Regional Geriatric Program of Eastern Ontario 2015 ANNUAL GENERAL MEETING

Transcription

1 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

2 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

3 CDN: Where We ve Come From 1 Project Definition & Scoping 2 Review of Models 3 of Care Environmental Scan Project Advisory Committee Models of the Dementia Experience Proposed scope of integration Engagement of Primary Care January 2013 Literature review: Integrated Dementia Programs Caregiver Surveys Key Informant Interviews: Select Chronic Care Programs Review of regional needs surveys National / Provincial Database reviews Champlain CCAC dataset 4 Analysis 5 Integrated Model of Dementia Care 6 Final Report Developed Profile Review of Organisational Best Practices Best Practices adaptation from System Integration Toolkit Advisory Committee Strategic Framework Proposed activities Focus Groups On-Line Survey March 31, 2013

4 Preliminary Profile of Persons with Dementia

5 Preliminary Profile of Persons with Dementia: Champlain 2012 People With Dementia 3,739 LTC 3,100 New 175 K Primary Care Visits (ICES 13.6) 55 K Day Pgm. Days 1,688 PWD 6.2 K Visit ED (ICES 45.9%) 5.2 K Visited By Home Care (ICES 38.5%) 3.2 K Admitted ALOS (ICES 23.7%) 3.3 K Retirement Homes 1.1 K Newly Placed (ICES 7.9%) 18,400 PWD: 30% Increase ,588 in Community (ICES) 4 th Highest of 14 LHINs 34 % 1/3 PWD Admissions ALC ALOS (ICES) 34% of ALL ALC Days (CIHI) +3,100 New 1.3 K New First Link (AS) % Experience a Decline In Health (ASO Evidence Brief) Caregivers

6 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) 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 Estimated average cost of inpatient hospital services (CIHI Cost Estimator for Ontario )

7 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)

8 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!

9 Integrated Model of Dementia Care Strategy Outcome Public Awareness Detection & Diagnosis Self-Management & Caregiver Support System Navigation Coordinated Pathways of Support System Integration Improved awareness & community support Earlier detection & diagnosis of Persons with Dementia Promotion of activities & attitudes to live well with dementia. Persons with Dementia & caregivers know what to expect and where to find it Prevent & manage the complications of dementia, by providing choices that matter Enable a system of support that is tailored & targeted to their changing needs

10 Where we are today System Integration System Integration Regional Steering Committee* Coordinated Funding Envelope Caregiver Support Role in governance & planning* First Link* / Caregiver Support Line 2013 / 14: $320 K Early Detection & Diagnosis Primary Care Memory Clinics* Memory Disorder Clinic 2014 / 15: $426 K Public Awareness Regional Coordination of Dementia Education* Year 2 of Rethink Dementia Public Education Campaign Pathways of Support LHIN Liaison Link with Diabetes Clinics * New Investments by Champlain LHIN

11 Pilot Project: Coordinated Access & Caregiver Support 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

12 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

13 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

14 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

15 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)

16 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 16

17 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 17