Strategic Plan 2013- 2015 - CentralEastLHIN/media/sites/ce/... · System planning (Strategic Plan...

CENTRAL EAST REGIONAL SPECIALIZED GERIATRIC SERVICES

RSGS

Strategic Plan 2013- 2015

Toward the best health experience for frail seniors in the Central East LHIN

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RSGS

◦ A comprehensive, coordinated system of specialized health and mental health services for frail seniors

◦ Differentiated from seniors’ services based on higher frailty of the population served, greater specialization and use of interprofessional teams in its delivery, and increasing customization of care to respond to patient and client needs.

◦ Focus on greater inter-organizational collaboration and use of evidence-informed, standardized approaches

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RSGS

Mobility level

Cognition and memory

Level of independence

Physical Health

Financial and/or housing status

Social supports

Increasing number of medications

Physical and social isolation

Age and the use of health services

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RSGS

1. Ensure that seniors can access a seamless system of care organized around their needs and improving their quality of life.

What does that look like to older people and their families?

“I see now that people can live with dementia and still have quality of life, I know that I can do things that help my mom feel

more comfortable even when things are stressful for her” (Family caregiver of an SGS program)

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RSGS

2. Build on significant investments made within the CE LHIN for programs such as: Geriatric Emergency Management (GEM) Nurses

Nurse Practitioners Supporting Teams Averting Transfers (NPSTAT)

Geriatric Assessment and Intervention Network (GAIN)

Senior Friendly Hospital initiatives

Behavioural Supports Ontario (BSO)

Introduction of “Home First”

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“A patient and his wife attended our clinic – he suffered a stroke 6 years ago and is aphasic. [He] suffers from moderate dementia and superimposed depression. His wife was very distressed re: behavioural issues and was feeling that she couldn’t care for him at home anymore – she was beside herself over this, as she didn’t want to place him in LTC. After the assessment, we changed some meds, were able to put in some supports at home. Within a month, he improved drastically and has been able to remain at home with a good quality of life” (Interprofessional Team Member of an SGS program)


RSGS

The Central East LHIN is focused on helping its residents spend more time in their homes and communities, ensuring patients receive access to the right care, in the right place at the right time.

Currently there is an unmet need for long-term care and an expected increase in demand generated by a growing and aging population within the Central East LHIN.

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RSGS

In 2013, the RSGS Governance Authority commissioned Preyra

Solutions Group to:

◦ Assess the current and future specialized geriatric service needs of the Central East LHIN population

◦ Assess the capacity of specialized geriatric services in the Central East LHIN

◦ Examine the gaps between needs and capacity for different sectors that provide specialized geriatric services

◦ Suggest services, subpopulations, and activities that should be prioritized for system reconfigurations

◦ Identify system reconfigurations and resource redistributions to achieve an integrated system of specialized geriatric services.

The final report was completed in October 2013 and is posted on the Central East LHIN website

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RSGS

There are an estimated 96,573 seniors in the Central East LHIN who may be considered frail.

This population is estimated to grow by 27% over the next ten years, with almost 50% growth in Durham, twice the growth rate in North East and four times as much in Scarborough

9% of frail seniors reside in LTC or CCC; the remainder live in the community

Roughly half (52%) of frail seniors in the community segment had no in-year contact with either hospitals or home care.

Therefore, physician offices and other community and outreach services are currently the only potential Specialized Geriatric Services (SGS) contacts for approximately half of the frail seniors in the LHIN.

Focusing only on LTC, hospital and home care could leave many seniors without the benefit of SGS and thus at risk for decline.

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RSGS

To access a full copy of the RSGS’s Need for Specialized Geriatric Services in the Central East LHIN report please visit

http://www.centraleastlhin.on.ca/Page.aspx?id=20426

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RSGS

Accountable for the governance functions of RSGS related to development, delivery and monitoring of an integrated regional system of Specialized Geriatric Services for frail seniors.

These functions include: ◦ System planning (Strategic Plan and Priorities) ◦ Service coordination ◦ Performance monitoring ◦ Advocacy, communication and education around the needs of frail

seniors ◦ Capacity building for specialized services to meet seniors’ unique

health challenges

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RSGS

Glenna Raymond, Chair

Catherine Danbrook, Vice Chair

Ken Tremblay

Randy Filinski

Don Ford

Dr. Jenny Ingram

Helen Leung

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Deborah Hammons / James Meloche

Lydia Rybenko

Heather Power

Dr. Rob Drury

Brian Payne

Dr. David Ryan


RSGS

Our strategic plan reflects many influences and is aligned with other system plans, directions and reports

RSGS

Strategic

Directions

Governance

Authority

Retreat

2012 Central

East LHIN

IHSP

PSG Service

Needs &

Capacity

Analysis

Ontario

Senior’s

Strategy

(MOHLTC

& OSS) Consumer &

Family

Consultation

Stakeholder

Consultation

KPMG

Jurisdiction

al Review

Central

East LHIN

Option

Report

(2011)


RSGS

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Vision:

Best health experience for frail seniors in the Central East LHIN

Mission: Working as a Regional System to create a high quality,

integrated, person-centred system of care that supports the best quality of life for frail seniors and their families.

Improving Care Fostering Excellence Increasing

Awareness of Age Related Needs

Strategic Directions


RSGS

Improving Care

Patients and families have

access to specialized

geriatric services with

smooth transitions, tailored

to individual needs, and

found on partnerships with

providers

1. Improved access to care

2. Increased comprehensiveness of care

3. Improved Caregiver Services

4. Improved care experience

Fostering Excellence

Health care providers will

have knowledge and tools

to deliver high quality care

and effectively and

continually monitor and

improve their

performance.

1. Increased adoption of

leading practices

2. Improved system

monitoring

3. Improved System

Performance

Increasing Awareness

There is increased

awareness of the needs of

frail seniors and the

creation of regional

programs to address those

needs.

1. Increased presence of

professionals with a

specialization in geriatrics

2. Increased provider

participation in screening and

assessments

3. Increased enrollment in home-

based care and communication

programs for our “target

population

Strategic Priority

Strategic Direction

Strategic Goals


RSGS

Strategic Priority:

Goal: Description:

Improving

Care

Improved access to and comprehensiveness of care

• Seniors will receive their first contact from SGS services within 2 days (or less) of referral

• There will be capacity in the SGS system to accommodate urgent referrals

• System-wide, more seniors who need it will receive a comprehensive geriatric assessment within 14 days of referral regardless of location

• Seniors and families will be able to access and receive geriatric physical and mental health services through a single mechanism

• The frailest seniors who need/desire intensive case management services will receive them

Improved care experience

• Seniors, families and seniors advocacy groups will inform SGS design activities

• RSGS system design efforts will incorporate principles of experience based co-design

• RSGS will understand “comprehensiveness ” and the care experience from a patient perspective

Improved caregiver supports

• Caregivers will get the support they need to manage the daily care needs of their frail family member at home

• Fewer seniors will require crisis placement to LTC due to caregiver stress


RSGS

Strategic Priority:

Goal: Description:


Increased adoption of leading practices

• CE-LHIN HSP’s will include senior friendly measures and indicators, such as indicators related to delirium and functional decline, in QIPs

• RSGS will support infrastructure development for clinical excellence in gerontology to facilitate growth in capacity in the field

Improved system monitoring

• RSGS will have the information needed to inform timely SGS planning region-wide

Improved system performance

• All designated SGS programs will operate within budget

• All designated SGS programs will achieve/exceed operational outcomes/targets

• HR vacancy rates will be low among SGS providers

• Opportunities for strategic recruitment will be explored


RSGS

Strategic Priority:

Goal: Description:


Increased presence of professionals with a specialization in geriatrics

• Health professionals with geriatric/gerontology experience will choose to work in the CE-LHIN

• New linkages with experts in geriatrics/gerontology external to the CE-LHIN will be forged

• There will increased opportunities for education in geriatrics available in the CE-LHIN

• There will be regional coordination of professional development activities in SGS

• There will be a cohesive communication plan to support the engagement of patients and providers and increase awareness of specialized geriatrics LHIN-wide

Increased provider participation in screening and assessments

• Health providers caring for the frail elderly in the CE-LHIN will adopt a common approach to comprehensive geriatric assessments

Increased enrollment in home/community based care

• Frail, high risk seniors who wish to will participate optimally in home-based care programs

• There will be community support services available for enrolled frail seniors

• There will technological options to support home-based care


RSGS

Strategic Priority:

Key Initiatives: Current Status

Improving Care

GAIN Design

• Design process underway, leveraging BSO and Health Links experience


Senior Friendly Initiatives Defining core metrics

• SF Working Group • Regional SF Action Plan


Communication and Engagement Plan Educational Needs Assessment & Curriculum Inputs Leveraging technology in the care of frail seniors

• Co-designing engagement strategy

• Regional orientation program & curriculum development

• Technology Evaluation in the Elderly Network project


RSGS

““We have a high percentage of seniors [in our practices] and we need all the help we can get. Thank you – Keep up the good work”

(Central East LHIN Primary Care Providers)

“I just wish this kind of care was more openly available. In other words it should be part of every senior's care.

Everything is covered and I didn't once hear the words "you are getting old and these things happen".

Thank you.” (Patient of an SGS service)


RSGS

Share your thoughts Join a working group Read the “Network News” Watch for a new and improved RSGS webpage Send us a message

Kelly - [email protected] Rhonda – [email protected] Stacey – [email protected] Cheryl – [email protected] Jennifer – [email protected]

mailto:[email protected]





Strategic Plan 2013- 2015 - CentralEastLHIN/media/sites/ce/... · System planning (Strategic Plan...

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