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Regional Geriatric Program of Eastern Ontario 2015 n cdn slides...System Integration “Toolkit’...
Transcript of Regional Geriatric Program of Eastern Ontario 2015 n cdn slides...System Integration “Toolkit’...
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Regional Geriatric Program of Eastern Ontario
2015 ANNUAL GENERAL MEETING
Promoting Collaboration:
Optimizing the Health Outcomes of Seniors in Champlain
Champlain Falls Prevention Strategy – Christine Bidmead
Champlain Integrated Model of Dementia Care – Natasha Poushinsky
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Introduction
The progression of Falls Prevention and the
Dementia Strategy in Champlain
• Where we have come from
• Where we are
• Where we need to go
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CDN: Where We’ve Come From…
2 • Literature review:
Integrated Dementia Programs Caregiver Surveys
• Key Informant Interviews: Select Chronic Care Programs
Review of Models of Care 3
• Review of regional needs surveys
• National / Provincial Database reviews
• Champlain CCAC dataset
Environmental Scan
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• Project Advisory Committee
• Models of the Dementia Experience
• Proposed “scope” of integration
• Engagement of Primary Care
• January 2013
Project Definition & Scoping
4 Analysis
• Developed ‘Profile’
• Review of Organisational Best Practices
• Best Practices adaptation from System Integration “Toolkit’
5 Integrated Model of Dementia Care
• Advisory Committee
• Strategic Framework
• Proposed activities
• Focus Groups
• On-Line Survey
6 Final Report
• March 31, 2013
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Preliminary Profile of Persons with Dementia
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Preliminary Profile of Persons with Dementia: Champlain 2012
3,100 New
People With Dementia
Caregivers
1/3 PWD Admissions ALC ALOS 39.95 (ICES)
34% of ALL ALC Days (CIHI)
34%
18,400 PWD: 30% Increase 2020
13,588 in Community (ICES)
4th Highest of 14 LHINs
New
1.3K
New First Link
(AS)
35-60%
Experience a
Decline In Health
(ASO Evidence Brief)
175K
Primary
Care Visits
(ICES 13.6)
55K
Day Pgm.
Days
1,688 PWD
6.2K
Visit ED
(ICES 45.9%)
3.2K
Admitted
ALOS 18.64
(ICES 23.7%)
1.1K
Newly
Placed
(ICES 7.9%)
3,739 LTC
5.2K
Visited By
Home Care
(ICES 38.5%)
3.3K
Retirement
Homes
+3,100
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The Hospitalized Person with Dementia
• Not all chronic conditions equivalent, with respect to impact on patient outcomes and health care utilisation (Heckman p.3)
• Dementia / delirium resulted in 6x more ALC hospitalisations than diabetes, hypertension and asthma combined (Heckman p.3)
Estimated average cost of inpatient hospital services (CIHI Cost Estimator for Ontario 2008-09)
Condition Avg $ / Utilization
Dementia $19,302
Heart Failure $6,633
Fractured Femur $6,219
COPD $6,561
Asthma $2,470
Essential HT $3,419
Type 2 Diabetes $5,306
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Dementia as a “Keystone” Diagnosis
Clustering of four chronic conditions - not random
• HF – increased risk of dementia, dementia increased risk of HF
• COPD associated with increased risk of dementia, dementia associated with reduced compliance with meds of COPD
• Dementia associated with increased risk of falls
Pts with dementia + account for 88% of dementia ALC days (CIHI)
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Dementia Caregivers (Ottawa Needs Assessment)
Problems Accessing Services
Survey
• Communication Problems with different service providers
• Complex system
• Difficult communicating with Agency
• Waiting Time to get help, to return calls, and waiting lists too long
• Amount of respite insufficient and little follow up
Focus Groups
• Persons with Dementia refuse service
• Cost of services
• Need to move to get services in French
System not designed to respond to needs of PWD and their caregivers!
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Strategy Outcome
Public Awareness Improved awareness & community support
Detection & Diagnosis Earlier detection & diagnosis of Persons with Dementia
Self-Management & Caregiver Support
Promotion of activities & attitudes to ‘live well’ with dementia.
System Navigation Persons with Dementia & caregivers know what to expect and where to find it
Coordinated Pathways of Support
Prevent & manage the complications of dementia, by providing choices that matter
System Integration Enable a system of support that is tailored & targeted to their changing needs
Integrated Model of Dementia Care
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System Integration
Caregiver Support
• Primary Care Memory Clinics* • Memory Disorder Clinic
Public Awareness
Pathways of Support
System Integration • Regional Steering Committee* • Coordinated Funding Envelope
• Role in governance & planning* • First Link* / Caregiver Support Line
Early Detection & Diagnosis
• Regional Coordination of Dementia Education* • Year 2 of Rethink Dementia Public Education Campaign
• LHIN Liaison • Link with Diabetes Clinics
* New Investments by Champlain LHIN
2013 / 14: $320 K
2014 / 15: $426 K
Where we are today…
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Care Coordinator Coach
- "Go to" person for designated care coordinators
Supports 25 designated care coordinators each (total of 50)
Designated Care Coordinator
"Go to" person for client
Identified by the client
Each care coordinator supports 1 client
Clients (50)
- Recruitment to reflect varied groupings
e.g. Live in / Live out / No caregiver; Different levels of ADL / IADL assistance needed; Language; Culture Urban/rural; Behaviour issues; Stage of disease; Income
Pilot Project: Coordinated Access & Caregiver Support
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Describing the Coordinated Access Model • Care Coordinator Coach (2 FTEs new resource to the system for 1 year):
• Assists in client enrollment and designation of care coordination from circle of care (including caregiver as potential DCC) – or when DCC needs to change
• Mentors, assists, provides information to designated care coordinators to support functions of care coordination, shift scope and practice approach
• Short-term intensive care coordination and support if client’s needs change
• Designated Care Coordinator (existing staff in the system – could be CCAC, First Link, GPCSO, primary care provider, PSW, caregiver, friend etc.):
• “Go-to” person for the client
• Relationship with the client
• Develops the service plan / care coordination plan with the client and caregiver (or ensures that one is in place)
• Ensures the right services are involved / engaged in service planning and delivery – services reflect the Dementia Journey mapping and beyond
• Not the provider of all things, but the navigator to the needed supports
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Education and Training
• Brought together key leaders in dementia and dementia-related education and training to identify:
• Current programs and processes
• Challenges and opportunities
• Update previous education and training inventory
• Identify next steps in improving regional coordination
• Emerging model:
• Creation of a leadership table to support regional planning and monitoring of education and training
• Look beyond the “usual suspects” – opportunities to build collaboration with other key sectors e.g. diabetes, palliative care, falls prevention
• Ensure planning support in place to support leadership table
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Public Awareness Campaign • Launched February 2015: rethinkdementia.ca
• Focus on service providers and the general public
• Incorporated development of key messaging and targeted social media strategy (Twitter, Facebook)
• Links audience to microsite containing information about:
• Brain health
• Risk reduction strategies
• Where to go for help
• Opportunities to integrate work from coordinated access and caregiver support
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Early Detection & Diagnosis • Centre for Family Medicine FHT Memory Clinic Model (Dr. Linda
Lee): implementation of PCM Clinic model in 15 primary care practices over 3 years (LHIN funded): to date, 8 have been implemented
• Primary Care Geriatric Clinic Assessment Model: integrates geriatric assessor with 5 primary care practices to date to support assessment, diagnosis and management of patients at risk for, or living with, cognitive impairment
• Memory Care Program: Builds on past education activities focused on building capacity in primary care related to dementia including CDNs Physician Education Lunch and Learns offered at many family practices (Dr. Bill Dalziel)
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Integrated Pathways of Support
• Partner initiative between diabetes services and CDN to:
• Outline dementia risk assessment process for people with diabetes
• Streamline referral to specialized services for full assessment
• Enhance level of education and knowledge of services providers of the interconnectedness of diabetes and dementia
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Where we’re going…
• Expanding meaningful engagement of persons living with dementia and caregivers in system design and evaluation
• Implementation and evaluation of Coordinated Access model
• Big picture thinking on what navigation looks like: online, by phone, in person (within dementia sector but more broadly)
• Broadening integrated pathways of support to other chronic diseases
• Development of a systems-level ‘report card’ for dementia
• Enhancing online presence of dementia services (for providers and families)
• Implementation of Regional Education/Training Leadership initiative
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