North East Specialized Geriatric Services. North East Specialized Geriatric Services. Strategic Plan

North East Specialized Geriatric Services North East Specialized Geriatric Services Strategic Plan 2010-2014

City of Greater Sudbury The North East LHIN has a higher population age 65+ than the rest of the province (i.e. 16.3% vs. 13.5%). 1 The percentage of the population aged 75 and over in the NE LHIN is expected to rise from 7.2% in 2006 to 13.2% in 2031. 2 Core Services and Functions 3 Direct Care Indirect Clinic Care Program and System Development Education Research and Program Evaluations The City of Greater Sudbury s efforts to develop the North East Specialized Geriatric Services culminated with the recruitment of Dr. Jo-Anne Clarke by way of a three year service contract and her appointment as clinical lead for the program. The remainder of the program was made possible with the Ministry of Health and Long Term Care announcing the Aging at Home Strategy. 1 2006 Census of Canada, Statistics Canada 2 Ontario Ministry of Finance Population Projections, 2007 based on original data from Statistics Canada Population Estimates for 2007 3 Summary Report of THE EXPERT PANEL on SPECIALIZED GERIATRIC SERVICES (SGS), Submitted to the Ministry of Health and Long-Term Care November, 2000, Policy Planning Plus Inc. Hamilton, Ontario 2 North East Specialized Geriatric Services Strategic Plan

North East Specialized Geriatric Services Strategic Plan Table of Contents Core Services and Functions...2 Introduction...4 Vision...5 Mission...5 Values...5 Strategic Positioning...6 Current Challenges...........................7 Internal Analysis...8 Moving Forward...9 Financial Information... 10 Goals...11-15 Conclusion... 16 Appendix...17-18 Glossary... 18 The NE SGS, Regional Geriatric Program affiliate, has been instrumental in guiding the planning and implementation of a model of geriatric service delivery at the Hôpital Régional Sudbury Regional Hospital. The NE SGS staff have facilitated linkages with other programs and providers and taken a lead role in educating professionals in Sudbury and the northeast to improve the delivery of client centered care for the elderly. David McNeil, VP Clinical Programs and Chief Nursing Officer, HRSRH City of Greater Sudbury 3

City of Greater Sudbury Introduction The North East Specialized Geriatric Services (NE SGS) is located on Notre Dame Avenue in Sudbury, Ontario on the campus of what is now referred to as the North East Centre of Excellence for Seniors Health. The City of Greater Sudbury administratively manages the program, with operational funding provided by the North East Local Health Integration Network s Aging at Home Strategy. The North East Specialized Geriatric Services is a Regional Model and operates throughout the North East LHIN district. The NE SGS works with the advice of an Advisory Panel whose membership is reflective of the geographical area and diversity of the partners. (Appendix A Terms of Reference) The North East Specialized Geriatric Services is a recognized affiliate program of the Regional Geriatric Programs of Ontario, and the NE SGS s goals are reflective of the mandate of the RGP s of Ontario, while being true to the unique needs of the North East. Program Functions To provide specialized geriatric assessment and treatment to medically complex, frail elderly. To provide education and knowledge transfer promoting best practices for geriatric care. To increase capacity in geriatric care throughout Northeastern Ontario. To be responsive to the needs of the communities of Northeastern Ontario. This is accomplished through a specialized team of health care professionals who provide interdisciplinary clinical assessment and treatment services for older people including a geriatrician, registered nurses, physiotherapist, occupational therapist and a geriatric resource educational coordinator. 4 North East Specialized Geriatric Services Strategic Plan

North East Specialized Geriatric Services Strategic Plan Vision Our vision is to improve the independence, quality of life and health outcomes for the frail elderly throughout Northeastern Ontario. Mission As a team the NE SGS will improve the quality of life, independence and health outcomes of the frail elderly in Northeastern Ontario through the delivery of specialized clinical services, knowledge transfer and the advocacy of specialized program development in the field of geriatrics. Values We value the independence and dignity of our clients. We value the contribution of partners in care throughout Northeastern Ontario. We value the importance of shared knowledge and best practices in Geriatrics. Key Success Factors Specialization through education, training and experience Geriatrician(s) and Care of the Elderly (COE) Collaboration with Partners in Health Care Specialized Team of Professional Staff: - Nurse Practitioner(s), Nursing, - Occupational Therapist, Physiotherapist Research and Program Development Technological Capacity and Innovation Sustainable funding City of Greater Sudbury 5

City of Greater Sudbury Strategic Positioning Due to the high industry strength and stable financial strength, the North East Specialized Geriatric Services has the capacity to focus on aggressive goals. Industry Strength Aggressive Goals Financial Strength Achievements Surpassed all LHIN deliverables within the first year of operation. Built sustainable relationships with partners in care. Recognized as an official affiliate of the Regional Geriatric Programs of Ontario. Actively engaged in the development and accreditation of the first ever post graduate year (PGY) 3 Enhanced Skills Program in Care of the Elderly program through NOSM. 6 North East Specialized Geriatric Services Strategic Plan

North East Specialized Geriatric Services Strategic Plan Current Challenges First and foremost of these challenges is an ever increasing demand for services (through a high number of referrals), demands for education and expertise, coupled with limited resources. Other significant challenges are the large geographical area, existing gaps in geriatric services in the continuum of care, limited system development to coordinate referrals across the North East, and limited practitioners practicing full time geriatrics. With one geriatrician providing consultation and no nurse practitioner or care of the elderly support, the current wait list is 8 months, which is not ideal for this frail elderly population. Environmental Scan Growing senior s population will increase demand for specialized geriatric services. Demographics 400,000 square kilometres Population 560,000, (65+ = 96,900) 26 Hospitals 54 Long Term Care Facilities (4,956 beds) 1,896 Retirement Beds + Community Support Services, FHT, CHC s, CCAC, NBRHC City of Greater Sudbury 7

City of Greater Sudbury SWOT Analysis Strengths, Weaknesses, Opportunities, Threats Strengths Geriatrician and other geriatric specialist in Northeast Ontario Telehealth/E-health Collaboration with partners in care Administrative support from the City of Greater Sudbury NELHIN Aging @ Home funding Satellite clinics and home visits Status as Regional Geriatric Program affiliate Weaknesses Large Geographical area & weather Barrier of transportation Shortage of physicians in the Northeast Gaps in geriatric services in the continuum of care Continual improvement of administrative systems. Opportunities Northern Ontario School of Medicine Research opportunities with the academic learning sites Go green = Electronic Medical Record (paperless) Provincial alternate payment funding model for current and new geriatricians Threats Sustainability of funding for Geriatrician Recruitment of additional Geriatricians/care of elderly trained physicians Growing demand for services 8 North East Specialized Geriatric Services Strategic Plan

North East Specialized Geriatric Services Strategic Plan Moving Forward Implementation Goal 1 Adequately resource the North East Specialized Geriatric Services Goal 2 Establish and coordinate a Regional Geriatric Network Goal 3 Recruitment of additional Geriatric Specialist that will translate regionally Goal 4 Continuum of Geriatric Care Dr Clarke and the team is a great resource for our team. They provide clinical expertise in a timely fashion which is greatly appreciated. They also function as an educational resource which is appreciated by the Timmins clinical teams (physicians, pharmacist, SW/RNEC & RN s). We wholeheartedly support and appreciate their efforts on behalf of our geriatric population. Dr. Judy Gillies, Timmins City of Greater Sudbury 9

City of Greater Sudbury Financial Information The North East Specialized Geriatric Services has an operating budget of approximately $1,000,000 annually. The operating budget is funded 100% by the North East Local Health Integration Network (NELHIN). Survey Results The progress and the success of the North East Specialized Geriatric Services is determined on how a service is provided to not only patients but to the medical community as well. Two different evaluations are distributed to those served throughout Northeastern Ontario. The first is an evaluation of the service directed to patients and or their substitute decision makers and the next was directed to physicians. Patient Evaluation A total of 200 evaluations were distributed with a 35% response rate. It is also important to note that 40 evaluations were directed to French speaking patients. Overall the response was quite favourable and most expressed an appreciation that they were treated with respect, dignity, clear explanations, responsive to their needs. As well, the surveys were distributed to many patients assessed via outreach and the satisfaction rating there as well was favourable. The only concern some respondents brought forward was the signage was poor and that the parking was costly for the outreach clinics. Physician Evaluation A total of 200 evaluations were distributed to medical practitioners who refer to our program throughout Northeastern Ontario with a 26% response rate. Overall responses were quite favorable, 99% indicated they will continue to refer to the service. The physician group did however indicate that the wait times could improve. As well many of the physicians were unaware of the educational opportunities the NESGS offers. The strategic plan will certainly address all of the recommendations that have come forward as a result of the evaluations. 10 North East Specialized Geriatric Services Strategic Plan

North East Specialized Geriatric Services Strategic Plan Goal 1: Adequately resource the North East Specialized Geriatric Services. The high volumes of referrals necessitates new resources to support the need for operational growth. The NE SGS program will need to recruit additional geriatric and COE supports. Immediate action is required to meet current program demand: 2 FTE nurse practitioners 1 additional FTE clerical position 1 FTE Geriatric Nurse Clinician/Case Coordinator Geriatric Case Coordinator alternate funding plan for geriatrician There is a need to develop and implement specialty outpatient clinics: 2010 Frail to Fit Falls Prevention Program 2011 Bone Health clinic 2012 Continence clinic The above listed clinics and program are models provided by other RGPs, and can be effectively implemented with minimal use of geriatrician clinical time. All can be translated into regional models through education and outreach models. Proposed Strategy Expand the potential for telemedicine consultation. Expand the indication for telemedicine assessment, as appropriate given the skills and expertise of the local Enhanced Geriatric Teams. Explore the possibility of collaboration with other researchers to use the InterRai assessment tool as part of this strategy. Performance Indicators Reduced Wait times Increase number of patients being referred to specialty clinics Satisfaction Surveys City of Greater Sudbury 11

City of Greater Sudbury Goal 2: Establish and Coordinate a Regional Geriatric Network. Existing models in Ontario, for example the South-western Ontario Regional Geriatric Assessment Network SWOGAN based out of the London Regional Geriatric Program, provide leadership where enhanced geriatric teams have been created to meet geographic and human resource challenges. The proposed program for NE SGS would see the creation of such Enhanced Geriatric Teams across Northeastern Ontario. The NE SGS regional model could be created with existing partnerships through the CCAC and seniors mental health outreach workers. Referrals for geriatric assessment would go to the local Enhanced Geriatric Team. Each Enhanced Geriatric Team would provide: geriatric medicine and geriatric psychiatry assessments, recommendations/advice to caregivers and care providers, consultative and educational support to caregivers and care providers, educational opportunities, linkages back to NE SGS via consultation, weekly case conferencing via telemedicine or teleconference with the identified geriatric lead for that region. All teams would need support by locally identified physicians, ideally care of the elderly trained physicians. The Network Coordinator would be an additionally funded position, governed through NE SGS, and would be responsible for: developing capacity, facilitating innovative processes and practices within the NE LHIN Enhanced Geriatric Teams. Additional resources needed: 1 FTE Geriatric assessors located in each community 0.3 COE support to each Enhanced Geriatric Team 1 FTE Network Coordinator position Additional geriatrician support (2 FTE). Performance Indicators An integrated system of referral Greater regional representation and capacity. Better linkages and integration with existing health teams Satisfaction surveys 12 North East Specialized Geriatric Services Strategic Plan

North East Specialized Geriatric Services Strategic Plan Goal 2: Establish and Coordinate a Regional Geriatric Network. NE SGS will continue to be a leader in the provision of training opportunities, in partnership with the RGPs of Ontario as well as the Northern Ontario School of Medicine. As the North East Centre of Excellence for Seniors Health (Pioneer Manor) continues to evolve and establish best practices in dementia care, the NE SGS will provide consult and advice to the development of best practice models and will support the partnerships of research in dementia care. Algoma COE NE SGS/GA +/- NECCAC/NBRHC SMH Cochrane COE(2) NE SGS/GA(2) +/- NECCAC/NBRHC SMH Parry Sound COE NE SGS/GA +/- NECCAC/NBRHC SMH NE SGS 1 Geriatrician NE SGS/Specialized Team (Consultation, advocacy, education, research) 1 FTE Network Coordinator Nipissing COE NE SGS/GA +/- NECCAC/NBRHC- SMH Timiskaming COE NE SGS/GA +/- NECCAC/NBRHC SMH City of Greater Sudbury 13

City of Greater Sudbury Goal 3: Recruitment of additional Geriatric Specialist regionally. In 1992, a Delphi consensus survey estimated a need of 1.25 full-time geriatric specialists per 10,000 people age 65+ 1. The North East LHIN has a higher proportion of the population age 65+ than the province, suggesting a present need for 11.25 full-time geriatric specialists in Northeastern Ontario. To support the number of programs suggested to date, a complement of (8) COE/Geriatric Medicine Specialists will be required. 1 Patterson C, Dalziel WB, Goldlist BJ et al. Geriatric medicine in Ontario: Manpower predictions based on a Delphi consensus survey. Ann RCPSC 1992; 25:99 102. Phase 1 2 Geriatricians 6 Care of the Elderly (0.3FTE) Increase in: Expand on outreach/ambulatory clinics Support to HRSRH (ACE) and St. Joseph s CCC (GRU) Increase in the delivery of OTN/revised scope of service Support to Enhanced Geriatric teams/ NESGAN Knowledge Transfer Phase 2 4 Geriatricians 6 Care of the Elderly (0.3FTE) Increase in: Expand on outreach/ambulatory clinics Support to hospitals within LHIN 13 (ACE, Geriatric Inpatient, Geriatric Day Hospital, GEM) and St. Joseph s CCC (GRU) Increase in the delivery of OTN/ revised scope of service Support to Enhanced Geriatric teams/nesgan Knowledge Transfer 14 North East Specialized Geriatric Services Strategic Plan

North East Specialized Geriatric Services Strategic Plan Goal 4: Continuum of Geriatric Care using the expertise within the NE SGS to support the development of not yet existing services and existing services throughout Northeastern Ontario. A main focus of the RGPs is to help build the geriatric capabilities by building capacity amongst health care professionals and community education. The North East Specialized Geriatric Services has recognized this commitment and the mandate set out by the NE LHIN and feels that this goal will contribute to improved care in Northeastern Ontario. The proposed services under development will increase capacity in caring for medically complex seniors. These are all evidence based strategies that form the basis of regional geriatric programs currently in existence throughout the remainder of the province. Proposed Strategy (Included but not limited to) Ambulatory and specialty clinics (NE SGS) The Hospital Elder Life Program (HRSRH) The Acute Care of the Elderly Unit (HRSRH) The Geriatric Day Hospital (HRSRH) The Geriatric Emergency management program (HRSRH, NE SGS) The Geriatric Rehabilitation unit, and assess and restore units. (ST Jo s CCC) City of Greater Sudbury 15

City of Greater Sudbury Conclusion The City of Greater Sudbury partnered with the North East LHIN to create a geriatric program centred on the recruitment of the area s only practicing Geriatrician. This program has assessed over 900 patients, hosted OTN clinics, conducted outreach clinics and home visits in a number of northern communities and has also put a focus on education to other health care professionals. The health care needs of the seniors population in the North East LHIN continues to exceed the amount of care that NE SGS can reasonably provide. The NE SGS has developed this strategic plan to continue to meet the needs of the area s senior s population as well as expand and improve the program to address the needs of the future. The plan outlines four goals along with a proposed implementation strategy in order to achieve success. In summary, the partnership between the North East LHIN and the City of Greater Sudbury to create the NE SGS has had a direct, measurable benefit to the seniors population of Northeastern Ontario. Additional investment of staff and resources is required to grow and improve the NE SGS program over the short and long term. 16 North East Specialized Geriatric Services Strategic Plan

North East Specialized Geriatric Services Strategic Plan Appendix Regional Geriatric Services Advisory Panel Terms of Reference 1.0 PURPOSE The primary purpose of the North East Specialized Geriatric Services advisory panel is to provide guidance and collaboration in the development and integration of the North East Specialized Geriatric Services. 2.0 OBJECTIVES 2.1 To effectively collaborate with our North East partners and senior service providers on the program development of the NE-SGS and to ensure that it is reflective of the needs and diversity of the seniors population across Northeastern Ontario. 2.2 To establish the guiding principles and a strategic direction that will achieve the short and long term goals of integrating the specialized geriatric services across Northeastern Ontario. 2.3 To ensure that the guiding principles of the NE-SGS reflects the mandate of the existing RGP s of Ontario. These are: Education and best practice Consultation Research and evaluation Advocacy 2.4 To establish a communication plan that will engage and establish an information network outlining the scope of the progress and the program at large. 3.0 MEMBERSHIP Suggested Membership ( excl. resource staff) Consulting Geriatrician Dr. Jo-Anne Clarke 1 member from City of Greater Sudbury Council 1 member of the NE-LHIN s ex-officio member from the Regional Geriatric Program (Ontario) 1 member of NOSM 1 member from the NE-CCAC (CEO or alternate) 1 member from the NEMHC City of Greater Sudbury 17

City of Greater Sudbury Appendix Regional Geriatric Services Advisory Panel 3.0 MEMBERSHIP (CONTINUED) 1 member from a recognized provider/advocate of education for seniors with chronic health conditions ie: Alzheimer s Society 1 representative from Long Term Care (medical director) 1 member from a First Nations health centre (North Shore Tribal Council) 1 member from the acute care sector (CEO or alternate) 1 member from the francophone community health sector -vacant 1 member from the Family Health Team 1 member from the Centre for Rural & Northern Health Research 1 consumer Members are selected based upon their expertise in the sector and do not represent directly the opinion of the organization where they work. 4.0 OPERATING PROCEDURES 4.1 Conflict of Interest All declarations of conflict of interest will be noted at the beginning of each meeting and hose members in a conflict interest position will refrain from discussion or voting on those agenda items. 4.2 Selection of Chairperson City of Greater Sudbury Council will appoint a representative of Council as chair of the Advisory Panel. 4.3 New Members The decision to add new members on the Advisory Panel will be based on maintaining a cross-section of representatives from the various service components that comprise the North East. Membership will be reviewed at the discretion of the Advisory Panel. 4.4 Term Members will be required to commit to a two year term with 50% of membership being re-appointed for an additional two year term to a maximum of four years. 4.5 Quorum Fifty per cent plus one of the memberships will constitute quorum. 4.6 Decision-making Each member of the advisory panel is entitled to one vote. Decisions will be made by a majority. 5.0 Frequency of Meetings Bi-monthly meetings (every two months) or at the call of the Chair. 18 North East Specialized Geriatric Services Strategic Plan

North East Specialized Geriatric Services Strategic Plan Glossary NE SGS North East Specialized Geriatric Services NOSM Northern Ontario School of Medicine SWOGAN South Western Ontario Geriatric Assessment Network NE LHIN North East Local Health Integration Network NE CCAC North East Community Care Access Centre NEMHC North East Mental Health Clinic CGS City of Greater Sudbury CCC Complex Continuuing Care RGP Regional Geriatric Program OTN Ontario Telemedicine Network SSM Sault Ste. Marie GiiC Geriatric interprofessional, interorganizational ollaboration MOHLTC Ministry of Health and Long Term Care COE Care of the Elderly PGY Post Graduate Year Post medical school residency NP Nurse Practitioner HRSRH Hôpital régional Sudbury Regional Hospital SMH Seniors Mental Health NE ON Northeastern Ontario ALC Alternate Level of Care APP Alternate Payment Plan EMR Electronic Medical Records LTC Long Term Care FTE Full Time Equivalent RN Registered Nurse NODAC Northeastern Ontario Dementia, Assessment and Consultation Service SGS Specialized Geriatric Services OT Occupational Therapist PT Physiotherapist SW Social Work MD Medical Doctor CME Continuing Medical Education OMA Ontario Medical Association NE North East City of Greater Sudbury 19

North East Specialized Geriatric Services North East Specialized Geriatric Services 960 D Notre Dame Avenue Sudbury, Ontario P3A 2T4 Tel: (705) 688-3970 Toll Free: 1-866-551-6501 Fax: (705) 688-7720 nesgs@greatersudbury.ca www.greatersudbury.ca/geriatrics