RGP GEM 7th NetworkSenior Friendly Emergency DepartmentsEmerging Services in Interface Geriatrics

September 21, 2011 1500 – 1600

Holiday Inn Markham

1

GAIN Geriatric ClinicsGeriatric Assessment & Intervention Network

Better Care for Frail Seniors

Michelle Acorn, Lead Nurse Practitioner – GAIN Clinic - Oshawa

2

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.

3

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

4

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

GAIN: Inter-organizational Committee Structure

Steering Committee

Project Implementation Team

(Core Team)

PRHC

Working Group

LHO

Working Group

RVHS

Working Group

TSH

Working Group

“Sign-Off” Members

“Time to time”

Members

9

10

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.

Dynamic Interprofessional Team around the needs of a particular patient

Core Skills Core Skills

Core Skills

Social Work

NP

Pharmacist

OT

Core Skills

CCAC Case Manager

Social Worker

Core Skills

Core Skills

Geriatric Specialist/ Physician

Core Skills

SeniorSenior

PT

11

Michelle Acorn & Jaclyn McLeod GAIN NP Lead & GEM CNS

November, 2010

Geriatric Emergency Management (GEM)

& GAIN Geriatric Clinic

Your Geriatric Services

13

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

14

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

16 16

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

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

17

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

18

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 19

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

20

Site Emergency Department Referrals

Community Referrals Post Hospitalization Referrals

Total Referrals

  April May June Year to Date

April May June Year to Date

April May June Year to Date

April May June Year to Date

PRHC

1 16 17 34 4 8 19 31 3 8 5 16 8 32 41 81

TSH

37 46 43 126 12 28 30 70 36 24 25 85 85 98 98 281

RVHS39 14 19 72 14 11 4 29 0 1 0 1 53 26 23 102

LH20 35 25 80 33 29 48 110 10 12 11 33 63 76 84 223

TOTALS 97 111 104 312 63 76 101 240 49 45 41 135 209 232 246 687

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

21

Site

Number of GAIN seniors seen by Geriatrician

Post Assessment: # seniors admitted to ACE Unit

April May June Year to

DateApril May June

Year to Date

Peterborough Regional Health

Centre1 2 7 10 0 0 0 0

The Scarborough

Hospital4 25 20 49 0 0 0 0

Rouge Valley Health System

12 17 19 48 1 0 1 2

Lakeridge Health 0 0 0 0 0 1 2 3

TOTALS 17 44 46 107 1 1 3 5

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

22

Referral Form

Found on: Hospital

Websites

23

May 9, 2011 GAIN Geriatric Clinic Referral Form

Referral Source: ED Referral Community referral Post Hospitalization Triage: Emergent 24-48 hours Urgent < 72 hours Non urgent < 1 – 2 weeks

Applicant Information: Patient Name: ______________________________________ Address: ________________________________________ ___________________________________________ City: _______________________ Postal Code: _________________ Phone: (Res.): __________________________________ (Other): ____________________________________________ Date of Birth: ___________________________________ Health Card Number: ___________________________________ Day Month Year

Whom does patient live with?___________________________________________________________________________

Pharmacy: _______________________________________________________________ Phone #: _______________________________________ Fax #: ___________________________________________ Contact Person Information: Contact Person/SDM/Other: ___________________________________ Relationship to patient: ____________________ Phone: (Res.) ______________________________________ (Other): _________________________________________

Is contact person also Power of Attorney? □Yes □No Call and speak with patient directly? □ Yes □ No

Alert - Do not call: __________________________________________________________________________(name) Primary Healthcare Provider (MD/NP) Name: ____________________________________________________________ Address: ______________________________________________________ City: ________________________________ Postal Code: __________________ Phone: __________________________ Fax: ________________________________

Health Information: (To enable us to assess urgency with which patients need to be seen, please fill out as completely as possible)

Reason for referral: _________________________________________________________________________________

□ Multiple complex health problems □ Psychosocial problems □ Functional Decline □ Cognitive Decline

□ At risk for falls □ Difficulty coping □ Safety Concerns □ Other

□ Have experienced falls □ Medication assessment

*Attach Supporting Documents: Currently linked/referred to these services in the Community:

Patient Profile 1. Medication List 2. Consultations 3. Recent/Relevant Lab/Diagnostic Reports

(critical to assessment)

_____________________________________ _________________________________________ Primary Healthcare Provider Name: (please print) Signature _____________________________________ _________________________________________ Date Billing #

GAIN Geriatric Clinic REFERRAL form □ Lakeridge Health Oshawa 1 Hospital Court Oshawa, ON L1G 2B9 Phone: 905-576-8711 x 4832 Toll Free: 1-866-338-1778 Fax: 905-743-5311

□ The Scarborough Hospital General Campus 3050 Lawrence Ave. E. Scarborough, ON M1P 2V5 Phone: 416-431-8200 x 6355 Fax: 416-289-2961

□ Rouge Valley Health Centre 2867 Ellesmere Road Toronto, ON M1E 4B9 Phone: 416-284-3118 Fax: 416-281-7384

□ Peterborough Regional Health Centre Medical Outpatient, 1 Hospital Drive Peterborough, ON K9J 7C6 Phone: 705-876-5021 Fax: 705-876-5058

1. 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.

2. 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!

24

Patient Testimonials

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

25

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

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

Transforming Health Care through Nurse Practitioner Innovations

Regulation 965 Authority to treat and discharge in-patients:

July 1, 2011.

Admitting to hospital planned for July 2012.

GAIN Teams Coming Together!

29