriatric Assessment & Intervention Network Better Care for Frail Seniors Michelle Acorn, Lead Nurse Practitioner – GAIN Clinic - Oshawa

  3. What is GAIN? Geriatric Assessment & Intervention Network Vision • Better Care for Frail Seniors • Broad system of services designed to ensure better outcomes for frail seniors. • The Geriatric Clinic is one component. Goal • To increased the ability for GAIN seniors to remain in the community and to support reduced hospital stays, emergency department visits and hospital admissions.

  4. GAIN Geriatric Clinics • Aging At Home • Year 3 funding of $4.8 million • 4 urgent/emergent Geriatric Clinics in CE LHIN’s 4 largest community hospitals: • Lakeridge Health Oshawa • Peterborough Regional Health Centre • Scarborough Hospital, General Campus • Rouge Valley Health System, Centenary Campus

  5. Model Development • 2 year collaborative effort with community partners, CELHIN hospitals, RGP of Toronto • Original proposed model of care was a regional model, building community capacity to care for the frail elderly, to decrease reliance on ED

  6. Model Development • Subsequent to LHIN Peer Exchange forums in May and June 2010, the model was reworked to more directly target reductions in ALC and ED visits. • Clear alignment with the LHIN’s Strategic Aim “to save one million hours of time patients spend in CE LHIN Emergency Department by 2013”

  7. Expected Outcomes • Reduce unnecessary hospital admissions through the Emergency Department • Expected reduction in over 11 000 ALC days • 2000 client visits per hospital site

  8. Who Will Support the Geriatric Clinic? • A specialized interprofessional geriatric team including: • 2 Nurse Practitioners • Physiotherapist • Occupational Therapist • Social Worker • Pharmacist • 2 CCAC Health Career Case Managers • Access to a supporting Physician with geriatric training/Geriatrician for consultations • Dedicated Clerical support • Collaboration with GEM nurse. 10

  9. Dynamic Interprofessional Team around the needs of a particular patient NP OT Core Skills Core Skills PT Social Worker Senior Core Skills Core Skills CCAC Case Manager Geriatric Specialist/ Physician Social Work Pharmacist Core Skills Core Skills Core Skills

  10. Geriatric Emergency Management (GEM) & GAIN Geriatric Clinic Your Geriatric Services Michelle Acorn & Jaclyn McLeod GAIN NP Lead & GEM CNS November, 2010

  11. GAIN and GEM • GEM role is integral within GAIN team • Liaises with GAIN team to determine appropriate referral • May bring senior directly to GAIN for assessment • Or may send senior home with GAIN appointment • GAIN team allows for urgent referrals from the ER • The GEM referral allows for assessment by the GAIN team either in the ER or in the clinic

  12. How to Refer in The ED… If your patient meets any of the criteria and/or you have geriatric concerns: • Order entry GEM/GAIN (1 referral) and • Page the GEM/GAIN pager During coverage hours the patient will be assessed by: • GEM CNS or • Member of the GAIN Geriatric Clinic team

  13. Who Will be Seen in the Geriatric Clinic? • Seniors that are generally aged 75+ present as frail and require rapid assessment • Exhibit at least one of: • Multiple complex medical, functional, mental health and psychosocial problems • Recent functional or cognitive decline • At risk for falls or have frequent falls • Live at home or in retirement residence • Long term care residents are excluded 16

  14. Comprehensive Geriatric Assessment • Multidimensional assessment: • Physical health • Functional ability (ADL/IADL) • Cognitive and mental health • Socio-environmental situation • Establish a baseline • Identify change in condition/function • Follow up

  15. PATH (Palliative and Therapeutic Harmonization) • The GAIN clinics will incorporate the PATH ideology by: • Streamlining the assessment in order to allow for more clients to have access to our services • Resetting the focus of care on the client, taking into consideration their whole picture of health • Better communication and education with the client and their caregivers to allow for informed decision making about health care interventions and planning for the future

  16. Benefits for Primary Care Providers Comprehensive Geriatric Assessment for frail elderly by an interprofessional team with geriatric expertise, including: • Linking to community supports with senior friendly services • Ongoing care with a CCAC Health Career Case Manager • Direct access to the ACE Unit • Timely feedback through Senior Care Plan Summary/Dictations for ongoing management

  17. 1st Quarter (April 1 -June 30, 2011) Referral Summary

  18. 1st Quarter (April 1-June 30/11)

  19. Referrals Accepted • From ER for urgent/urgent assessment within 24-48 hrs. • From inpatient services when the senior is being discharged home. • Family Physician or Nurse Practitioner

  20. Referral Form Found on: • Hospital Websites

  21. Patient Testimonials • I am truly so impressed with the GAIN program. All my family want to personally thank the entire team for being there for my Mom. She told us how GREAT and kind all the people she met that day. She is now more relaxed and focused for she knows that others wanted to help her out. The program is so organized and efficient and I have been telling others both inside and outside the corporation what a wonderful program it is. • Thanks very much for the treatment he received from all. What wonderful people you are! This is the greatest treatment we have received. We are so happy & confident!

  22. Community Compliments: • … you were key in her sister’s acceptance of getting Meals on Wheels and has asked me to contact you in hopes that at her follow up appointment, you would be able to speak with her about the caregiver relief program. Thanks! Community Care Durham

  23. Controlled Acts - NPs After Proclamation of Bill 179 • Applying a prescribed form of energy (e.g., cardioversion) • Setting / casting a bone fracture or joint dislocation • Prescribing, dispensing, selling, and compounding a drug broadly Transforming Health Care through Nurse Practitioner Innovations

  24. HPRAC and Bill 179 • Professional accountability, self-regulation and safety • Improve access to care • Enable NPs and other regulated professionals (PT, Pharmacists) to: • Reduce wait times, • Navigate complex health systems (community, hospital, LTC) • Improve system efficiencies and effectiveness Transforming Health Care through Nurse Practitioner Innovations

  25. Regulation 965 • Authority to treat and discharge in-patients: July 1, 2011. • Admitting to hospital planned for July 2012. Transforming Health Care through Nurse Practitioner Innovations

  26. GAIN Teams Coming Together!

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