A n n u a l Report 2016/2017

Transcription

1 Annual Report 2016/2017

2 Kathy Wright Award winner for exemplary care in Geriatrics 2016 GERIATRIC ASSESSMENT OUTREACH TEAM (GAOT): BUILDING GERIATRIC SYSTEM CAPACITY The Geriatric Assessment Outreach Team (GAOT) located at Bruyere Continuing Care and Queensway Carleton Hospital, over the years has built geriatric capacity through clinical interventions, teaching, training and community engagement. The GAOT receives recognition from the system for their outstanding clinical work related to the comprehensive geriatric assessment and intervention and less so for their work related to knowledge translation and community engagement. In building system capacity, several key provincial strategies highlight the need to (1) enhance the geriatric competence of the entire workforce and (2) improve the way geriatric care is delivered across the continuum. Highlighted below are examples of how the GAOT has contributed to building system capacity for older adults. Enhancing Geriatric Competence The GAOT have been the leaders in developing the content, as well as delivering the Geriatric Education Series which has been modified to improve access to a larger audience. The current format is delivered four times per year to approximately 130 participants. The team provides opportunities for other clinicians such as family medicine residents to attend clinical observation visits. Family Medicine Residents have noted that the visits assist greatly in identifying high risk seniors who would benefit from Specialized Geriatric Services and helps shape a patient profile for early identification and early intervention within their primary care practices. The GAOT have completed an evidenced based review of their comprehensive geriatric assessment interview guide that is shared with other clinicians working in the community to support the early detection. Improving the way geriatric care is delivered across the continuum GAOT have been engaged in delivering education to the community through presentations, health fairs and healthy living presentations. The team has also engaged with key community members in building geriatric capacity through services such as Health Links, Diabetes and Cardiac Rehabilitation Clinicians, Primary Care specifically building dementia and fall prevention capacity, and a conference on research initiatives for safe and sustainable discharges. The GAOT has continued to engage and partner with key organizations so that together they can optimize the health outcomes of older adults. 1

3 A NETWORK OF NETWORKS The RGP has benefitted greatly from its many partners: The Ottawa Hospital, Bruyere Continuing Care, Queensway Carleton Hospital, Montfort Hospital, Champlain LHIN, Dementia Society of Ottawa and Renfrew County, Eastern Counties Specialized Geriatric Services Network, Renfrew County Specialized Geriatric Services Network, Pembroke Regional Hospital, Cornwall Community Hospital, Glengarry Memorial Hospital, Winchester and District Memorial Hospital, Renfrew Victoria Hospital, Arnprior and District Memorial Hospital, Champlain Dementia Network, The Perley and Rideau Veterans Health Centre, Champlain LHIN Home and Community Care Branch, Ottawa Public Health, The Council on Aging of Ottawa, Carefor Health and Community Services, The Royal (Royal Ottawa Mental Health Centre), Ottawa Community Support Coalition, Hawkesbury & District General Hospital, Primary Care Outreach, Health Link Authorities, United Way Ottawa, Alzheimer Society of Eastern Counties. Geriatric Education Series Didactic sessions on: Introduction to Geriatrics, Function, Mobility and Falls, Cognition, Driving, Caregiver Stress, Elder Abuse, Living at Risk Clinical Didactic sessions to medical students and residents: Introduction to Geriatrics & RGPEO Mobility and Falls Presentations to: Health Links: RGPEO Diabetic and Cardiac Rehabilitation Clinicians Primary Care: RGPEO & Falls North SGS Annual Conference Research workshop on Discharge Planning Observation Visits: 128 Mentorship Orienting and Mentoring: 2 new geriatric assessors Mentoring and Educating: Geriatric Emergency Management Nurses Enhancing Geriatric Knowledge Community Presentations Displays Health Living presentation Representation Elder Abuse Consultation Team RGP Ontario Conference Committee Competency Framework for Comprehensive Geriatric Assessment (CGA) Program Evaluation Committee Completed Evidence Based Review Updated CGA Interview Guide Updated 15 Clinical Decision Algorithms Practice Guidelines for each clinical topic 2

4 SHARING OUR KNOWLEDGE RGPEO staff continue to be at the forefront of research and innovation in the care of the elderly. We are pleased to share some of the peer reviewed contributions published by RGPEO staff in Byszewski A, Power B, Lee L, Gaeun G, Parson R, Molnar F. Driving and Dementia: workshop module on communicating cessation to drive. Canadian Geriatrics Journal, 2017 (under revision) Byszewski A, Bezzina K, Latrous M. What Kind of Doctor Do You Want to Be? Geriatric Medicine Podcast as a Career Planning Resource. BioMed Research International, vol. 2017, Article ID , 6 pages, doi: /2017/ Petit D, Lochnan H, Byszewski A. Boosters for clerkship professionalism curriculum: online Self-learning Modules. Medical Education 2016 Nov;50(11): Azad, N., Srivaratharajah, K., Khoury, L. An approach to management of advanced heart failure in the older person. The Canadian Geriatrics J. CME volume 6, issue 2, 2016 Azad, N., Mielniczuk, L. A Call for Collaboration: Cardio-Geriatric Program Canadian Journal of Cardiology - (2016) 1e4 S X(16) /fulltext Leafloor, C.W., Huang, A.R., Code, C.C., Lochnan, H,A. Facilitating the STEP from junior to senior resident. Med Educ 2016 May;50(5): Pub Med Azad, N, Lemay, G., Li, J., Benzaquen, M., Khoury, L. Perspectives from Geriatric In-patients with Heart Failure, and their Caregivers, on Gaps in Care Quality. Can Geriatr J 2016 Dec 23;19(4): Pub Med MacDonald M, Klair K, Khoury L, Molnar FJ. 4D-AID: A practical approach to the assessment of orthostatic hypotension in older patients. Canadian Geriatrics Society CME Journal 2016, Volume 6, Issue 1, P Molnar F. Canadian Medical Association Driver s Guide; Determining Medical Fitness to Operate Motor Vehicles Wilding, L., Abdulaziz, K., Brehaut, J., Taljaard, M., Emond, M., Sirois, M-J., & Perry, J. (2016). Geriatric Emergency Management nurse s views on prediction and management of functional decline in older adults after a minor trauma. Perspectives, 39(1), MacKenzie, T. (2017, May). The evolution of the Champlain Falls Assessment and Streamlined Treatment Clinic. Canadian Gerontological Nursing Association National Conference, Ottawa, Ontario. DiMillo, A.M., MacKenzie, T., & Waggott, M. (2017, May). Safe smooth transitions for high risk seniors Improving care through collaboration. Canadian Gerontological Nursing Association National Conference, Ottawa, Ontario. Jenkins, D., Lamoureux, U., Lumley-Leger, K., Mundy, I., Turcotte, S. (2017, Sept). Improving Transfers from ED to LTC: Communicating What Matters. Canadian Gerontological Nursing Association 2017 Conference, Ottawa, Ontario 3

5 LEARNING AND TEACHING More than 14,692 hours of education and training were provided to 7,569 students in the Faculties of Medicine and Health Sciences (includes CMEs, Videoconference sessions, Regional Geriatric Rounds) by the Division of Geriatrics, clinicians working within SGS at The Ottawa Hospital and the RGP of Eastern Ontario. Here is a breakdown of the student placements through The Ottawa Hospital: Medicine Postgraduates (59 placements) Medicine Undergraduates (29 placements) Geriatric Residents (2 placements) Allied Health (41 placements) Nursing (24 placements) SERVICES AND RESOURCES This is how clients used specialized geriatric ambulatory services coordinated by the Regional Geriatric Program of Eastern Ontario: 1. Geriatric Emergency Management Team: Year Number of Patients Seen by GEM Nurse in ED and Discharged Home not returning to ED within 30 days from index ED visit not being admitted to hospital within 30 days from the index ED visit ,596 68% 89% ,520 67% 89% 4

6 2. Outreach: Year Referrals Visits Number of FTEs ,317 1, ,158 1, Nurse Led Outreach Team: Year Referrals Not Transferred to ED Not Admitted to Hospital ,378 92% 96% ,672 93% 97% The total high risk seniors served by RGP coordinated clinical services (Nurse Led Outreach Teams, Geriatric Assessment Outreach Teams, Geriatric Emergency Management and Clinics) was approximately 7,368 older adults. The high risk seniors seen within these services were captured under the ED/ Hospital Diversion strategy that the RGP has been promoting for several years. The services are working with numerous community partners and agencies in implementing early identification processes to optimize reversibility and preventable interventions in supporting older adults in staying in their homes and community. Utilization of specialized geriatric ambulatory services (The Ottawa Hospital, Queensway Carleton, Bruyere Continuing Care, Arnprior and District Memorial Hospital, Renfrew Victoria Hospital, Pembroke Regional Hospital, Cornwall Community Hospital, Winchester District and Memorial Hospital, Montfort Hospital and The Royal) 1. Day Hospitals: Year Spaces Visits , , Clinics: Year Spaces Visits