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
4
Projected Prevalence of Dementia
300,000 Today - Over 750,000 Projected in 1
Generation
750
500
000s
300
2000
2031
2011
Canadian Study of Health Aging Working Group.
CMAJ 1994 150899-913
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

6
Health care challenges facing seniors

• 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.

Seniors Health Teams, June 2010
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
8
(No Transcript)
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.

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 gt65 (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
Areas of Focus

• 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

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 contd

• 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

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 GPs
• 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