Raymond Applebaum Peel Senior Link “Helping seniors live independently” Mississauga/Halton LHIN
description
Transcript of Raymond Applebaum Peel Senior Link “Helping seniors live independently” Mississauga/Halton LHIN
Senior’s Health & WellnessASSIST Model
CSS – Building Community Capacity to Deliver Care
Conference, June 26, 2007Raymond Applebaum
Peel Senior Link“Helping seniors live independently”
Mississauga/Halton LHIN
Page 2
Integration Priorities & Enabling Strategies
• Alternate Level of Care
• Surgical Throughput
• Critical Care Capacity
• Wait Times
• Long-Term Care
Placement Time
• Quality of Care –
Patient Perception
• Readmissions for Acute Myocardial Infarction
Local Solutions for Provincial Priorities:
Enabling Strategies:
• Information and Technology Solutions
• Human Health Resources Planning
• Promotion and Prevention
• Education and Knowledge Sharing
• Easy Movement Through the System
Improving System Performance
StrengtheningPrimary Health Care
Preventing & ManagingChronic
Conditions
IntegratingMental
Health & Addictions
EnhancingSeniors Health & Wellness
• Alternate Level of Care
• Surgical Throughput
• Critical Care Capacity
• Wait Times
• Long-Term Care
Placement Time
• Quality of Care –
Patient Perception
• Readmissions for Acute Myocardial Infarction
Local Solutions for Provincial Priorities:
• Alternate Level of Care
• Surgical Throughput
• Critical Care Capacity
• Wait Times
• Long-Term Care
Placement Time
• Quality of Care –
Patient Perception
• Readmissions for Acute Myocardial Infarction
Local Solutions for Provincial Priorities:
Enabling Strategies:
• Information and Technology Solutions
• Human Health Resources Planning
• Promotion and Prevention
• Education and Knowledge Sharing
• Easy Movement Through the System
Enabling Strategies:
• Information and Technology Solutions
• Human Health Resources Planning
• Promotion and Prevention
• Education and Knowledge Sharing
• Easy Movement Through the System
Improving System Performance
StrengtheningPrimary Health Care
Preventing & ManagingChronic
Conditions
IntegratingMental
Health & Addictions
EnhancingSeniors Health & Wellness
Mississauga/Halton LHIN - IHSP
Page 3
The Burning Platform
• Mississauga/Halton LHIN is projected to have the second highest growth rate in seniors to 2018 among the 14 LHINs.
• Home to over 1 million people including close to 215,000 older adults (over age 55)
• Over next 10 years this number of older adults is expected to increase by 48% to over 317,000 people (67,881 >75 yrs 21%)
Page 4
The Burning Platform for Change – Service Utilization
• The proportion of seniors receiving home care increases with age from 8% among those aged 65 to 74 to 42% among those aged 85 or older.
• About one-quarter of senior men and one-third of senior women with five or more chronic conditions had received home care in the year before. This compares with only 5% of those who reported no chronic conditions.
• Hospitalization rate of seniors was three times the rate for individuals younger than 65 during the fiscal year 2002/03 (16,500 / 100,000 population 65+; vs 5,000 <65). The rate for 85+ patients was 28,000 / 100,000 population.
(source: Statistics Canada: Canadian Community Health Survey; Hospital Morbidity Database)
Page 5
The Road Today…….
Jan 2005 Hospitals meet and agree to work together on a regional geriatric model with DHC
May 2005 CCACs join and “White paper” written to identify the challenges and current resources. Recognize we need broader community input.
Oct 2005 “A Call to Action”
Nov 2005 Regional Geriatric Advisory Task Force formed (RGATF)
Jan 2006 Price-Waterhouse-Coopers engaged to support the RGATF in developing an integrated model of senior’s health delivery
.
March 2006 Vision Day
April 2006 Final Report
Page 6
Operationalizing the Plan…
• May 2006 Presentation to MH LHIN
• November 2006 MH LHIN integrates the ASSIST Model
within approved IHSP
• April 2007 ASSIST Model Design Team Initiated
• May 2007 Falls Prevention Sub-Committee Formed
Page 7
The GATF Core Team Members Organizations
Page 8
Page 9
Vision
•Working together for seniors’ good health
Mission
•Maximizing health and independence in seniors through an integrated and comprehensive
continuum of care
Vision, Mission
Page 10
Guiding Principles
DignifiedDignifiedEvidenceEvidence
BasedBasedPracticesPractices
ChoiceChoice
ContinuumContinuumofof
CareCare
Inter-Inter-disciplinarydisciplinary
Easy Easy AccessAccess
JointJointAccount-Account-
abilityabilitySustainableSustainable PassionatePassionate
Page 11
Building Blocks of ASSIST for MH LHIN
Linkages to and Fit withinthe Continuum
Information Requirementsand Flow
Scope of Services Provided within Model
Approach to Assessment
Consistencyof Care
Classification
Size of Population(Catchment vs Residence)
PopulationDefinition
Points of Access/ Entry
Vision, Values/Principles, Goals
PerformanceManagement
Accountability Coordination
Page 12
“ASSIST”: The Model for Service Delivery to Seniors in Mississauga Halton LHIN• All-inclusive
• Seamless
• Services for
• Independence of
• Seniors for
• Today and Tomorrow
Page 13
Core Components of the ASSIST Model
• Central Intake/Referral
• Common Assessment
• Senior’s Health and Wellness Centers based in Primary Care/Prevention
• Care Coordinators/Case Managers that follow client throughout the continuum of care.
• Shared electronic health record across the system
Page 14
ASSIST Model (Client can enter at any point)
FHTFHT
GPs orSpecialistGPs or
Specialist
GPsGPs
Family Health Team
Family Health Team
Adult Day Centre
Adult Day Centre
Family SupportFamily
Support
Teaching Centres
Teaching Centres
RGPRGP
SeniorsHealth and
Wellness Centre
Care Coordinator(s)Exact Services TBD
SeniorsHealth and
Wellness Centre
Care Coordinator(s)Exact Services TBD
SHWCSHWC
GPsGPs
FHTFHT
Patient/C
onsumer a
nd Circ
le
Patient/C
onsumer a
nd Circ
le
of Support F
ocuse
d Service
of Support F
ocuse
d Service
Delivery
Delivery
Central Information and
Referral
Central Information and
Referral
SHWCSHWC
SHWCSHWC
RespiteRespite
Long Term Care
Long Term Care
Community Services &Agencies
Community Services &Agencies
GPsGPs
FHTFHT Emergency Room/ Urgent Care
Emergency Room/ Urgent Care
Acute,Specialists
Acute,Specialists
Tertiary Care
Tertiary Care
Quaternary Care
Quaternary Care
Page 15
Existing Networks
Mississauga Halton LHIN Board
Integration Advisory
Group
Rapid Action Team
DPA TeamAction Plan
2
DPA TeamAction Plan
1
DPA TeamAction Plan
2
Health Human
Resources Advisory
Group
e-Health Steering
Committee
Community Advisory
Committee
DPA TeamAction Plan
3
DPA TeamAction Plan
1
LTC Action Group
DPA Team Action Plan
1
Integrated Care
Pathways Action Team
DPA TeamAction Plan
1
MH&A Rapid Action Team
Transportation
Health Care Leaders
Collaborative
Page 16
Keys to Success
• representation from across the health care sector including consumers
• co-chairs from across the healthcare continuum
• short time line
• LHIN environment
• support from our organizations
• building on prior work and experience
• clear project focus
• Consultant support
• Letters of Support
Page 17
Barriers to Success
• Failure to recognize the magnitude of the transformation required.
• Inability to change our silo thinking.
• Lack of integration at Ministry and Municipal levels.
Page 18
INTEGRATION
Stick with the vision
Focus on the needs of the patient/client
What is the function of my organization within an integrated system?
ASSIST MODELASSIST MODEL
Working together for seniors’ good health
www.peelseniorlink.com