GAIN Comprehensive Primary Health Care for Seniors in the Central East LHIN. James Meloche Senior Director, System Design and Implementation

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1 GAIN Comprehensive Primary Health Care for Seniors in the Central East LHIN James Meloche Senior Director, System Design and Implementation 1

2 Investing in the Seniors Aim A Comprehensive Primary Health Care Model for At-Risk Seniors GAIN Community Teams Comprehensive System Navigation Adult Day Programs Assisted Living Services Improved access to CCAC home care services.

3 Central East LHIN Specialized Geriatric Service Entity (RSGS) The LHIN and the RSGS are active collaborators in the design and implementation (pending approval) of the proposed GAIN enhancement. RSGS and LHIN Leadership have established project management structure that will engage patients, system leaders and front-line staff in the implementation of this strategy.

4 Recommended Community Investments COMPREHENSIVE SYSTEM OF PRIMARY HEALTH CARE FOR AT-RISK SENIORS

5 Comprehensive Primary Health Care: Opportunities and Solutions At-risk frail seniors should receive primary care by interdisciplinary Primary Health Care Teams All primary health care teams should have: interdisciplinary geriatric programs for complex chronic seniors that includes mental health services Care coordination from nurses across the continuum have access to specialized services with a network. 5

6 What the Research Tells us about Successful Models of Comprehensive Care for At-Risk Seniors Includes collaboration between community-based primary health care and at least one of home care, secondary/specialist, or tertiary/acute; provides care to a population defined within a geographic boundary or defined network of providers; is person-focused, that is, not defined by a specific disease or condition; and includes (but is not necessarily limited to) older persons with complex health and social needs. Walter Woodchis (2013) 6

7 Creating Systems of Primary Health Care For Seniors In The Central East LHIN A Central East LHIN Comprehensive Primary Care Model for Seniors will be embedded in a system of care that features: GAIN Community Teams Inclusive care planning, navigation and service delivery Community-based geriatric teams working in concert with Primary Care Access to specialized geriatric services (GAIN clinics) and programs, such as Assisted Living and Adult Day Programs. GAIN Clinics Primary Care Assisted Living Adult Day Programs 7

8 Origins: Geriatric Assessment and Intervention Network Local Community Inter-professional Team Health Career Case Manager for Frail Seniors Specialized Geriatric Services Team Urgent/Emergent Clinics Technology and Tools Community Assessment Capacity Building Health and Social Service system Navigation Roster of in-home clients Liaise with Hospitals, clinics and community providers Assess and Provide Support for complex cases referred from Primary Care Refer/Link with specialists Support community interprofessional team Rapid assessment and referral Ambulatory care for seniors with urgent / emergent needs Common Assessment Sharing Health information Enhanced use of telemedicine. We are here We are here In 2010, stakeholders across the LHIN created a model to support frail seniors. The LHIN was able to initiate a part of this vision through the establishment of 4 GAIN clinics 8

9 Seniors System of Care Opportunity in The Central East LHIN Accelerate the realization of the comprehensive GAIN strategy, adapted to current context (e.g., Health Links) to realize a Comprehensive Primary Health Care Model for At-Risk Seniors Expand GAIN Clinics from a treatment, assessment (and follow-up) model into a comprehensive managed care model or philosophy supporting Primary Care models within a Health Link. Create GAIN Community Teams that will support patients at-home, in the community. GAIN enrolled patient population would be determined through a shared clinical assessment (including CCAC) and willingness of Primary Care team (NP, Physician) to agree to a shared care approach Establish a comprehensive case management/navigation role through Health Career Case Managers. 9

10 Central East LHIN System of Care for At-Risk Seniors: Principles Enrollment for high risk seniors within a defined population Inter-professional clinical care model supported by gerontological best practices, standardized assessment and protocols. Patient Integrated Care Plans supported by enhanced system navigator role. After Hours patient support. Rapid Team mobilization. Enrolled patients tethered to community health services, namely Adult Day Programs, Assisted Living, Transportation, and home care supports. Patients Remain with their primary care provider. Mutual support/shared care between primary care and GAIN teams. 10

11 Health Career Case Management Stakeholders are collaborating on a enhanced model of a patient navigator, the Health Career Case Manager. Key Features of the Role: RN role to work directly with Primary Care physician and other clinicians in carrying out integrated care plans for each client Intensive case management (1 HCCM to 30-45patients) Navigate clients across health sectors and social services. This includes both direct access to the GAIN Community Team and facilitated access to community supports. Positioned within the Central East CCAC to compliment, but extend beyond, current CCAC case management models. 2 HCCMs embedded within each GAIN Community Team

12 GAIN: A Comprehensive Primary Health Care Model for Seniors Integrated Care Plan GAIN Pharmacy GAIN Rehab GAIN Social Work GAIN NP Patient GAIN BSO Primary Care Geriatric Specialists GAIN Health Career Case Manager Access & Navigates Adult Day Program Social Supports Transportation In Home Care (CCAC & CSS) Assisted Living Acute Care (ACE) Rehabilitation / Restorative (Hospital/LTC) Psychogeriatric Services Palliative Care Direct Care In-Direct, Facilitated Care Denotes dedicated GAIN resources Denotes patient s existing physician 12

13 Primary Care ADP Primary Care ADP Community Support Assisted Living Community Support Assisted Living 13

14 Expectations of Successful GAIN Community Applicants Participate in the Design, Implementation, Branding and Quality Improvement initiatives supporting the strategy. Provide/leverage in-kind supports to the GAIN community team, such as position sharing, back-office, other. Establish MOUs with other health service providers defining the circle of care (ADP, ALSSH, Transportation, Home visiting, etc) in order to improve patient access to services, health care information and follow-through on shared care plans. Enter into similar shared care arrangements with interested primary care providers within the geography Report on progress/results Be fully implemented no later than March

15 GAIN Community Team: Staff Resources Teams will reflect best practice for comprehensive primary care teams for seniors. Core functions will need to be met by each team. Teams will be provided some flexibility in recruitment and staffing approaches within human resource budgets. HSPs will be expected to leverage inhouse resources to support the directcare team. Position Required / Optional Health Career Case Manager (RN) Behavioural Support Staff Nurse Practitioner MSW Pharmacist PSW Dietician Occupational Therapist and/or Physiotherapist Speech Language Therapist Clinical Admin Required Focused Investment Required/In- Kind Optional Required Optional Optional Required Optional Required 15

16 GAIN Clinic-Community Pairings Scarborough Cluster GAIN Hub: TSH General and RVHS Centenary GAIN Community teams: St. Paul s L Amoreaux Centre Carefirst Seniors Durham GAIN Hub: LH Oshawa GAIN Community Teams Oshawa CHC North East GAIN Hub PRHC GAIN Community Teams Kawartha Lakes-Haliburton: RMH/CCKL Northumberland: Port Hope CHC Peterborough: PRHC 16

17 Aligning Behavioural Supports to GAIN Teams (1) We know that a large percentage of the target population of at-risk seniors supported by the GAIN teams will have mental health issues or dementia. Behavioural Supports Ontario: Background The LHIN has a well-established BSO model within the LTC Sector. Progress Continues. We have anticipated the expansion of the BSO model to the Community (i.e., clients living outside of Long-Term Care), but have lacked a delivery model to effectively implement. Community BSO Resources have resided at the Central East CCAC until the Community Stream was developed 17

18 Aligning Behavioural Supports to GAIN Teams (2) The LHIN proposes to utilize the GAIN enhancement as a means to deploying behavioural support staff to the community. This will require the reallocation funds presently at the CE CCAC as per the following: GAIN Clinics will receive BSO Staff to support clients and education of GAIN teams. 1 FTE: PRHC, RVHS, and TSH GAIN Clinics 2 FTE: LH GAIN Clinic 1 FTE: Port Hope CHC and City of Kawartha Lakes CHC GAIN Community Teams Additional funds for approximately 3 additional FTE will continue to reside at the CCAC for future consideration. 18

19 Health Service Provider Commitment The Central East LHIN has reviewed the GAIN strategy, expectations, and funding parameters with the Health Service Provider proponents whose proposal was selected by the review process. All six proponents have committed to the strategy and expectations as outlined herein. The LHIN and Health Service Providers are committed to have the GAIN community teams implemented no later than April 1, 2014.

20 Key Messages to Primary Care Physicians GAIN teams seek to support Primary Care physicians with their complex elderly patients. Patients enrolled with the GAIN community team will remain with their existing primary care provider. GAIN will work with all primary care models in the assessment, design, implementation and monitoring of individualized, integrated care plans for each patient. There will be open access and communication between the GAIN team, primary care team, and patient/family supported primarily through the patient s Health Career Case Manager (RN). Primary care will be involved in patient conferencing as required, and will provide advance access as needed. Primary Care can continue to refer patients to the GAIN clinics for comprehensive geriatric assessments. The LHIN has shared this concept with its Primary Health Care Advisory Group to positive reviews. The LHIN is committed to work with Primary Care physicians in the further development of this model. 20

21 Weaving the GAIN Teams into a Comprehensive System of Primary Health Care Through the Community Funding, the LHIN deliberately set out to create systems of care by bundling GAIN Community Teams with local investments in Adult Day Programs and Assisted Living Services. Within each cluster, funded health service providers will be expected to enter into formal MOUs with other health service providers defining the circle of care (ADP, ALSSH, Transportation, Home visiting, etc) in order to improve access, information sharing, and shared care.

22 Adult Day Programs The Adult Day Programs play a key role in supporting an individual and their caregiver(s) in leading active and meaningful lives. ADP services were expanded in various locations across the LHIN in 2008/09 through Aging at Home Strategy funding. Further investments were made in: : 45 new clients : 135 new clients Adult Day Programs are a core feature of the comprehensive system of care for at-risk seniors as they: Provide activation for patients, and relief to informal caregivers Provide opportunity of a medical home for the GAIN Community Team

23 Assisted Living for High Risk Seniors ALSSH to be provided to eligible high risk seniors at all times (24/7) both on a scheduled and unscheduled basis. Services Include: Personal Support Services Homemaking services Security checks or reassurance services Care Co-ordination Central East LHIN is using 30 clients as a guideline for an optimum number of clients to be served within a hub with a target response time of <15 minutes and a minimum response time of 30 minutes

24 Final Thoughts: Comprehensive Primary Health Care for At-Risk Seniors Low estimate at 60 enrolled clients per GAIN Community Team, with teams funded at a maximum of $620,000: $10,333 cost per patient / yr 131,400 more days at home or in the community each year 240 additional seniors receiving Assisted Living Services for $3,151,780 $13,132 cost per client / yr 87,600 more days at home or in the community each year The model is scalable and spreadable.

25 Thank You! Discussion