Canadian Coalition for Seniors’ Mental Health

The Southwestern Ontario Geriatric Assessment Network

Catherine GloverDr. Lisa VanBussel

September 24-25, 2007

Declaration

We are unaware of any apparentconflict(s) of interest that may have

a direct bearing on the subject matter

of this presentation.

SWOGAN

Network of specialized teams of clinicians located in the ten counties of Southwestern Ontario that provide specialized services to the frail seniors and their caregivers.

 

SWOGANFigure 1: Map of Southwestern Ontario

Table 1: Population 65 years of Age and Older in Southwestern Ontario

AreaPopulation 65+,

2001% 65+, 2001

% 65+, 2006

% 65+, 2010

% 65+, 2016

Bruce 11,100 17.4 18.0 20.0 24.4Chatham-Kent 16,210 15.1 15.3 16.0 18.4Elgin 11,195 13.7 13.8 14.7 14.4Essex 47,980 12.8 12.5 12.9 14.4Grey 16,035 18.0 18.4 20.0 23.3Huron 10,365 17.4 17.7 18.5 21.3Lambton 20,085 15.8 16.3 17.8 21.2Middlesex 52,570 13.0 13.2 14.1 16.2Oxford 14,910 15.0 15.0 15.8 18.0Perth 10,745 14.6 14.3 14.5 15.8

Note: 2001 information from 2001 Census data, Statistics Canada; 2006, 2010 and 2016 population projections from the Ministry of Finance

Vision

To lead and sustain a network of care in the Southwestern Ontario region that builds local capacity to care for older adults with multiple, complex needs.

Programs and Service Delivery

• Consultation• Education• Research• Evaluation

Implementation• Integration of programs and services:

local and specialized; Geriatric Mental Health and Geriatric Medicine

• Leadership• Infrastructure creation• Partnership • Implementation of education initiatives • Network-wide evaluation framework.

Service Delivery Model• Vision of the Network• Why a “Service Delivery Model”• Current function• Future opportunities• Breakthrough success

Reference: Making It Happen MOHLTC 1999

Partnership

LocalFamily Doctor with

Expertise in EldercareAlzheimer Society

Local Geriatric NurseHome Care

CommunityFamily Doctor

Long Term CareLocal Hospital

Specialized

Geriatric Psychiatry Geriatric Medicine

Collaborative Care

Service Delivery Model

• Development and implementation of network-wide service delivery model.

• This model is expected to support timely and consistent access to expertise in Geriatric and Psychogeriatric care throughout the Southwest.

Service Delivery Model

SWOGAN Evaluation FrameworkDevelopment of a Network Balanced

ScorecardConsensus approach

Framework Quadrant themes Indicator selection Data collection procedures

Feedback Local team meetings Leadership forum discussions

Education

• Build Capacity• Links with Academic Community

and Resources• Links with LHIN’s• Links with provincial and national

bodies

Innovation and LearningIndicators

• Number of educational opportunities delivered and received.

• SWOGAN Spring Team Exchange.• Research and Evaluation Inventory.

Challenges• Categories.

Process• Submitted annually.

Utilization and QualityIndicators

• # referrals, # consultations, # initial assessments, # follow-ups, wait times

Challenges• Definitions• Setting targets

Process• Collected throughout year• Data quality checks• Submitted quarterly• Summaries available within 1 month

Client SatisfactionIndicators

• Tool development.

Challenges• Some pre-existing tools / expectations.• Additional work.• Satisfaction of other stakeholders also

important.

Process• Clients seen in 1st & 3rd quarter sent

questionnaire in 2nd or 4th quarter.

Infrastructure

• Network Strategic Plan• Communication Mechanisms• Structures and processes for

clinical collaboration.• Provincial linkages

Staff: IndicatorsPercent of Time Allocated to Each Activity: SWOGAN

0

10

20

30

40

50

2002-03 20.0 30.0 5.0 10.0 9.0 5.0 20.0

2003-04 19.1 31.5 7.1 17.9 9.3 7.1 7.9

2004-05 22.5 28.4 8.4 12.8 8.6 3.5 15.8

2005-06 19.2 30.0 7.2 14.6 10.1 4.6 13.8

Direct Patient CareIndirect Patient

CareTravel Time

Educ Delivered & Received

Team Developmnt/ Admin

Linkages and Marketing

Vacation/Sick Time

Data CollectionChallenges

Staff burden.• Complexity of data entry.

Process• Four 1-week snapshots.• Face-to-face meetings with local teams

about data collection processes.• Ongoing support.

2002-2006 New and Follow up Assessments

1501

12441146

1673

1119

14861572

0

200

400

600

800

1000

1200

1400

1600

1800

New Assessment Follow up Assessment

# o

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ts s

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n

2002-2003

2003-2004

2004-2005

2005-2006

ne

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Strategic Planning

• SWOGAN continues to grow and the commitment of Network partners to develop an evidence-based model of care is further reflection of its commitment to evidence-based practice, evaluation, and the full engagement of Network partners in planning.

Getting back to Vision• Increase in quality of care provided to

frail seniors in a large geographic area• Locally available with access to

specialized services when necessary• Influence on Public policy• Influence on Education of Health

providers• Collaborative care within communities

combined influencing methods of care delivery across the Region

Getting There

• Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed it’s the only thing that ever has”

Margaret Mead

Breakthrough Success

• Work of the task team• Discussion and Consensus process

today• Delivering on the strategic goals• Abstracts and publications• Service to clients: Blueprint• Local access –Regional access

Contacts

• Bonnie Kotnik, Director, Geriatric Psychiatry Program

• Maureen Vickers, Director, Specialized Geriatric Services

• Dr. Lisa Van Bussel, MD Physician Leader, Regional Psychogeriatric Program