Appendices and Attachments Page 1

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1 APPENDICES AND ATTACHMENTS R E G I O N A L S P E C I A L I Z E D G E R I A T R I C S E R V I C E S I N T H E C E N T R A L E A S T L H I N: O P T I O N S F O R C O O R D I N A T E D D E L I V E R Y, O R G A N I Z A T I O N A N D G O V E R N A N C E APRIL 2011 Appendices and Attachments Page 1

2 List of Appendices Appendix A: Terms of Reference... 3 Appendix B: List of Champions and Key Informants Interviewed... 5 Appendix C: List of Attendees at Stakeholder Sessions... 6 Appendix D: Vision, Mission, Values & Principles for a Regional Specialized Geriatric Program in the CE LHIN... 8 Appendix E: Planning Framework for Integration of Specialized Geriatric Services in the CE LHIN Appendix F: SGS Service Definitions Appendix H: Perspectives on Integration APPENDIX I: OVERVIEW OF THE FIVE (PLUS ONE) RGP s IN ONTARIO APPENDIX J: MOU BETWEEN RGPEO AND THE OTTAWA HOSPITAL Appendix K: RGP Toronto Participation and Agreement Appendix L: RGP Toronto Service and Funding Agreement Appendix m: Models for Integrating Care for Frail Seniors Appendix N: Other Provincial Integration Activity and Innovations for Seniors Integrated Care Appendix O: Summary of Stakeholder Consultation Appendix P: Essential Features of an Integrated System for Frail Seniors What and Why? Appendix Q: Draft Terms of Reference: CE-RSGS Governance Authority Appendices and Attachments Page 2

3 Appendix A: Terms of Reference CE-LHIN Regional Geriatric Advisory Committee (Expert Panel) Background and Project Scope: The CE-LHIN Specialized Geriatric Services landscape reflects a number of local services that have evolved over many years in response to the changing demographics of an aging population and the local commitment to deliver specialized services for frail seniors. Health Service Providers in the Central East LHIN have long recognized the value of planning and delivering services collaboratively; the need to bring together the system of services designed to meet the needs of high-risk frail seniors living in the community is a common goal. As such, the CE-LHIN has been strategically investing in these services over the last 5 years, including significant enhancements in Geriatric Emergency Management, Nurse Practitioner Outreach and, most recently with the announcement of the region-wide Geriatric Assessment and Intervention Network (GAIN). The CE-LHIN and its health service partners recognize that in order to further advance the planning and implementation of a network of specialized services across the LHIN, inter-organizational collaboration and overall system coordination are now more critical than ever. Through the creation of an organized system and common infrastructure, partners can leverage their existing investments in SGS, potentially extending service delivery beyond what is currently possible. This level of integration requires careful orchestration and full collaboration across and between sectors in order to ensure that a truly seamless model evolves. one that moves Central East closer to a truly ``regional`` geriatric program. The project scope includes: Preparation and submission of a proposed model (including options, recommendations and timeframe) for the organization and coordination (including regional management and governance) of a Regional Specialized Geriatric Program in the CE-LHIN. The model will leverage existing LHIN investments in Specialized Geriatric Services (including GEM, NPSTAT and GAIN) and will incorporate Specialized Psychogeriatric Services in order to ensure enhanced coordination, organization and synergies in overall approach. The proposed model will be principles-driven, built on commitments from health service organizations and will move the region closer to achieving consensus on a vision for Specialized Geriatric Services in the CE- LHIN. Purpose and Accountabilities: The purpose of the Advisory Group will be to provide timely, objective advice and direction on the project within a local context. Specifically the group will: Review the work completed by the Project Lead and provide insight and direction as needed, Be available for just in time advice throughout the project Provide overall direction to ensure that the work is on track to meet deliverables, Deliberate and debate aspects of the regional model and determine where consultation with a broader stakeholder focus group would be advisable, Assist with facilitating some aspects of the focus groups (2 anticipated) in order to maximize input from stakeholders and achieve consensus when needed, Review and approve the final report, including the preferred model, with recommendations and timelines. Appendices and Attachments Page 3

4 Membership: Carol Anderson (Chair) LHIN Lead for SGS Planning Kate Reed LHIN Lead for Integration Dr. David Ryan Regional Geriatric Program (RGP) Representative Linda Dacres Clinical Director, NPSTAT CE LHIN s Nurse Practitioner LTC Outreach Teams Clara Tsang GEM Nurse Practitioner, Rouge Valley Health System (RVHS) Laszlo Cifra Program Director, Aging at Home (CECCAC) Nancy Veloso Director, The Scarborough Hospital (TSH) Pat Dingman Interim Director, Lakeridge Health (LH) Sheryl Bernard Director, Seniors Mental Health (Ontario Shores) Dr. Jenny Ingram Geriatrician, Peterborough Regional Health Centre (PRHC) Dr. Jim Park Physiatrist (Physician with an Interest in the Elderly) Randy Filinski CE LHIN Seniors Advocate, Public Member Meetings and Requirements: Duration of Advisory Group: early February through end of April, Frequency of Meetings: Face-to-face meetings: 4 meetings (early February, late February, mid-march, mid-april) Just-in-time advice: Available by phone or for single issue consultation (? 2-3X) Focus groups: available to assist with facilitating and consensus-building (2 afternoons) Appendices and Attachments Page 4

5 Appendix B: List of Champions and Key Informants Interviewed Raymond Applebaum, CEO, Peel Seniors Link Marlene Awad, Director Administration and Information Management, RGP of Toronto Dr. Barb Clive, Geriatrician, Geriatric Lead, Mississauga Halton LHIN Sandra Easson-Bruno, Project Director, Regional Services, North Simcoe Muskoka LHIN Jodeme Golhar, Project Lead, Integrated Care for Complex Seniors, Toronto Central CCAC Lynn Harrett, Senior Director, Strategic Integration & Community Relations, Central CCAC David Jewell, Director RGP and Juravinski Research Centre RGP Central (Hamilton) Charissa Levy, Executive Director, GTA Rehab Network Dr. Barbara Liu, Medical Director, Regional Geriatric Program of Toronto Annette Marcuzzi, Director Strategic Alignment, Central LHIN Elizabeth McCartney, Director SGS, Southwestern Regional Geriatric Program (London) Jane McKinnon-Wilson, Waterloo Wellington Geriatric Systems Coordinator, Trellis Kelly Milne, Program Director, Regional Geriatric Program of Eastern Ontario - Ottawa Vince Pileggi, Director, Durham Regional Cancer Program, Cancer Care Ontario Eleanor Plain, Administrative Lead SGS and Complex Continuing Care, Providence Care, Kingston Kim Rossi, Manager, Regional Geriatric Services, Regional Municipality of Sudbury Dr. David Ryan, Director of Education and Knowledge Processes, Regional Geriatric Program of Toronto Kelly Simpson, Regional Coordinator, Regional Psychogeriatric Program RMHC London Appendices and Attachments Page 5

6 Appendix C: List of Attendees at Stakeholder Sessions Anderson Carol CE-LHIN 04-Mar Anderson-Roy Doreen VON 04-Mar Barrow Vicki St. Joseph's at Fleming 04-Mar Button Robin Peterborough Regional Health Centre 04-Mar Cassells Janice Ross Memorial 04-Mar Decaire Wendy Ross Memorial 04-Mar Dunn Jodi Ross Memorial 04-Mar Groves-Foley Bev Ross Memorial 04-Mar Hickey Donna PRHC 04-Mar Ingram Dr. Jenny PRHC 04-Mar Jarvis Dave Haliburton Highlands Health System 04-Mar Jilani Dr. Amer PRHC 04-Mar Parr Jane PRHC 04-Mar Raine Jan Campbellford Memorial 04-Mar Readman Terri Ross Memorial 04-Mar Rosenberg Jane Extendicare Haliburton 04-Mar Waters Janice CMHA KL 04-Mar Younis Murad Seamless Care Drug Therapy 04-Mar Bochenek Judy Lakeridge Health 04-Mar Acorn Michelle Lakeridge Health 10-Mar Anderson Carol CE-LHIN 10-Mar Babic Suzanne Durham Region 10-Mar Bowers Tabatha The Scarborough Hospital 10-Mar Brenner Helen Northumberland Hills Hospital 10-Mar Cifra Laszlo CE CCAC 10-Mar Dacres Linda NPSTAT 10-Mar Driver Debbie The Scarborough Hospital 10-Mar Engels Susan The Scarborough Hospital 10-Mar Graham Mark CMHA Peterborough 10-Mar Heffern Judy The Region of Durham 10-Mar Hong Eric Yee Hong 10-Mar James Naresh CMHA KL 10-Mar Kirby Angie Pinewood 10-Mar Lachman Mark RVHS - Psychiatrist 10-Mar Laine Elaine The Scarborough Hospital 10-Mar Lepine Kim Community Care Durham 10-Mar MacDermaid Laura Durham Region 10-Mar MacLeod Cheryl Community Care Durham 10-Mar McLeod Jaclyn Lakeridge Health 10-Mar Appendices and Attachments Page 6

7 McMaster Catha Oshawa Community Health Centre 10-Mar McMullan Janet Lakeridge Health 10-Mar Park Dr. Jim Lakeridge Health 10-Mar Pepin Scott Northumberland Hills Hospital 10-Mar Peto Dr. John RVHS - Geriatrician 10-Mar Secord Paul CMHA Durham 10-Mar Tsang Clara Rouge Valley 10-Mar Veloso Nancy The Scarborough Hospital 10-Mar Wong Roberta St. Paul's L'Amoreaux 10-Mar Yaraskavitch Anne Marie Consumer/Advocate 10-Mar Locke Susan The Region of Durham 10-Mar Oketch Consolata Oshawa Community Health Centre - MD 10-Mar Eyman Theresa Rouge Valley 10-Mar Bernard Sheryl Ontario Shores 10-Mar Ceccato Natalie Lakeridge Health 10-Mar Appendices and Attachments Page 7

8 Vision: Appendix D: Vision, Mission, Values & Principles for a Regional Specialized Geriatric Program in the CE LHIN Better Health Outcomes for Frail Seniors in the CE LHIN Mission: Together, we are accountable to create and deliver an integrated continuum of care that is responsive to the needs of frail seniors and their caregivers and achieves equitable and timely access to quality services at the right time in the right place Core Values: Health planning and delivery of seniors services is guided by a set of core values, including: Integrity Dignity Independence Participation Security and Safety Transparency Trust Foundational Principles: The following principles create the foundation for integrated health services for frail seniors across the Central East LHIN: Equitable Access to Care Innovation and Best Practice Seamless Care Timeliness, Responsiveness Collaboration and Respect Accountability and Commitment Appendices and Attachments Page 8

9 Foundational Principles for a Regionally Integrated Model: Principle Client Perspective Service Provider Perspective Equitable Access Innovation, Creativity & Best Practice Seamless Care Timeliness, Responsiveness Collaboration and Respect * there will be similar options for care irrespective of where I live in the CE LHIN *I know that I will received the best practices/most current care possible *Transitions in care are smooth and I do not need to worry about them (independent of who the provider is) *I trust that I will get what I need when I need it *I take responsibility for my selfcare when I am able and I have confidence that my (primary care provider/team) understands me and assists me with managing my ongoing needs *potential clients receive the same level of service, including identification of those at risk, regardless of where they reside in the Central East LHIN *health practitioners, seniors and caregivers are prepared to test new waters and are open to new ideas and as a result clients receive ``state of the art`` care *providers facilitate a smooth journey for clients at all levels and intersections across the continuum of care *the continuum of care is easily accessed and responsive to the needs of frail seniors when they need it, and *planning, decision-making and service delivery utilize a ``relationship-based`` approach in which seniors, caregivers and service providers work collaboratively to provide care and build capacity Foundational Principle: Accountability and Commitment All providers are committed to, and hold their organization and service providers accountable for, 1. delivering client-centred, integrated senior friendly care, 2. ensuring that decision-making is streamlined and organizational policy and structure are not barriers to timely decision-making or action, and 3. measuring what we do, to ensure that we are delivering on our commitments, and continuously improving upon our performance Appendices and Attachments Page 9

10 Client-Centred Value Statements: I believe that my health team has integrity I want to be treated with respect and dignity I value my independence and want to remain this way for as long as possible I want to participate in my care decisions as a member of the team It is important to me to feel safe and secure I know that my health team is honest and open (transparent) with me I trust that my family and community will make it possible for me to stay in my home as long as possible Appendices and Attachments Page 10

11 Better Health Outcomes for Frail Seniors Together, we are accountable to create and deliver an integrated continuum of care that is responsive to the needs of frail seniors and their caregivers and achieves equitable and timely access to quality services in the right place at the right time INTEGRITY DIGNITY Collaboration & Respect PARTICIPATION Seamless Care Timeliness & Responsiveness INDEPENDENCE Equitable Access Innovation & Creativity Best Practices TRANSPARENCY Accountability and Commitment Client-Centered, Streamlined Decision-making and Continuous Measurement SECURITY TRUST Appendices and Attachments Page 11

12 Linkages: Linkages with Hospitals: (purchase specialty services, in -reach, mandate for coordination, MD consultation Linkages with Primary Care: (co-location of staff, review physician remuneration, mixed model of care) Linkages Other Social and Human Services: (purchase of service for specialty services, high-level crosssectoral committees) Appendix E: Planning Framework for Integration of Specialized Geriatric Services in the CE LHIN Funding Integration (system): Transfer payment arrangements/agreements Financial incentives to promote prevention and Downward substitution of services Excellent Leadership; physician participation Administrative Integration (system): Umbrella organization to guide strategy and service delivery Clear statement of philosophy enshrined in policy Excellent Leadership; physician participation Shared vision and goals Organizational Integration: Co-location of Services Inter-agency planning Discharge/transfer agreements jointly managed programs Strategic alliances or organized provider networks Service affiliations, networks, alliances, MOU s, Service Delivery Integration: Single coordinated entry system Inter-professional Teamwork Ongoing system level Case Management 24/7 on call coverage/access Centralized Intake, referral and info. Joint training and education Integrated information systems Clinical Integration: Standardized/uniform assessment Standardized diagnostic criteria client and family involvement shared clinical records joint care planning Common decision support tools common clinical protocols, guidelines and language Philosophical and Policy Prerequisites Belief in the benefits of the system + Commitment to a full range of services & sustainable funding Commitment to the psycho-social centred care model of care Commitment to client Commitment to evidence based decision making Appendices and Attachments Page 12

13 Appendix F: SGS Service Definitions Inpatient: Acute Care of the Elderly (ACE) Unit/Acute Geriatric Medical Unit (AGMU): Ace Units are inpatient general medicine units for acutely ill older persons who require an admission to an acute care hospital for shortterm diagnostic investigation and treatment AND are at high risk for a prolonged hospital stay due to frailty. These individuals are admitted directly from the ED and would benefit from the ongoing expertise of a specialized geriatric team, as well as a preventative environment. An ACE unit is not equivalent to an ALC unit or an Assessment unit. Inpatient: Geriatric Rehabilitation Units: These are inpatient rehabilitation units for older frail persons who require the expertise of a geriatric team and individualized assessment and treatment in order to regain/maximize function and independence. These units are often located in Complex Continuing Care and the client is admitted for a short duration (typically 4-6 weeks). Note: some hospitals use the term Geriatric Assessment and Treatment Unit or Geriatric Assessment Unit to describe their non-acute inpatient unit for persons with complex medical conditions who require an individualized assessment and rehabilitation program for a short duration. Inpatient: Geriatric Internal Consultation Teams: Specialized geriatric inter-professional teams who provide consultation and assessment for frail older inpatients within an acute care hospital. Consultation teams support the development of care teams and physicians in hospital through education and capacitybuilding. In some situations, the teams participate in case finding for ACE Units or Geriatric Rehabilitation Units, facilitating the seamless transfer to the most appropriate setting. Ambulatory/Outpatient: Geriatric Emergency Management (GEM): Consultation in the hospital emergency department by a specialized geriatric health professional (most often a nurse with gerontological training) who provides: identification of high risk seniors, assessment, diagnosis, initiation of the treatment plan, and linkages with the community and primary care. The GEM practitioner/team work to avoid hospital admissions for non-acute frail seniors wherever possible and provide linkages internally when an admission cannot be avoided. Ambulatory/Outpatient: Geriatric Day Hospital: These hospital-based ambulatory programs provide diagnostic, rehabilitative and therapeutic services to persons living at home who have complex needs and require the expertise of the geriatric inter-professional team for a period of several months. Many clients have been recently discharged home from hospital and have specific individualized needs in order to regain or maximize function and continue to reside safely in the community. Ambulatory/Outpatient: Outpatient Geriatric Clinics: These are specialized clinics used to assess, treat and monitor elderly persons who can travel to the hospital. Clinics may be highly specialized (e.g. memory, incontinence, falls) in order to meet the specialized needs of certain client groups, while other clinics provide comprehensive geriatric assessment. Ambulatory/Outpatient: Outreach Teams: Comprehensive geriatric assessments in the older person s place of residence are conducted by 1 or 2 professionals in geriatric medicine, nursing, social work, psychiatry, physiotherapy or occupational therapy. Other health professionals from the inter-professional team may be called upon to assist with specific care management concerns (e.g. pharmacy, speech language pathology, diet, etc.). Appendices and Attachments Page 13

14 Appendix H: Perspectives on Integration Integration, within the context of Canadian health care, continues to be an elusive concept subject to different interpretations, depending upon one s perspective. According to Banks (2004), integration is a spectrum ranging from tolerance to cooperation, joint ventures, partnerships and mergers. The type of integration activities, as well as the forms and levels of connectedness, depend upon the desired outcomes (MacAdam, 2008). As shown in Table 3, integration can be described in 3 different ways; the type of integration (how strong are the connections between service between providers), form or direction of integration (horizontal or vertical) and level of integration (from clinical to system). In the creation of an integrated health service model for frail seniors, integration activities can involve different levels, types and directions, depending upon what the overall objective of the specific initiative. Table 3. Health Service Integration: Types, Levels and Forms Type Level Form (direction) Full: New organizational entities with authority over the system and control over funding and deliverables (mergers) System: includes responsibility for joint activities for all included services within a geographic area or region (strategic planning, budgeting) Horizontal: integration activities that occur across multiple organizations and settings (disease-based regional programs) Coordination: Explicit agreements and relationships are in place (Memorandums, Funding Agreements, Transfer Agreements) Linkage: Relationships between and among providers Organizational: coordination and management of specific activities between multiple agencies and organizations (central intake, common assessment) Clinical: direct care activities with specific clients (care planning) Vertical: coordination of care delivery between departments and service areas within one organization Note: ( = increasing complexity of integration) According to Kodner (2002), increasing levels of integration are required for populations that are increasingly complex and vulnerable. Specifically, populations with physical, cognitive or developmental disabilities, often coupled with chronic conditions and complex illnesses, have complex needs, resulting in significant challenges related to providing the right services within the context of the existing health care infrastructure. Such vulnerable populations not only have episodic exacerbations of health problems, but also have complicated ongoing needs, (medical, physical, psychological and social), experience challenges with regular everyday living, and require a mix of both care and cure services delivered sequentially or simultaneously in a variety of settings. This population requires well-integrated services in order to maintain both their quality of life and to reduce the overall cost to the health care system. Hence it is not surprising to see that there has been significant work over the last few decades, both nationally and internationally, in the area of integrating health or health and social services for frail seniors. Table 4 provides an overview of the level of integration and maps this to the severity of health issues in the population of interest. Appendices and Attachments Page 14

15 Appendices and Attachments Page 15

16 Table 4. Type of integration and population complexity (adapted from Herbert et al., 2003; and MacAdam, 2008). Level of Integration Features Population Considerations Linkage Formal Coordination Full Integration *Protocols to facilitate referral or collaboration yet each organization continues to function within their respective jurisdictions, responsibility and operational rules. *Formal coordination agreements are established at every level of the participating organizations *Involves the development and implementation of defined structures and mechanisms to manage the complex and evolving needs of patients in a coordinate fashion. Every organization agrees to participate in an ``umbrella system`` and adapt its operations and resources to the agreed upon processes. *An integrated organization is responsible for all services, either under one umbrella structure or by contracting services with other organizations. *Allows individuals with mild to moderate health care needs to be cared for in systems that serve the whole population without requiring any special arrangements *Allows individuals with moderate health needs (utilization of several different services) to be cared for within explicit structures that coordinate care across acute and other health care sectors *Allows for those special populations that are high needs and high risk to be cared for in structures that are responsible for coordinating and delivering the full continuum of services (often health and social) Appendices and Attachments Page 16

17 APPENDIX I: OVERVIEW OF THE FIVE (PLUS ONE) RGP s IN ONTARIO The Southwestern Ontario Regional Geriatric Program London The Southwestern RGP (based in London) has a catchment area covering ten counties and two LHIN planning zones (Erie St. Clair and Southwest LHIN). They focus on providing consultation, education, community development and evaluation, but do provide direct services as well. The program is housed within Specialized Geriatric Services at St. Joseph s Health Care London. The Southwestern Ontario Geriatric Assessment Network (SWOGAN) is a network of specialty teams throughout Southwestern Ontario offering care in ambulatory, outreach and inpatient settings that specialize in the assessment, intervention, and management of frail older persons. SGS programs and services are provided at 2 hospitals (St Joseph s Health Care and London Health Sciences Centre) across all 6 campuses and in a variety of setting across Southwestern Ontario. The Southwestern RGP did not establish itself as a separate entity from its host hospital, but rather as an integral part of the St. Joseph s Health Care London. In the early 1990 s, the Ministry of Health decided not to maintain separate VOTE funding for the RGP s of Ontario and the Southwestern RGP base budget was added to the hospital global allocation. As a result of this budget amalgamation, the RGP, although a separate cost centre, has been exposed to the same hospital financial pressures and annual budgetary challenges were transferred to the RGP as with other hospital programs and services. Over time, the RGP as a unique entity has become a customer-focused service within a much larger network of geriatric services in the region. The RGP provides education, capacity building, training and consultation for complex cases for residents across the entire catchment area. It is noteworthy that London and the surrounding area has moved forward with system-wide planning well ahead of many other regions in the Province and have developed a significant network of geriatric services that are well integrated, innovative and are founded on the principle of capacity building across the system. This has been accomplished largely as a result of both highly supportive hospital administrative champions and the well organized network of Geriatricians (10 FTE s within St Joseph s Health Care London) who work with inter-professional teams across sectors and counties. SGS clinicians are visible, have developed credibility and are seen as supportive to the entire system. The SWOGAN (Southwestern Ontario Geriatric Assessment Network) initiative is an excellent example of capacity building in primary care whereby CGA occurs locally and collaboratively across the region through a network of providers. The network links geriatric and geriatric mental health assessment teams in the ten counties. Regional Geriatric Program of Eastern Ontario RGPEO) The RGPEO serves seniors within the Champlain LHIN. RGP administrative offices are located at the Civic Campus of The Ottawa Hospital. The Ottawa Hospital is an academic health sciences centre and is affiliated with the University of Ottawa for research and academic activities. The RGP provides some direct service delivery (GEM and Outreach), but the other SGS s in the region are administered and operated by the individual organizations involved. Given that RGP s ceased to be funded as a VOTE program in the 1990 s and that there has been no additional MOH RGP funding, each individual hospital has evolved SGS from their own operating funds embedded within their global budget. This does present some challenges as organizations can make significant changes to the services delivered without advice or consultation with the RGP. RGPEO is accountable to its constituents through the Ottawa Hospital and its respective Board. In order to maintain some independence to service the needs of frail seniors across the region, the RGP has a Memorandum of Understanding (see Appendix J) with the host hospital that articulates responsibilities and accountabilities for each organization. RGP is an active participate on the Regional Geriatric Advisory Committee (RGAC) the unofficial planning body per se for geriatrics in the region. This committee originally was established to provide governance, strategic direction and operational advice to the region and has been supported by the RGP. However, with the provincial Appendices and Attachments Page 17

18 implementation of the LHIN s in 2005, the RGAC was asked to expand their mandate and include multiple service providers with an interest in the coordination of care for seniors across the continuum. The mere size of the group (30+ members) has now made it challenging to focus the work on specific initiatives or programs and it has become an information sharing forum. Although much of the work and decision-making related to regional planning is centralized with the RGAC, the committee is an affiliation of service providers without any formal decision-making authority. Major decisions impacting policy or funding require ratification by relevant partner organizations and their separate Boards. In 2009, the Ottawa Hospital made operational changes that impacted the RGP and its leadership. This created a conversation within the RGP as to whether the program should re-locate to another host hospital or consider incorporation and the creation of a separate and distinct governance structure. However, the RGPEO is relatively small (from a resource perspective), but rich from a geriatric expert knowledge perspective. Also, the current LHIN environment encourages cross-sector/continuum planning, integration and coordination. Therefore, the decision was made to remain with the Ottawa Hospital and strengthen the effectiveness of the RGAC through committee re-structuring. In addition, they continue to pursue their mandate through leading collaborative initiatives and projects, where the RGP are clearly viewed as the group that brings informed evidence to the table and facilitates collaboration across the region on issues pertaining to seniors health. The Regional Geriatric Program - Central (Hamilton) The Regional Geriatric Program Central (RGPc) is affiliated with McMaster University and is hosted by Hamilton Health Sciences Centre. The catchment area covers seven distinct areas and now encompasses 3 LHIN planning areas. The RGP administrative staff members are located at St. Peter's Hospital in Hamilton and the program is accountable through the chair and Steering Committee. With the assistance and support from the RGP, the LHIN s have made significant advancements with respect to planning and delivering organized models in geriatric care. In fact, the Mississauga Halton LHIN has a well developed strategy for a regional geriatric program and has begun the implementation of some service delivery level integration work (ASSIST Model). The Waterloo Wellington LHIN has developed innovative programs including the Geriatric Emergency Management Program and Intensive Geriatric Service Worker. They have an established Specialized Geriatric Services Steering Committee and have set priorities. One of the current priorities is the need to integrate more of their service planning. With the implementation of the LHIN s, the RGPc experienced some challenges given that their existing catchment area now spanned three LHIN planning zones with different priorities and approaches. However, the existence of the cross- LHIN RGP Steering Committee (the body responsible for information sharing, planning and coordinating joint activities), already had a strong history of collaboration and was leveraged to facilitate this on an ongoing basis. The RGPc works closely with the Hamilton Niagara Haldimand Brant (HNHB) LHIN where the host hospital is located. During the first year of implementation and through the community consultation process, the HNHB LHIN established priorities that would guide strategic investments over the coming years. Seniors and their health needs were identified as the top 2 priorities for the HNHB LHIN. As such, the Geriatric Assessment and Integration Network (GAIN) Council was created as a go to group for LHIN consultation and advocacy for seniors services across the region. The RGP was also commissioned to complete a foundational piece of work ( Priorities for Specialized Geriatric Services in the HNHB LHIN ) which continues to guide priorities and investments across the LHIN. The RGPc is accountable to the Steering Committee which represents different sectors of care across three LHIN areas. As Hamilton Health Sciences is the host site, the RGPc is accountable to them in relation to overall operations including financial performance. The RGPc is not incorporated, however through the current collaborative structure, the RGPc views itself as fairly nimble with significant autonomy to determine strategic priorities and establish programs and initiatives that are in the best interest of frail seniors in the region. Specialized Geriatrics Kingston, Ontario (formerly the Southeastern Regional Geriatric Program) Appendices and Attachments Page 18

19 The Southeastern Regional Geriatric Program (RGP) located in Kingston, Ontario was fully implemented in It is affiliated with Queen s University has been referred to as Specialized Geriatrics (SG) since 2005 when the host hospital, St. Mary s of the Lake Hospital site of Providence Care, adopted a program management model. The catchment area of Specialized Geriatrics includes Hastings, Prince Edward, Lennox & Addington, Frontenac, Leeds & Grenville and parts of Lanark and Northumberland Counties. The goal of the Specialized Geriatrics Program is to reduce the burden of disability associated with frailty, by detecting and treating reversible conditions and recommending optimal management of chronic conditions. SG is involved in the provision of both assessment services (outreach, clinics and inpatient consultation) and rehabilitation services (inpatient and a Day Hospital). In more recent years, other initiatives have evolved in the region such as the Centre for Studies in Aging (CSAH) under the direction of Dr. John Puxty, Medical Director of SG and Chief of the Division of Geriatric Medicine, Department of Medicine, Queen s University. Through its research and inter-professional educational activities, CSAH located at the Mental Health Services site of Providence Care, strives to increase the capacity and competency of health care professionals in the care of the elderly in various care practice settings. Southeastern Ontario is well known for having a strong Geriatric Psychiatry Program that is well integrated into the community under the leadership of Dr. Ken LeClair, Program Director. One of the priorities established for the SG program included increased collaboration between SG and Geriatric Psychiatry Services (GPS). Subsequently, a small working group (Let s Get Started), consisting of representatives from both programs, came together in 2010/11 to develop strategies to enhance integration between these two services. One of the successful outcomes from this partnership was the development and implementation of a knowledge-to-practice strategy, Creating Future Leaders in Elder Care a strategy that brought together the two specialties to build a Community of Practice. The SG-GPS Let s Get Started working group continues to meet regularly and work towards further clinical service integration activities such as client information sharing between the two Programs. The Regional Geriatric Program of Toronto The RGP of Metropolitan Toronto serves a broad geographic catchment area with a large population base comprising many frail seniors. To best meet the needs of these seniors the RGP has focused on facilitating the development of evidence based frailty focused services that span the continuum from home, hospital, post-acute and rehabilitative care, building capacity across the system. These strategic areas of focus are enabled by developing services/programs across multiple sites, making it easier for people to get services close to home, and developing and making tools and educational materials available broadly to clinicians, regardless of where they practice. The RGP in Toronto is unique in being accountable for achieving key deliverables across multiple hospitals. These include the original set of academic teaching hospitals now linked in a network that supports seniors services and capacity building in 28 organizations. In 1993, the RGP formed a corporation governed by a Board of Trustees. The Board, comprised of representatives of key stakeholders from across the community, establishes the strategic directions to be implemented by the RGP Administrative Team and its network. The RGP is led by an Executive Director with administrative headquarters at Sunnybrook Hospital Health Sciences Center. Through its governance structure the RGP is able to support the preservation of services, provide a credible source of advice on seniors care across the region, and link otherwise independent organizations in building better health outcomes for frail seniors. The RGP facilitates the preservation of services in network organizations through participation agreements. The RGP of Toronto s participating organizations are linked formally by Service and Funding Agreements (see Appendix K) which outline expectations and accountabilities for RGP funded services and Participation Agreements (see Appendix L) that clarify expectations and roles related to network activity. The RGP has been successful in sustaining SGS services in originally funded hospitals, obtaining new monies to develop and diffuse service innovations within the network and across the five LHINs with which it is directly affiliated. In addition to their local impact, though their broad focus the RGP of Toronto also leads provincial initiatives including the 90 member Geriatric Emergency Appendices and Attachments Page 19

20 Nursing Network, the Geriatric Inter-organizational Inter-professional Collaborative (GiiC) and more recently the Provincial Senior Friendly Hospital Self Assessment Process. The North Eastern Regional Geriatric Program Sudbury Perhaps one of the more unique arrangements for the organization and coordination of regional geriatric services in Ontario is the North East Specialized Geriatric Services (NE SGS). The program had it s genesis in a 1999 municipal master plan that acknowledged a rapidly aging population. As years went by the City of Greater Sudbury recognized the need to dedicate resources to this initiative and in 2005 collaborated with the Regional Geriatric Program s of Ontario. The City had also established communication with a PGY4 medical resident (with a local connection to the area) who later became and continues to be the first permanent Geriatrician in the region. In 2007 a proposal was drafted in collaboration with the RGP s, medical resident and City that identified the need to create an interprofessional model to support the sole Geriatrician. In 2008, the LHIN provided seed money to begin to build the North East Specialized Geriatric Services, but it was expected that the program would support a regional mandate. The City of Greater Sudbury, in 2008, continued to support this regional model by entering into a three year purchase of service agreement with the sole geriatrician who services the whole North East. The North East Specialized Geriatric Services was operational March 2009 and the funding was doubled to enable the creation of a LHIN-wide regional program. To date the program continues to be managed by the City of Greater Sudbury and the specialized geriatric team, which consist of administrative support, and allied health care professionals are all employees of the local municipal government and are accountable to the public through city council. Funding flows through the municipal long term care home envelope. The program is supported by an Advisory Panel with broad representation from stakeholders and interest groups. Specialized Geriatric Services continues to flourish as the local hospital (Sudbury Regional) has invested in hospitalbased geriatric services, such as GEM, Day Hospital and ACE Unit, as well as the St. Joseph s Complex Continuing Care Unit has a Geriatric Rehabilitation Unit, all of which are supported by the North East Specialized Geriatric Services with respect to capacity building (planning, education and staff development). The NE SGS is affiliated with the Northern Ontario School of Medicine as a clinical placement site for PGY3 students in The Care of the Elderly as well as medical and allied health care students. Currently the NE SGS is involved in regional capacity building (host for the GiiC work for the entire region), direct service in the community (outreach and clinics) and advocacy for service enhancement and resources. The NE SGS is recognized as an affiliate of the RGPs of Ontario. They have currently drafted a strategic plan with four goals and are currently focusing on Goal #1 which is to adequately resource the NE SGS and Goal #2 to establish and coordinate a Regional Geriatric Network. There is an immediate emphasis on access and the development of primary care capacity. The plan includes the use of Geriatric Assessors and family physicians with training in Care of the Elderly a realistic interim plan given the health human resource crisis that is exemplified in remote regions of the province. The NE SGS articulates several factors that facilitated their success in developing a regional model including: i) a supportive LHIN that provided funding, ii) Physician Champion that was well-respected in a leadership role, iii) support from several of the RGP s in capacity building and regional planning, iv) a collaborative approach with the partners in care, and v) gaining primary care support through a supportive approach ( how can we help you to care for these clients? ). It is also likely that the success of this program and the ability to develop a strong sense of community responsibility was the programs independence from any one individual organization. Appendices and Attachments Page 20

21 APPENDIX J: MOU BETWEEN RGPEO AND THE OTTAWA HOSPITAL Appendices and Attachments Page 21

22 Appendices and Attachments Page 22

23 Appendices and Attachments Page 23

24 Appendices and Attachments Page 24

25 Appendix K: RGP Toronto Participation and Agreement THIS AGREEMENT made as of the 1st day of, The Regional Geriatric Program of Metropolitan Toronto Participation Agreement BETWEEN: The Regional Geriatric Program of Metropolitan Toronto, an Ontario Corporation referred to as the RGP AND RECITES as follows: HOSPITAL NAME referred to as the Participating Organization, an Ontario corporation A. The objectives of the RGP are to promote and facilitate the development of Specialized Geriatric Services for frail seniors in the Greater Toronto and surrounding Areas and to further academic development in geriatric teaching and research. The RGP achieves this objective through collaboration among its Participating Organizations, each of which signs a Participation Agreement, and through its affiliation with the University of Toronto. B. The RGP and a Participating Organization enter into this agreement for the purpose of strengthening the capacity of the RGP and the Participating Organization to achieve the RGP s vision and advance its mission of service, teaching, research, advocacy, and regional leadership (new vision and mission in Schedule A), and of strengthening the Participating Organization s capacity to advance its own Specialized Geriatric Services. C. The parties intend to set out in this agreement their understanding of the relationship. Appendices and Attachments Page 25

26 NOW THEREFORE the parties have agreed, for good and valuable consideration (the receipt and sufficiency of which is hereby acknowledged), as follows: I DEFINITIONS In this agreement: Board of Directors means the board of directors of the RGP. Catchment Population means that portion of the Target Population being served by a Participating Organization, usually defined by geographic boundaries. Client means a member of the Target Population receiving Specialized Geriatric Services through a Participating Organization. Funding Agreement means the form of the agreement entered into annually between the RGP and each Participating Organization in receipt of annual operating funds through the RGP. Members of the Corporation means those organizations and individuals that have been admitted by the Board of Directors as members of the RGP. Network means an interconnected system of organizations, agencies, and providers sharing a common purpose and mutual benefit. Participation Agreement means this and identical agreements between the RGP and other Participating Organizations. Participating Organizations mean those providers of Specialized Geriatric Services that have signed Participation Agreements with the RGP. RGP Core Services means the following Specialized Geriatric Services endorsed by the RGP: acute geriatric units, geriatric rehabilitation units/geriatric assessment and treatment units, internal consultation teams, outreach teams, day hospitals, geriatric clinics, and geriatric emergency management. Specialized Geriatric Services means those services, which are provided on a consultative basis by an interdisciplinary team of health professionals in a variety of home, ambulatory, long-term care, and inpatient settings. The services provided include diagnoses, treatment and rehabilitation of frail seniors with complex and multiple medical, functional and psychosocial problems. Target Population means frail seniors, in any setting, whose health, independence and dignity can be enhanced by Specialized Geriatric Services. The target population is characterized by complex and multiple medical, functional, and psychosocial problems II Purpose and Principles This agreement is standard to all Participating Organizations. The parties concur that the purpose of the agreement is to: 1. express mutual respect and support of the Participating Organization for the RGP s vision and mission and of the RGP for the Participating Organization s vision, mission, and operating practices in carrying out the RGP s mandate; and 2. express a mutual commitment to promote and facilitate thoughtfully planned and carefully managed Specialized Geriatric Services. The parties concur that the principles underlying the agreement are: Appendices and Attachments Page 26

27 1. equitable access by the Target Population to high quality Specialized Geriatric Services based on the needs of the Client and the Catchment Population; 2. a commitment to achieve outcomes and deliverables consistent with the RGP s strategic plan and that of the Participating Organization; and 3. collaborative working relationships among Participating Organizations and others concerned with providing services to the Target Population and mutual responsibility for achieving the RGP s vision. III RGP Responsibilities and Deliverables The relationship between the RGP and the Participating Organizations is reciprocal and based on mutually agreed responsibilities and deliverables. The RGP agrees to: 1. undertake initiatives that add value to the Network of Participating Organizations. 2. make every reasonable effort to develop a regional consensus, with Participating Organizations, Members of the Corporation, local health integration networks (LHINs), and other interested parties as to the need for, distribution of, and best practices for Specialized Geriatric Services; 3. advocate for the resources required to develop sufficient Specialized Geriatric Services to meet the needs of the Greater Toronto and surrounding Areas; 4. promote close working relationships among providers of specialized geriatric and psychogeriatric services to eliminate duplication and gaps in service; 5. develop information systems and databases that support the information needs of the RGP, its Participating Organizations, and the Ministry of Health; 6. collect and analyze appropriate aggregate data, identify and review trends, prepare reports, and disseminate relevant information to Participating Organizations, referral sources, and the Ministry of Health & Long-Term Care to support planning and policy development for Specialized Geriatric Services; 7. comply with PHIPA (the Ontario Personal Health Information Protection Act); 8. foster quality of geriatric care by: a) offering relevant continuing professional education, b) providing regional leadership for effective geriatric research, education, and training programs within Participating Organizations, members of the Corporation, and in collaboration with the University of Toronto, c) conducting appropriate evaluative studies of Specialized Geriatric Services, and d) stimulating the identification, development, dissemination, and use of evidence-based practices; 9. develop and implement annual operating plans that reflect the RGP s vision, mission, strategic direction; and Appendices and Attachments Page 27

28 10. Actively promote the activities and accomplishments of the RGP and its Participating Organizations to the health care community, government, and the public. IV Participating Organizations Responsibilities and Deliverables In turn, the Participating Organization agrees to: 1. support and participate in the activities of the RGP; 2. provide consistent clinical and management leadership that supports the activities of the RGP; 3. support health care providers in the delivery of interdisciplinary, senior-friendly, and evidence-based care that optimizes the function and independence of seniors and supports aging in place; 4. support and participate in: a) the RGP s data collection initiatives and reporting mechanisms; b) evaluative studies of Specialized Geriatric Services; c) health systems planning related to assessing the need for, distribution of, and best practices for Specialized Geriatric Services; d) RGP educational initiatives; and e) coordinating and ensuring access to local Specialized Geriatric Services; and 5. disseminate pertinent information to appropriate staff within the Participating Organization. V Liability and Indemnity The Participating Organization shall indemnify the RGP and shall hold it harmless with respect to any claim and/or associated cost relating to any settlement or judgement due to the fault of any employees of the Participating Organization or any other person for whom it is legally responsible. The RGP shall indemnify the Participating Organization and shall hold it harmless with respect to any claim and/or associated cost relating to any settlement or judgement due to the fault of any employees of the RGP or any other person for whom it is legally responsible. Appendices and Attachments Page 28