engaging the community to develop a better approach to seniors care

1

Engaging the Community to

Develop a Better Approach to

Seniors Care

C5 | Redesigning Care for Older Adults

Belinda Boyd Leader, Community Engagement

Venie Dettmers Leader, Health Services Planning

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Objectives of Seniors Initiative

• Improve effectiveness of primary and community care

for:

patients over 70

with moderate to high complex chronic conditions &

increasing risks or signs of frailty

• Keep seniors well in their home and community and

experience a better quality of life.

• Reduce unnecessary emergency department &

medical inpatient use, and ensure appropriate use of

residential care.

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Seniors Prototype

Communities

Vancouver –

Westend/Fairview

North Shore

Richmond

How will we ensure a

transformative change? • We are developing the improved model of care in

partnership with a dedicated cross agency team –

VCH, PHC, DoFP, community partners &

patients/families – not working in silos

• New models of care will be driven by patient/client

needs - through robust community stakeholder

engagement

• The models will:

– expand upon international best practice, and

– will not be constrained by current funding models or

ways of working

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Model Development

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Forum 2

Forum3

Forum 1

Best

Practices

&

Literature

Data and

Community

Profile

Local

Knowledge

&

Experience

Understanding the

Care Experience

Defining Better Care

Confirming New Approach

New Models of Care

Innovation based

upon patient, family

and caregiver needs

MoH

Emerging

Model

Community Engagement

Community Engagement Process

• Identified and invited to forums:

Patients, families and caregivers

GPs and front-line clinicians

Funded contracted services & community-based

agencies

• Using the story of Estelle or Alfred

• Progressively and collaboratively plan a

new approach

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7

Community Engagement

Process

Identifying Needs

Defining Better Care

Confirming a New

Approach to Care

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Identified Gaps in

Clinical/Medical Care Needs to focus on:

• Access to care outside

regular business hours

• Create integrated care

among providers to improve

experience and quality of

care

• Case managers and their

communication with clients

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What could better care look like:

• Provide a 24 hour a day and 7 day

a week service, including on call

family doctors, or someone to talk

to when clients have an urgent

need

• Ensure coordination of the care

plan between client/family and

health care providers such as

home health, mental health, family

doctors and specialists.

• Be responsive to the client needs

and provide the level of care that

clients need, including regular

contact and surveillance

Linked

Community

and

Residential

Care

Service

Specialist

as part of

the Primary

Care Home

Team

Closer

Partnership

with

Community

-based

Agencies

Advance

Care

Planning &

End-of-Life

Care

Improved

Transition

s from

ED/

Hospital Enhanced

Social and

Caregiver

Support

Vancouver: Repositioning Health Care for Seniors - Prototype

Aligned

Older Adult

Mental

Health &

Addictions

and Home

Health

Services

Collaborate

Primary Care Physician

+

Interdisciplinary Team

Person

&

Family

Primary Care Home

Multidisciplinary Teams • Interdisciplinary Intensive Care Management

Team including Home Health (HH) and Older

Adult Mental Health & Addictions (OA MH&A)

integrated with the Primary Care Home (Home

Visiting and 24/7 access).

• Expanded Three Bridges Primary Care Clinic

with focus on frail seniors and integration with

HH and OA MH&A; services 12 hours/7 days

with 24/7 access and home visiting.

• Rapid access to diagnostics.

Adult Day Programming, Respite • Expanded Respite Continuum including adult

day centre, in-home respite & overnight respite.

Residential Care • 24/7 Medical Respite in the Community

• DoFP/HA partnership: Residential Care Initiative

Home Support • Home Support better aligned with clinical teams

and improved connections with Better at Home.

Palliative Care • Expanded Hospice and End-of-Life Capacity

in Community (24/7).

ED iCARE/Quick Response Team

• Expanded ED iCARE/quick response teams at

VGH, St Paul’s & Mt St Joseph Hospital Service

7 days per week/12 hours per day.

PHC Outpatient Parenteral Antibiotic

Therapy

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North Shore Concept Model

Adult Day Programing, Respite Increased ADP 16/17 by 12

Increase ADP/Respite 17/18 by 20+12

Increase program access & flexibility

Residential Care Rapid access to Diagnostics

Rapid access to lab testing

Home Support Hub Model of Care

Proactive Support

Linkage with ‘Better at Home”

Palliative Care * Additional Hospice Beds

Hospice Short Stay Program & community outreach

Resource and Information Media Campaign

Community Partnerships

Promoting Wellness Health fairs in high density senior

housing

Multidisciplinary Team A team wrapped around the client

Shared Care Plan

Core Team: GP or NP, Patient & Support, CM

Supporting Team: PT/OT/ Pharm, RT, Dietician, SLP, MH

24/7 point of contact; visits at regularly scheduled

intervals

Location: Virtual/Community Based/Home/GP Office

Intensity of service based on client needs

Initiatives under way to support Older Adults Repositioning Healthcare for Older Adults

Increased * Hospice

Space (VCH)

Palliative * Care

Redesign (VCH)

GP in the ED

(VCH/DoFP)

Expansion of Health

Connections Clinic

(VCH/DoFP)

Medical Home

Visiting by GPs

Program (VCH/DoFP)

Squamish Nation &

Tsleil-Waututh Primary

Care Clinics

Proactive Case Finding Population

70+: Frail/High

Chronic/RC/EOL

North Shore Seniors

Safe House (VCH, DNV,

HFSS,LV Lions,

NSCSS)

Feedback from Participants

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It is a privilege to

be invited to

participate in this

planning

Great turnout, good

discussion, always

could have more time. I

did broaden my

knowledge of how

important

communication is

between providers.

Overall it was excellent.

I like the diversity of

participants. It is very

evident that at the

end of the day, we all

have the same needs.

I was very cynical

about participating

but the process has

been very engaging

and productive.

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Benefits

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Broad-based engagement

of the community that is

collaborative and

empowering

Interaction of diverse

stakeholders promotes rich

conversation and creative

solutions

Built a better model of care

with input from those most

impacted by implementation

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Benefits

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Built interest and support in

implementation – many

participants indicated an interest in

continued involvement via

Reference Groups

Built relationship and trust between

participants and VCH as well as

between VCH and community

based providers

Thank you!

Questions?

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Belinda Boyd belinda.boyd@vch.ca

Venie Dettmers veneranda.dettmers@vch.ca