Neil Walker, Vice President North Simcoe Muskoka Local Health Integration Network

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1 190 Cundles Rd. East, Suite 205 Barrie, ON L4M 4S5 Phone : Toll Free : Annual Report Working in partnership to make our system better for seniors and their caregivers Carol Lambie, President & CEO Waypoint Centre for Mental Health Care We are pleased to report that the North Simcoe Muskoka Specialized Geriatric Services (SGS) Program completed its first full year of operation in ! It was an exciting year of successes and accomplishments. We worked with our partners to initiate the program and set our path for the future. The vision for the SGS clinical service was defined and plans were set in motion to redesign the North Simcoe Muskoka Behaviour Support System. With an early focus on older adults with cognitive impairment and responsive behaviours, new staff were hired, education was provided and the Behaviour Success Agent project was successfully completed in our NSM hospitals. New physicians Neil Walker, Vice President North Simcoe Muskoka Local Health Integration Network were also recruited into the region by the SGS team and our partners. We would like to express our thanks to the partners that helped us with the planning and implementation of the various SGS initiatives this year. It was amazing to see everyone s commitment to improving access to quality care for the residents of North Simcoe Muskoka. We would also like to recognize the families and informal caregivers of our seniors who work tirelessly to ensure their loved ones receive the care they need. As we move ahead in , we are excited to build on the accomplishments that have been achieved this year. Carol Lambie & Neil Walker Co-Chairs, NSM Seniors Health Project Team In This Report Year-End Message Page 1 What are Specialized Geriatric Services? Page Highlights Page 3 Key Projects Page 4 Looking Ahead Page 6

2 What are Specialized Geriatric Services? A New Program within North Simcoe Muskoka Specialized Geriatric Services SGS are hospital and community-based health care services supporting frail seniors and their caregivers. Care is provided by a team of health care professionals with expertise in geriatric medicine and geriatric psychiatry. The team supports the assessment, diagnosis and initial management of issues commonly seen in seniors with frailty. Team members typically include: specialist physicians like Geriatricians, Geriatric Psychiatrists, Care of the Elderly Physicians; Nurses; Social Workers; Occupational Therapists; Physiotherapists; Pharmacists; and Clinical Dietitians. Who is a Frail Senior? While most seniors live healthy and active lives, some become frail, facing complex health problems putting them at risk of losing their independence. This can increase the risk of Emergency Department visits, hospital admissions and/or being placed prematurely in a long-term care home. These seniors can have multiple chronic medical conditions as well as geriatric syndromes like dementia, depression, falls, weakness and other issues. This complex presentation can complicate accurate assessment, diagnosis and treatment. Oftentimes there are social situations at play which impact the senior s home situation or caregiver supports. This can further complicate care. It s a bit like a house of cards. pull one card out and things start falling apart! What Difference will this Program Make? Various Specialized Geriatric Services (SGS) have emerged in North Simcoe Muskoka over the last 10 years. Often working apart from each other, our goal is to begin to bring them together to build a single integrated system of services. The North Simcoe Muskoka SGS Program will: Improve the abilities, independence and quality of life of frail seniors and their caregivers to promote aging in place. Improve the quality of care provided to older adults with cognitive impairment and responsive behaviours. Enable better care coordination and communication among health care providers. Increase the knowledge and skills of health care providers to assess, diagnose and manage frail, complex seniors. Better use existing health care resources. Reduce avoidable Emergency Department visits, hospital admissions and premature admissions to long-term care. Page 2

3 Highlights A Year of Great Accomplishments Leadership The full SGS Program leadership team was hired. The SGS Physician Network was established. This gives doctors with expertise in seniors care a chance to regularly connect to discuss care and practice issues. The SGS Program joined the Regional Geriatric Programs of Ontario, connecting us with other SGS Programs across the province. An office site was established in Barrie providing a place for the team to work together and with our partners. Clinical The Clinical Design Report & Recommendations document was completed giving us a roadmap to help plan our clinical services and programs. New staff were recruited by the SGS Program and our partners which will help continue to improve care in the region. Initial work around the redesign of the NSM Behaviour Support System (BSS) was started to improve care to older adults with cognitive impairment and responsive behaviours. The Behaviour Success Agent (BSA) project was completed within all NSM hospital sites which included the establishment of new regional standards of practice. The Complex Case Resolution process was put in place to support discharge planning for seniors with complex responsive behaviours. The Victorian Order of Nurses (VON) secured funding for to continue their Enhanced SMART Program in Barrie and Orillia, targeting frail seniors requiring exercise programming. Education & Mentorship An Education Strategy was completed and will be used to guide our training, coaching and mentoring work in the coming years. A variety of education events were completed throughout the year to build the knowledge, skill and judgment of NSM health care providers Key Numbers 2 # new geriatric specialist physicians working in the region 6.6 # new permanent BSS staff 896 # seniors supported by BSS team & BSAs 5,605 # education encounters by BSS team & BSAs 220 # seniors admitted to VON Enhanced SMART classes Page 3

4 Key Projects Clinical Service Design In 2016, a Working Group of 33 individuals came together to develop a plan for the clinical services within the SGS Program. With frail seniors and their caregivers in mind, the group s design will: Improve patient outcomes Enhance system capacity Promote a more affordable, sustainable and accountable system The clinical design outlines key services and resources for frail seniors and their caregivers. It includes plans for a central intake service with the goal to create one number to call for those needing care from the SGS team. Within the clinical design, recommendations include: building five SGS teams across the region; building a toolkit of standardized regional resources; increasing partnerships between geriatric medicine and geriatric psychiatry teams; and improving communication among health care providers so everyone is aware of the senior s needs and plan of care. The clinical design plan will guide the implementation of our clinical services in the coming years. With this roadmap in hand we have a clear course ahead that will continue to improve the health and wellbeing of NSM seniors and their caregivers. Education Strategy In keeping with our mandate to build the knowledge, skills and judgment of frail seniors, their caregivers and health care providers, the Education Strategy was developed through this strategy we hope to: increase the number of skilled health care providers in the region; increase education and mentorship for providers and students interested in working with seniors with frailty; standardize and spread leading practices; and, increase the selfmanagement abilities of frail seniors and their caregivers. In within the SGS Program 45 education events took place. These events focused on SGS Program updates as well as clinical topics like delirium, dementia, polypharmacy, anxiety and pain. More than 1012 health care professionals participated in these sessions. Between December March 2017 additional education was rolled out specific to responsive behaviours. Using Behaviour Supports Ontario (BSO) funding, events focused on Behaviour Support System staff and other health care providers. Events focused on: Recovery Mental Health; PIECES; Intimacy and Sexuality in Dementia; and Compassion Fatigue. This funding provided 26 education days and 13,910 hours of education. As a highlight, 19 providers in the region became trainers in compassion fatigue and all Behaviour Support System staff received certification in Mental Health Recovery! Page 4

5 Key Projects Behaviour Success Agents: A Success Story! Between July March 2017 Behaviour Success Agents (BSAs) were placed in each NSM hospital site. This project between the NSM LHIN, the SGS Program and area hospitals, focused on improving the care of hospitalized older adults with cognitive impairment and responsive behaviours. Thanks to the hard work of all partners, including the BSAs, project deliverables were completed and our performance targets were met and surpassed! Description Targets Totals # Individuals Served # of Visits # of Education Occurrences To promote a standardized approach to care across the region, the BSAs developed a classification of behaviours, a best practice guideline and identified assessment tools for use. Education resources were developed to support staff and caregiver education and a Behaviour Support System Community of Practice was established. BSAs also received significant training and mentoring which they will carry forward into their post-project practice. During BSA involvement, there was a reduction in the frequency of the primary behaviour, the use of physical restraints and the frequency of behaviour medication use. New cases of delirium were identified (a geriatric emergency) and there was improved documentation and care planning. Several NSM hospitals saw such benefit in the BSA role that they have maintained the resource using their hospital funds. Other hospitals have built champions and put plans in place to help sustain project gains. I feel we have accomplished more than simply completing tasks and meeting deadlines. As a team, we have delivered sustainable, cohesive, patient-centered care. More important, we have emerged as a working example to all healthcare providers within our LHIN of what can be accomplished when organizations work together. Behaviour Success Agent Behaviour Success Agents Page 5

6 Key Projects Behaviour Support System Re-Design Using the Clinical Design Report & Recommendations document, this year focused on the redesign of the North Simcoe Muskoka Behaviour Support System (BSS). We examined current resources in the region, reviewed best practices and considered both provincial directions and the experiences of partners in other regions. The following key changes will be put in place in : Current resources in the region will be brought together to form a single, integrated team with the goal to improve communication and care. BSS team members will spend more time in each Long-Term Care Home (LTCH) to provide just-in-time support to staff and residents and to support behaviours before they become difficult to manage. The Behaviour Intervention Response Team (BIRT) will be disbanded and the resources used within the BSS team for more specialized care like behaviour mapping. This year additional resources were also added to the BSS team through new Behaviour Supports Ontario funding. This has helped us fill identified gaps in service. Looking Forward: With a focus on the needs of frail seniors and their caregivers, the SGS program will continue to work with our partners to improve patient outcomes, build capacity and foster system change. The focus in will be on redesigning the system, starting with the Behaviour Support System. We will be moving resources, standardizing practice and increasing staff knowledge and skills. Our goal is to complete BSS redesign this year. We will also watch and plan for the release of the provincial Dementia Strategy and associated funding, including new funding for behaviours across the province. In we will also be reviewing the Clinical Design Report & Recommendations document to identify our next steps in redesign planning beyond behaviours to include other services for seniors. The development of a guideline for LTCH prescribers for the appropriate use of antipsychotics for LTCH residents will be completed and rolled-out early in the year. Our work around an electronic health record will continue as we strive for improved communication and information sharing among providers within the senior s circle of care. Finally, we will stay connected with our local partners and our provincial SGS Program counterparts to ensure our work is aligned and that we are working together to advance care for frail seniors and their caregivers across the region and the province. Page 6