Update – GAIN Education Day October 2013/media/sites/ce/uploadedfiles/... · 2014-07-23 ·...

CENTRAL EAST REGIONAL SPECIALIZED GERIATRIC SERVICES

RSGS

Update – GAIN Education Day October 2013

Kelly Kay, Executive Director (Interim), RSGS

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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 collaboration and multidisciplinary teams in its delivery, and increasing customization of care to respond to patient and client needs.

◦ Are further differentiated from Specialized Geriatric Services based on greater inter-organizational collaboration and use of standardized best practices

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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.

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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RSGS

CE 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 CE LHIN.

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RSGS

In 2013, the RSGS Governance Authority commissioned Preya

Solutions Group (PSG) to: ◦ Assess the current and future specialized geriatric service needs of the

CE LHIN population ◦ Assess the capacity of specialized geriatric services in the CE 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 is being released today.

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RSGS

There are an estimated 96,573 seniors in the CE-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

Rural seniors are 9% less likely to be admitted to long-term care than

non-rural seniors. Low income seniors are 9% more likely than non-low income seniors to

be admitted to long term care. Seniors with Potentially Avoidable Hospitalizations account for 56% of

total hospital costs in the high use cohort or $158 million. Seniors that consumed a substantial and disproportionate amount of

hospital resources in 2011/12 were most often hospitalized in the previous two years; ◦ These seniors had many encounters with the acute system that could have

potentially triggered supportive services.

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


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) ◦ System funding ◦ Performance monitoring ◦ Advocacy, communication and education around the needs of frail

seniors ◦ Promotion of the enhancement of 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 Brian Payne Dr. David Ryan

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Deborah Hammons / James Meloche

Lydia Rybenko Heather Power Diane King Dr. Rob Drury


RSGS

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

RSGS Strategic

Directions

GA Retreat 2012

CE LHIN IHSP

PSG Service Needs & Capacity Analysis

Ontario Senior’s Strategy (MOHLTC

& OSS) Consumer & Family

Consultation

Stakeholder Consultation

KPMG Jurisdictional Review

CE 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

1.Improved access to care

•Patients will receive their first contact from SGS services within 2 days of referral •Patients will be able to receive comprehensive geriatric assessment within 14 days of referral regardless of location

2.Improved care experience

•Patients, families and seniors advocacy groups will inform SGS design activities •The frailest seniors who need/desire intensive case management services will receive them •RSGS system design efforts will incorporate principles of experience based co-design •RSGS will understand “comprehensiveness ” and the care experience from a seniors’ perspective

3.Increased comprehensiveness of care

•Seniors and families will receive geriatric physical and mental health services through a single referral mechanism •System-wide, more seniors who need it will receive a comprehensive geriatric assessment

4. 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:

Fostering Excellence

1.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

2.Improved system monitoring

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

3.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


RSGS

Strategic Priority:

Goal: Description:

Increasing Awareness

1.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

2.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

3.Increased enrollment in home-based care

•Frail, high risk seniors will participate 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: Improving Care:

GAIN Design

Fostering Excellence:

Senior Friendly Initiatives Defining core metrics

Increasing Awareness:

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


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]





Update – GAIN Education Day October 2013/media/sites/ce/uploadedfiles/... · 2014-07-23 ·...

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