engaging the community to develop a better approach to seniors care
TRANSCRIPT
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
2
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.
3
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
6
7
Community Engagement
Process
Identifying Needs
Defining Better Care
Confirming a New
Approach to Care
8
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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
13
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
15
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
17
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
