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

1

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

2

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

1

• 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

Preliminary Profile of Persons with Dementia

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

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

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)

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!

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

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…

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

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

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

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

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)

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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