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

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