NE LHIN Rehabilitation (Rehab) and Complex Continuing Care (CCC) Systems Review

Transcription

1 NE LHIN Rehabilitation (Rehab) and Complex Continuing Care (CCC) Systems Review June 1, 2012

2 June 1, 2012 Ms. Louise Paquette Chief Executive Officer North East Local Health Integration Network Dear Louise, I am pleased to submit the Report of the Rehabilitation (Rehab) and Complex Continuing Care (CCC) Systems Review to the North East Local Health Integration Network (NE LHIN), conducted between November 2011 and January This report will be followed by two additional, shorter reports, flowing from the first phase of the work. These consist of: An evaluation of the congruence with Best Practices for hip and knee replacements, hip fracture and stroke in the community; and A mapping of current programs for specific organizations for hip and knee replacements, hip fracture and stroke within the Rehabilitation and Complex Continuing Care Expert Panel framework/matrix. The work was supported by a Core Stakeholder Group created by the NE LHIN for the purpose of this project and was chaired by Terry Tilleczek, Senior Director, Emergency Department (ED)/Alternative Level of Care (ALC). The mandate of the Core Stakeholder Group was to review and advise on each step of the process in terms of content, methodology and timelines, including the final report. In addition, Erika Espinoza provided support throughout the process and with Rebecca Ducharme in the preparation of the reports. Stakeholders within the NE LHIN, including all the hospitals and the North East Community Care Access Centre, as well as other staff within the NE LHIN, were most helpful in providing the necessary data and information. The collaboration of the NE LHIN staff and stakeholders was a key factor in the completion of this project. It has been a privilege to engage in this work. Sincerely, Rika Vander Laan, RN, MScN Rehabilitation and Complex Continuing Care Officer 2

3 E X E C U T I V E SU M M A R Y 7 B A C K G R O UND 15 REHABILITATION AND COMPLEX CONTINUING CARE EXPERT PANEL 15 CARING FOR OUR AGING POPULATION AND ADDRESSING ALTERNATE LEVELS OF CARE 18 ENHANCING THE CONTINUUM OF CARE: REPORT OF THE AVOIDABLE HOSPITALIZATION ADVISORY PANEL 19 CCAC EXPANDED ROLE 20 M E T H O D O L O G Y 22 F INDIN GS 22 THE NE LHIN 22 CHARACTERISTICS 22 REHABILITATION AND COMPLEX CONTINUING CARE SYSTEM 23 DESIGNATED INPATIENT REHABILITATION BEDS 26 ALTERNATIVE LEVEL OF CARE (ALC) 28 TYPES OF PATIENTS SERVED 28 ADMISSION FUNCTIONAL INDEPENDENCE MEASURE (FIM) SCORES 30 OUTPATIENT REHABILITATION 32 UTILIZATION 32 CHALLENGES AND RECOMMENDATIONS 33 COMMUNITY REHABILITATIVE CARE CCAC 35 UTILIZATION 35 CHALLENGES AND RECOMMENDATIONS 36 COMMUNITY SERVICES (OUTPATIENT AND CCAC) 36 TRANSITIONAL CARE BEDS 36 COMPLEX CONTINUING CARE 37 HUB HOSPITALS AND ST. JOSEPH S CONTINUING CARE CENTRE (SJCCC) 37 UTILIZATION 37 ALC 38 COMMUNITY/RURAL HOSPITALS WITH CCC BEDS 39 LOS 39 UTILIZATION AND ALC 40 CASE MIXED INDEX (CMI) 41 CHALLENGES AND RECOMMENDATIONS 42 CONVALESCENT CARE 42 UTILIZATION 43 3

4 PR O G R A M D E F INI TI O NS A C R OSS T H E R E H AB A ND C C C SYST E M 43 CHALLENGES AND RECOMMENDATIONS 44 A C C ESS A ND R E F E RR A L 45 CHALLENGES AND RECOMMENDATIONS 49 C C A C E N H A N C E D R O L E 50 CHALLENGES AND RECOMMENDATIONS 50 R ESO UR C ES A ND C OST IN G 51 E N A B L E RS A ND B A RRI E RS 55 NORTH EAST REHAB NETWORK 55 PR OJE C T A C C O MPL ISH M E N TS T O D A T E A ND A C T I V I T I ES O U TST A NDIN G 56 N E X T ST EPS A ND IN F R AST RU C T UR E 58 NEXT STEPS 58 INFRASTRUCTURE 58 SU M M A R Y O F C H A L L E N G ES A ND R E C O M M E ND A T I O NS 59 INPATIENT REHAB 59 OUTPATIENT REHAB 60 COMMUNITY REHABILITATIVE CARE (CCAC) 61 CCC 62 PROGRAM DEFINITIONS ACROSS THE REHAB AND CCC SYSTEM 62 CCAC ENHANCED ROLE 63 NEXT STEPS AND INFRASTRUCTURE 64 4

5 APPE NDI C ES A. Project Charter B. Expert Panel Conceptual Framework Matrix C. Future State of Rehab D. Overview of services E. Rehab Inpatient Utilization F. Rehab Inpatient LOS G. Rehab Inpatient FIM scores H. Outpatient Utilization I. Community Hospital Outpatient services J. NE CCAC Data K. CCC Data L. CCC in Community Hospitals M. Admission Criteria and Staffing Ratios N. Rehab Inpatient Staffing O. CCC Staffing P. Convalescent staffing 5

6 NE LHIN Rehabilitation (Rehab) and Complex Continuing Care (CCC) Systems Review Executive Summary June 1,

7 As part of overall system planning and its Emergency Department (ED)/Alternate Level of Care (ALC) initiatives, the North East Local Health Integration Network (NE LHIN) initiated a project to review the Rehabilitation (Rehab) and Complex Continuing Care (CCC) system with a long-term goal of developing a comprehensive service delivery model. In the fall of 2011, a project plan and timeline was developed. In October 2011, a Core Stakeholder Group was formed to work with the NE LHIN and the Rehabilitation and Complex Continuing Care Officer to review and advise on each step of the review process in terms of content, methodology and timelines, including the final report. The group met for the first time on November 1, The scope of the work included a review of the four hub hospitals, (Health Sciences North (HSN), Timmins and District Hospital, North Bay Regional Health Centre and Sault Area Hospital (SAH)), West Parry Sound Health Centre, St. (SJCCC) and the North East Community Care Access Centre (NE CCAC). The smaller rural hospitals were also surveyed, although in a more limited way. One hundred (100) percent of facilities and agencies returned the surveys. Information was collected to determine: current capacity; utilization of beds (inpatient rehab and CCC); service volumes (outpatient rehab and CCC) over the past 3 years; patient criteria (Functional Independences Measures (FIM) scores); LOS; referral processes, sources and waitlists; and resources (staffing). Results The results and analysis revealed the following general findings: Population in the NE LHIN is older, spread out over a wide geographical area with poorer overall health when compared to the province Rehabilitative services are The role of smaller, rural hospitals is unique and unclear There are differences in practice, especially in musculoskeletal (MSK) across the system Limited data exists about the population in rehab Lack of outpatient services (and data) across the NE LHIN impacts inpatient stay, outcomes for patients and as a result, subsequent use of services Duplication of effort exists in some areas between CCAC and outpatient services Some overlap, inconsistency of program definitions and streamlining exists across the system Internal referrals are faster, more efficient than external referrals with inadequate access to rehab from smaller rural hospitals 7

8 Standardized referral processes and documentation are in place for inpatient rehab across the NE LHIN, although not consistently understood There are differences in wait times for inpatient rehab for different institutions (from NE Rehab Network audit), although current data is limited. Future audits will include all hub hospitals. Current process for external referral to CCC is cumbersome and slow There is inadequate data about wait times and targets are unclear Enhanced collaboration is needed from all sectors involved in rehabilitative care Summary of Challenges and Recommendations Following is a summary of the specific challenges and the subsequent recommendations that will move the system forward. Also included are specific actions and timelines that can serve as a future work plan. Specific parties who could/should assume responsibility for each action item are also identified. Inpatient Rehab Challenges Recommendations Action Responsibility Differences in practice, specifically around MSK and utilization of inpatient beds 1. Determine congruence with Best Practices in rehab for MSK and stroke as endorsed by the Expert Panel. Develop and implement a template for measuring congruence and complete by March 31, Core Stakeholders and Rehab and CCC Officer Limited Availability of PT, OT, SLP 2. Expand the concept of the rehab team to include a more enhanced role for nursing and provide training opportunities (i.e. Rehab certification through Canadian Nurses Association (CNA)) and training for the team to include a more enhanced role for nursing. This will enable a more around the clock/7 day a week approach to rehab. Disseminate information about CNA certification North East Rehab Network to facilitate with hub hospitals and core stakeholder group. March to November Follow up re: uptake January North East Rehab Network Core Stakeholders in rehab and CCC 8

9 Challenges Recommendations Action Responsibility Identification of ALC within rehab 3. Wherever possible clarify and create standard approach to classifying patients as ALC in rehab and CCC so data can be interpreted consistently and compared. Expand the mandate of LHIN group currently addressing classification of ALC in acute care to include rehab and CCC. March to May LHIN and Core stakeholders in rehab and CCC Limited data describing the population 4. Collaboration between NE LHIN, North East Rehab Network and the hub hospitals to develop and apply a template for system monitoring and comparisons across the rehab facilities and reduce duplication of effort to monitor the data. The template should include at least: o FIM Median and range as well as means o FIM Efficiency scores o ALC across rehab sites o Wait times o Key questions s re: shifts in outpatient changes in volumes and shifts in staffing between inpatient and outpatients Develop and apply a template, building on the North East Rehab Network template and this report, enabling system monitoring and ensuring congruence with the Expert Panel Data recommendations. Utilize existing systems (NRS). Determine a reporting schedule. Template to be completed by June 30, NE LHIN and North East Rehab Network First report ready June Outpatient Rehab Challenges Recommendations Action Responsibility Outcomes in outpatient programs, especially for MSK patients, are better than in home services as services can be more frequent and intense. 5. Review congruence with best practices for MSK, especially hip and knee replacements (together with recommendation #1) Develop and implement template for measuring congruence and complete by March 31, Core Stakeholders and Rehab and CCC Officer 9

10 Challenges Recommendations Action Responsibility Lack of outpatient services impacts inpatient stay Include questions in the rehab data template. June Shifting of staff from outpatient to inpatient services, resulting in decreasing the amount of outpatient service available 6.Add some key questions to the rehab template (R#4) to monitor : o longer inpatient stays related to lack of outpatient services o overall shifts in outpatient services o when outpatient services/volumes decrease because staff is reassigned to inpatient services. North East Rehab Network and LHIN Lack of knowledge about availability of rehab services in community hospitals 7. Disseminate information to providers about services available and about the NE Rehab Network web site. Develop communication about information available March 31, North East Rehab Network with LHIN communications Accessing rehab in rural and remote communities 8. Explore the possibilities for integrating Telemedicine in providing/accessing care as part of developing a comprehensive rehabilitative model. Engage with NE LHIN Telemedicine lead in preparation for model development to determine their capacity. Build on the experience of stroke and ABI. Initiate by March 31, Core stakeholder Group and NE LHIN Telemedicine lead Community Rehabilitative Care (C C A C) Challenges Recommendations Action Responsibility Variations in visits for specific diagnostic groups across branches 9. Review and apply best practices for MSK and stroke, together with recommendation #1. Develop and implement template for measuring congruence and complete by March 31, Core Stakeholders and Rehab and CCC Officer 10

11 Reduce duplication of effort between CCAC and outpatient services. 10. Work collaboratively with outpatient services in the various communities to leverage access to services. Partners within the North East Rehab Network to explore current collaborations across communities and identify opportunities such as sharing staff. In progress and ongoing. CCAC and outpatient providers Complex Continuing Care (C C C) Challenges Recommendations Action Responsibility Program definitions and streaming across settings To be addressed in program section (Recommendation #11) See action in program section. Classification of CCC patients as ALC See Recommendation # 3. Program Definitions across the Rehab and C C C System Challenges Recommendations Action: Responsibility Overlap in program descriptions, criteria for admission 11. Streamline programs, definitions and criteria across the system from rehab to CCC to convalescent care, utilizing the Expert Panel framework to inform the process. With core stakeholder group, using the Expert Panel Template, clarify and streamline definitions, where programs fit. Core stakeholder Group and Rehab and CCC Officer clinical data, including the Alpha FIM (for acute care) FIM (for rehab), and the RAI (for CCC and Convalescent elements and the clinical level intensity of care required. Utilizing the work of the Expert Panel, develop a clearer process across the NE LHIN for determining overall need and the data elements required to identify needs of individual patients. March to September NE LHIN and Transitional Care Units and Core Stakeholder Group 11

12 Access and Referral Challenges Recommendations Action Responsibility Development of a process for transition to rehab and CCC that meets the needs of patients and referring and admitting facilities 13. Evaluate the current process in place for CCC admissions to SJCCC and SAH as a pilot/test for future process. Process currently being undertaken to address the challenge. Report expected by February 29, CCAC and SJHC and HSN Improve wait time tracking Matching actual practice to targets for referral to assessment to decision to admission. Reduce wait times 14. Develop more specific tracking methods to measure: a) actual to targets for processes for all external referral transition points: to inpatient rehab; to CCC; and to the CCAC. b) Actual wait times. 100 % participation by hub hospitals with designated rehab beds in the North East Rehab Network External Referral Audit. Include data in the regular reporting template (See Recommendation # 4). North East Rehab Network and hub hospitals Initiate specific tracking of referrals through the CCAC to CCC and convalescent care of actual to targets. September 30, Monitor actual wait times. CCAC All core stakeholders Collaboration already in progress with ALC RM&R processes. 12

13 C C A C Enhanced Role Challenges Recommendations Action Responsibility Transition to enhanced CCAC role for CCC and rehab CCAC and Stakeholders 15. Support the CCAC initiative to develop case managers with particular expertise in rehabilitative care to manage transitions to rehab and CCC. Include rehab and CCC stakeholders as processes are being developed and tested. To November Create mechanism for CCAC collaboration with acute care, rehab and CCC as new processes are developed. Ongoing Next Steps and Infrastructure Challenges Recommendations Action Responsibility Collaboration from all the sectors involved in rehabilitative care LHIN and Core Stakeholder Group 17. Create a group that includes representation of all stakeholders involved in rehabilitative care across the NE LHIN, including all hospitals, NE CCAC, geriatric services and convalescent care, that will follow-up on this review and drive the development of a comprehensive service delivery model for rehabilitative care. April Create a strong stakeholder group under the NE LHIN umbrella with enhanced membership and mandate. Create NE LHIN rehabilitative care. 13

14 NE LHIN Rehabilitation (Rehab) and Complex Continuing Care (CCC) Systems Review Report June 1,

15 Background As part of overall system planning and its Emergency Department (ED)/Alternate Level of Care (ALC) initiatives, the North East Local Health Integration Network (NE LHIN) initiated a project to review the Rehabilitation (rehab) and Complex Continuing Care (CCC) system with a long-term goal of developing a comprehensive service delivery model. In the fall of 2011, a project plan and time line was developed as part of the NE LHIN Rehabilitation and Complex Continuing Care System Review Charter. The charter outlines the scope, activities, structure and a process for engaging stakeholders, including the identification of recommendations and an implementation plan to enhance access and patient flow to rehab and CCC occurring in the NE LHIN. The full charter and membership is found in Appendix A and B of this report. The initiative in this document supports the NE LHIN ED and ALC priorities. The project is also taking place alongside and concurrent with the work of a provincial Rehabilitation and Complex Continuing Care Expert Panel. A challenge to this project is the timing of both the Ministry of Health Long-Term Care (MOHLTC) Expert Panel and the recommendations of the NE LHIN in moving forward with their plan around rehabilitative care, in that the Expert Panel will not be completed its report until the fall of Rehabilitation and Complex Continuing Care Expert Panel The MOHLTC Rehab and CCC Expert Panel was formed in December 2010 as a sub-committee of the province ED/ALC Expert Panel. The purpose of the Rehab and CCC Expert Panel is to -think the delivery of rehabilitation and complex care across the acute and post- acute continuum including community settings, hospitals, transitional and convalescent care settings and in long-term 1 Phase I of the Expert Panel report focused on providing advice and guidance to the ED/ALC Expert Panel on how best to reduce ALC lengths of stay (LOS) throughout the system by properly utilizing the capacity, role and expertise available in rehab and CCC resources. Key recommendations for immediate action included endorsement of best practices for stroke, hip and knee replacement and hip fractures across the full continuum of service (acute, rehabilitative care and community) and for the LHINs to evaluate current congruence with best practices. 1 Rehabilitation and Complex Continuing Care Expert Panel: Phase I Report, June, 2011, p

16 A second phase, nearing completion, focuses on describing a framework for rehabilitative care. The framework is governed by the following foundational principles: Early access to rehabilitative care should be equitable; All of these programs and services can be described or measured by data elements; Every program or service can be mapped to a Canadian Institute for Health Information (CIHI) National Rehabilitation Reporting System (NRS) category or Continuing Care Reporting System (CCRS) category and to a Ontario Healthcare Reporting Standards (OHRS) category; The care delivered to every patient/client group, diagnostic cluster and in every location would be guided by best practices where they exist; All programs and services would be delivered in an age appropriate manner (e.g. seniors focused, developmentally appropriate); Within each program or service there is flexibility to care for patients/clients as their tolerance for treatment changes to minimize transitions; and There is recognition that clustering patients with similar care needs allows for care delivery by dedicated inter-professional teams which, in turn, leads to better outcomes. Key components of the framework focus on rehabilitative care rather than rehab and CCC beds. The desired outcomes of rehabilitative care will include one or more of: Maintenance or sustaining of functionality; Restoration of functionality; and Developing of adaptive capacity. The Expert Panel has developed a conceptual framework matrix that brings together five (5) functional groupings, best practices and locations of care. This conceptual framework describes the spectrum of programs and services that, in a future state, will be available to patients/clients who require rehabilitative care. The framework has been field tested in various settings for a variety of populations. The framework consists of the following three (3) elements: Element 1 Level of patient/client functioning, capacity for improvement and expected speed of recovery This concept is to distinguish between categories of patients/clients based on initial level of function, capacity for functional improvement, complexity and predicted speed of recovery. 16

17 There are five (5) groupings. This element describes for each of the five groups where (provincial, regional, local) care would be delivered (see Appendix B). Element 2 Patient/client clusters Placement in a cluster would be by most responsible rehabilitative diagnosis from the following 13 groups: Medically Complex, Stroke, Spinal Cord, Oncology, Acquired Brain Injury (ABI), Cardiac Rehab, Amputee, Pulmonary, Burn, Musculoskeletal (MSK) (Orthopaedic), Neurology, Geriatric and Paediatric. It is recognized that there may be overlap between clusters. The purpose of clusters is to enhance best practice and allocation of health human resources (HHR). The clusters also map well to existing CIHI and OHRS categories. Element 3 Locations of care and best practices (local, regional, provincial) In each box, the best practices each type of patient/client will receive in each location will be described (see Appendix B). There will be one matrix for each of the 13 clusters from Element 2. Completion of the matrix is based on best practices and conducted by content experts. Depending on the best practice, there may not be a role documented/noted for each location (e.g. local, regional, and provincial). An example might be stroke care delivered to a Group 4 patient/client, which would include acute care rehab, secondary prevention clinic and/or a community-based day program that is only available locally. It is recognized that the matrix may be different in different LHINs depending on resource availability. A map of a future state of rehabilitative care can be found in Appendix C. Work still in progress Once complete, the Conceptual Framework and corresponding Data Elements to be identified can be used to measure existing systems against systems defined by best practices. This work is expected to be completed by the Definitions Working Group in the spring of The last phase of the MOHLTC the size and site of the rehabilitative system, using the conceptual framework. A timeline of fall 2012 has been tentatively identified by the Expert Panel for completion of this phase. 17

18 Other Reports/Initiatives A number of other reports and initiatives are also informing the work of then NE LHIN Rehabilitation and Complex Continuing Care Systems Review Project. Highlights of each of these reports are summarized below. Caring For Our Aging Population and Addressing Alternate Levels of Care In June 2011, Dr. David Walker submitted his report, Caring for Our Aging Population and Addressing Alternate Levels of Care. 2 to meet the needs of an increasingly aging population who will live longer in states of both health and illness. To meet these needs, the system must shift to address six transformational pillars of care, by realigning, refocusing, and targeting investments, improve patient flow across the system and optimize an 3 A summary of the pillars and recommendations around each of the pillars from the report follows. Improve Access to the Right Care Through Community Investments Primary Care management of high-risk frail seniors sector NE LHIN Primary Care Lead Community Care Continuum of NE CCACs and CSS e Virtual Wards Improve Patient Flow Across the System Acute Care Hospitals Senior Friendly principles planning Assess and Restore Assess and Restore in CCC/Rehab and long-term care home (LTCH) pathways Optimize and differentiate Capacity Long-Term Care (L T C) Capacity capacity needs patients and complex care preferred beds LTCH 2 Caring For Our Aging Population and Addressing Alternate Level of Care, Report submitted to the Minister of Health and Long-Term Care, Dr. David Walker, Provincial ALC Lead, June 30, Caring For Our Aging Population and Addressing Alternate Level of Care, Report submitted to the Minister of Health and Long-Term Care, Dr. David Walker, Provincial ALC Lead, June 30, 2011, p

19 Improve Access to the Right Care Through Community Investments Improve Patient Flow Across the System Optimize and differentiate Capacity Special Needs Populations ialized units in community and LTC System Enablers: Governance and Accountability, Health Human Resources (HHR), Information Technology (IT), Health Professional and Public Education and Awareness, Process and Patient Flow Efficiency While all aspects of this report are relevant, the key element of the report for this project is around the ssess and Restore recommendations. Assess and Restore is seen as both a philosophy and func level of functioning and creating opportunities for them to be transferred home with enhanced, appropriate supports. The vision is to have Assess and Restore programs accessible within CCC, rehab or in short-term transitional programs in LTC and perhaps even acute care. The goal is to provide such services as quickly as possible, rather than risk deterioration. This could involve direct admission to an Assess and Restore Program from the ED, thus bypassing admission to an acute care bed. Enhancing the Continuum of Care: Report of the Avoidable Hospitalization Advisory Panel In November 2011, Dr. Ross Baker et al. 4 submitted a report focused on improving quality of care, sustainability of the health system and more effective use of health care resources in Ontario by reducing avoidable hospitalizations. The report calls for: Better planning for discharge; Improved communication between clinicians in different settings, as well as clinicians and patients; Medication reconciliation and management when patients return home; Patient and caregiver education; and Timely primary care follow-up in the community. 4 Enhancing the Continuum of care: Report of the Avoidable Hospitalization Advisory Panel Submitted to the Ministry of Health and Long-Term Care. November,

20 The report identifies clinical strategic partnerships across the health care system and collaboration across organizational boundaries as an essential element for reducing poor outcomes. It also states that efforts to improve care transitions need to be integrated into the system without adding unnecessary complexity or introducing duplication. Dr. Baker also refers to the recently passed (June 2010) Excellent Care for All Act ECFAA) 5, highlighting the promotion and dissemination of evidence based recommendations, supporting health care providers in quality improvement and adoption of best practices. One of the key populations of interest is the frail elderly and those with co-morbidities. Dr report and recommendations support both the work of the Rehab and CCC Expert Panel and the recommendations of the Caring for Our Aging Population and Addressing Alternate Levels of Care 6 report. C C A C Expanded Role In 2011, under new legislation, the Community Care Access Centres (CCACs) across the province will assume an expanded role as the core navigators through the health system. This includes rehab and CCC. Implementation strategies and timelines on this new role are being established at the LHIN level. The plan for the NE LHIN is for rehab and CCC to be ready for implementation in November Currently, the NE CCAC plays an enhanced role in some of the referrals to CCC/slow paced rehab/convalescent care in both Sault Ste. Marie and Sudbury. In light of this new expanded role, CCAC staff are members of the NE LHIN Core Stakeholder Group for the rehab and CCC systems. Alternate Level of Care Resource Matching and Referral (A L C R M & R) Project The ALC RM&R project is a provincial initiative. The LHINs have been divided into several clusters, of which the NE LHIN forms a cluster that includes the North West, South East and Champlain LHINs. The purpose of the Provincial ALC RM&R Business Transformation Initiative (BTI) is to standardize referral processes, forms and terminology across the province for in-scope referral pathways. The goal is to improve communication and patient flow, ensure acute care. The referral pathways include referrals to rehab and CCC and as such have relevance to the rehab and CCC project in terms of referral processes and pathways. 5 Ministry of Health and Long Term Care. Excellent Care for All Act (ECFAA), Enhancing the Continuum of care: Report of the Avoidable Hospitalization Advisory Panel Submitted to the Ministry of Health and Long-Term Care. November,

21 Geriatric Services The Northeast Specialized Geriatric Services (NE SGS) was established in 2009, which allowed for the recruitment of a Geriatrician and the hiring of an inter-professional team located in Sudbury. Since that time and through additional funding, some of which included the MOHLTC Aging at Home funding distributed via the LHINs, the service has been able to evolve further throughout the NE LHIN with the development of teams (including Care for the Elderly physicians and nurse practitioners) in a number of communities across the NE LHIN, development of standardized assessment, a Falls program, case management and Telemedicine clinics. In 2010, a Geriatric Rehab Unit (GRU) was established, as well as a Geriatric Day Hospital (GDH). As there is only one Geriatrician in the NE LHIN, the program uses a consultation model to provide services to those in northeastern Ontario. The program is focused on identification of frail and at-risk elderly, preventing disability and decline and restoring their overall function. The team is working on capacity building and planning for sustainability. Another initiative related to the geriatric population includes the Geriatric Emergency Management (GEM) nurses who assist ED staff in developing geriatric knowledge and skills and assist them in interfacing with the community. Many hub hospitals (the Sault Area Hospital (SAH), Health Sciences North (HSN) and West Parry Sound Health Centre (WPSHC)) now have a GEM program in place. In January 2010, a report entitled Developing Specialized Geriatric Services and Programs in Sudbury Hospitals was submitted to the Sudbury ALC Steering Group. The report was commissioned by Health Sciences North (HSN) (formerly the Hôpital régional de Sudbury Regional Hospital (HRSRH) and completed by an external consultants. The report identified opportunities for the development of a model of specialized geriatric units and teams in Sudbury hospitals. Some of the recommendations and next steps identified in the report have been implemented (GRU, GDH) while some of the suggested integrations of services remain works in progress. 7 7 Developing Specialized Geriatric Units and Programs in Sudbury Hospitals. Prepared by Maureen Vickers, January,