GiiC Investigators

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					The Geriatrics, Interprofessional Practice and Interorganizational Collaboration (GiiC) Initiative: Enhancing Shared Care of Frail Seniors

The GiiC initiative is a collaboration of the Regional Geriatric Programs of Ontario located in Hamilton, Kingston, London, Ottawa and Toronto, the Centre for Education and Research on Aging and Health (CERAH) at Lakehead University in Thunder Bay and the North East Specialized Geriatric Services (NESGS) Group in Sudbury. CERAH and the NESGS Interest Group are affiliated with the Northern Ontario School of Medicine.

Acknowledgements The GiiC Project is funded by the Ministry of Health and Long-Term Care through a HealthForceOntario, Interprofessional Care Education Fund and supports the Provincial Interprofessional Care Blueprint for Action. The willingness of Family Health Teams and Community Health Centres across the province to join our initiative is gratefully acknowledged as is the support of the Quality Improvement & Innovation Partnership, the Association for Ontario Health Centers and the Arthritis Community Research and Evaluation Unit

GiiC Investigators
Dr. David Ryan, PhD, CPsych, Project Director Director of Education & Knowledge Processes Regional Geriatric Program of Toronto Assistant Professor, Faculty of Medicine University of Toronto Dr. Cheryl Cott, BPT, MSc, PhD Associate Professor, Faculty of Medicine, University of Toronto Director, Arthritis Community Research & Evaluation Unit Dr. William Dalziel, MD, FRCPC Chief, Regional Geriatric Program of Eastern Ontario Dr. Iris Gutmanis Director of Evaluation & Research Regional Geriatric Program of Southwestern Ontario Assistant Professor, Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario Mr. David Jewell, MSW, MHSc Administrative Director, Regional Geriatric Program of Central Ontario Assistant Clinical Professor, Dept of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton Dr. Mary Lou Kelley MSW, PhD Director, Centre for Education & Research & Aging & Health (CERAH), Professor, School of Social Work & Northern Ontario School of Medicine, Lakehead University, Thunder Bay Dr. Barbara Liu, MD, FRCPC Executive Director, Regional Geriatric Program of Toronto Assistant Professor, Faculty of Medicine, University of Toronto Ms. Catherine Matheson, BSW, MBA, CEC General Manager, Community Development City of Greater Sudbury Dr. John Puxty, MD, FRCPC Medical Director, Regional Geriatric Program of South Eastern Ontario Associate Professor & Chair, Division of Geriatric Medicine Queens University, Kingston

GiiC Initiative Steering Committee
Dr. Nick Kates, Director of Programs, Hamilton Family Health Teams Professor, Faculty of Medicine, McMaster University Ms Brenda McNeil Executive Director, Anne Johnston Health Station, Toronto Ms. Marlene Awad, BSC MHA Director, Administration & Information Management Regional Geriatric Program of Toronto Mr. Kelly Milne, BScOT Program Manager, Regional Geriatric Program of Eastern Ontario Ms. Linda Pisco, BA, MA Education Planner, Center for Research and Education in Ageing and Health Lakehead University Ms Lesreen Romain, RN, BScN, MHS GiiC Project Manager, Regional Geriatric Program of Toronto Kelly Simpson, M.A., Cert Ed Regional Development & Education Coordinator, Specialized Geriatric Services Regional Geriatric Program of Southwestern Ontario Ms. Maureen Vickers BScN Director, Specialized Geriatric Services Regional Geriatric Program of Southwestern Ontario And Dr. David Ryan, Project Director Dr. William Dalziel Dr. Cheryl Cott Mr. David Jewell Dr. Iris Gutmanis Dr. John Puxty Dr. Mary Lou Kelley Dr. Barbara Liu

The Project Evaluation Team
The Arthritis Community Research & Evaluation Unit Dr. Cheryl Cott, Director Ms. Nicole Donaldson, Research Assistant

GiiC Consultants
Deanna Abbott-McNeil, BScPT RGP Kingston Darlene Harrison, RN, HBScN, GNC(C) CERAH Mary-Lou van der Horst, RN, BScN, MScN, MBA RGP Hamilton Lyne Marcil, BScOT, Reg, Geriatric Assessor RGP Ottawa Catherine McCumber, RN, BScN, MN, GNC(C) RGP Ottawa Susanne Murphy, BScOT, MSc RGP Kingston Donna Scott, RN, BScN, CHRP RGP London Tanya Shute, MSW, RSW CERAH Deana Stephen, RSSW NE SGS Interest Group Ken Wong, BScPT, MSc RGP Toronto

GIIC Project Overview
Introduction Population aging presents significant challenges to the health care system in Ontario. Not the least of these is the fact that 82% of seniors have one or more chronic health conditions and 43% have three or more conditions. This later group of seniors is at risk of becoming frail. Frailty, characterized by complex bio-psycho-social and functional problems, is associated with increased health system usage and puts seniors at risk of loss of the capacity for independent living and lowered quality of life (Wolff et al, 2002). Within the aging demographic, frailty may be the fastest growing segment across the province and particularly in northern regions and outside high-density urban areas (Manuel & Schultz, 2001) Ageing demographics will have a significant impact on human resource planning and development in all professions working in many health care contexts across the circle of care (McKnight et al. 2003). Providing care to the expanding population of frail seniors requires an both an increase in the numbers of care providers and development of our skill sets. Our skill sets require expertise in three broad competencies - geriatrics, inter-professional practice and interorganizational collaboration. Competence in geriatrics is required because the clinical presentations of frail seniors are unique and include the ‘geriatric giants’ of dementia, delirium, falls, continence and poly-pharmacy often co-occurring in complex ways. Competence in interprofessional practice is required because the complexities of these clinical presentations are such that optimal care requires an interdisciplinary team. Inter-professional teamwork, as outlined in the recently published Health Force Ontario, Inter-professional Care: Blueprint for Action (Oandasan & Closson, 2007), is the care delivery method of choice in caring for frail seniors (Geriatrics Interdisciplinary Advisory Group, 2006). Finally, competence in inter-organizational collaboration is required because the management of frail seniors requires the sharing of care across many organizational boundaries from primary and community based care to emergency and hospital-based services. Table 1 provides an overview of these competencies. On the need for training in the core competencies Repeated surveys demonstrate that curriculum time devoted to geriatrics in the academic preparation of health professionals is insufficient. In our own surveys, for example, frailty-focused service ‘specialists’ in all disciplines tell us that they when they graduated they lacked the confidence and skill sets to care for frail seniors. They tell us that they required extensive continuing education that was acquired through informal ‘on the job’ processes, specific timelimited educational events and pilot projects though groups such as the RGPs of Ontario. These findings from the inter-professional geriatric ‘specialists’ appear independent of year of graduation (Ryan & Kirst, 2005). Limitations on geriatrics training are a challenge to the health systems capacity to meet the needs of an aging population. The need for renewed focus on preparing health professionals for inter-professional practice has recently been documented in the Health Force Ontario, Inter-professional Care: Blueprint for Action (Oandasan & Closson, 2007). The blueprint argues that because inter-professional practice is an essential characteristic of health care delivery in the real world, preparation for inter-professional practice must be formally incorporated into the academic and continuing

education of health professionals. Simply putting people together to work does not necessarily create effective teamwork. In formative academic training health professionals must build attitudes and expectations supportive of inter-professional practice that with appropriate support can be refined in the workplace to improve the quality of services to patients (Barr, 2000). The Inter-professional Care: Blueprint for Action and the emergence of Local Health Integration Networks in Ontario also guide us towards the importance of inter-organizational collaboration in the delivery of effective health care. But, just as simply putting people together to work does not necessarily create effective teamwork, so simply requiring organizations to work together does not necessarily lead to effective shared care. Inter-professional practice and inter-organizational collaboration require ongoing coaching, support and facilitation. Resources to meet this ongoing need are seldom available in the workplace. Between Specialized Geriatric Service providers affiliated with the Regional Geriatric Programs of Ontario, Community Health Centres and Family Health Teams who are and will increasingly be the primary source of care for the growing population of frail seniors, there exits a combination of skill sets and needs that can respond to the issues of human resource scarcity for geriatric care and the need to provide practice based training in inter-professional practice and interorganizational collaboration as outlined in the Blueprint for Action. Goals and objectives Through this initiative we propose the development of a network of excellence in practice based interprofessional education and interorganizational collaboration in primary care that will support the academic initiatives outlined in the Health Force Ontario, Inter-professional Care: Blueprint for Action and help the province in managing the consequences of its ageing population. The primary outcomes arising from this initiative are as follows: 1) The consolidation of a team of GIIC resource consultants situated within the RGPs of Ontario, the Centre for Education and Research on Aging and Health at Lakehead University and the North East Specialized Geriatric Services Group in Sudbury to train coach and mentor a provincial network of GiiC facilitators. 2) The development of a province-wide network of 200 GiiC facilitators situated in Family Health Teams (FHT) and Community Health Centers (CHC) to assist their teams and organizations in the delivery of collaborative shared care to frail seniors. 3) A set of GIIC teaching resources and facilitation tools with an online repository 4) An intersectoral and province-wide health services workforce with enhanced awareness and knowledge of each other and higher levels of skill in the three competencies 6) A sustainability plan for each network hub consistent with each group’s specific needs and leveraging existing resources and skill sets 7) Improved shared health care for seniors and especially frail seniors

Table 1. A framework of competencies for health human resource development The Geriatric clinical core competencies for frailty focused services 1. The nature of frailty 2. Dementia, delirium, depression, falls, continence, polypharmacy – the Geriatric Giants 3. Context specific geriatric assessment tools 4. Specialized geriatric services and their processes 5. Senior friendly environments and seniors safety. 6. Geriatrics and models of geriatric care giving The Inter-professional core competencies Assessment competencies include the ability to: 1. Assess the culture of a working team 2. Assess the characteristics of a team’s development 3. Understand the formal and informal influence processes on teams 4. Understand individual styles of behavior and problem solving 5 Assess team meeting behavior 6. Identifying the correct locus of decision-making Intervention competencies include: 1. Create consensus on a best practice 2. Engage formal and informal opinion leaders 3. Small group facilitation 4. Communication, confrontation and conflict resolution 5. Manage task and process needs 6 Edumetrics – measurement procedures that teach 7 The ability to engage patients/clients and their families as team members 8. Inter-professional mentoring and coaching 9. Inter-professional ethics Developing inter-organizational core competencies Inter-organizational assessment competencies include: 1. Recognizing teams within teams 2. Network analysis and system pragmatics 3. Assessment of boundary functions 4. Organizational culture and power analysis 5. Understanding expectancy dynamics 6. Privacy, confidentiality and inter-organizational collaboration 7. The colleges, the skill sets and cognitive maps of the health professions Inter-organizational intervention competencies include: 1. Network building and support 2. Managing change in a networked environment 3. Inter-organizational human resource facilitation 4. Diversity management 5. Inter-organizational negotiation and issues management

Selected References Allen, M, Ryan, D. & Sibbald, G. (2002). Information Technology & CME: Learning in Communities of Practice, Presented at the Annual Meetings of the Canadian Association of Continuing Health Education, Halifax. MacKnight, C, Beattie, BL, Bergman, H, Dalziel, WB, Feightner, J, Goldlist, B, Hogan, DB, Molnar, F & Rockwood, K. (2003) Response to the Romanow Report: The Canadian Geriatrics Society Geriatrics Today: Journal of the Canadian Geriatrics Society 6 (1), pp. 11-15 Wolff JL, Starfield B, Anderson G. (2002) Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. JAMA, 162: 2269–2276. Geriatrics Interdisciplinary Advisory Group (2006) Interdisciplinary Care for Older Adults with Complex Needs: American Geriatrics Society Position Statement. Journal of the American Geriatrics Society, 54(5), 849-852. Ryan, D. & Kirst, J. (2005) Core Competencies for Specialized Frailty Focused Services. Presented at the Annual Meetings of the Ontario Gerontology Association, Toronto 2005. Ryan, D., Cott, C. & Robertson, D. (1997) A conceptual tool-kit for thinking about inter-teamwork in clinical gerontology. Journal of Educational Gerontology, 23, 651-668. Ryan, D. (1996) A history of teamwork in mental health and its implications for teamwork training and education in gerontology. Journal of Educational Gerontology, 22(5), 411-431. Oandasan, I, Closson, T. (2007) Health Force Ontario, Inter-professional Care: Blueprint for Action. Online at Oandasan, I, Reeves, S. (2005) Key elements of interprofessional education. Part 2. Factors, processes and outcomes Journal of Interprofessional Care 19 (Suppl.1), 39-48 Manuel, DG, Schultz, SE (2001) "Adding years to life and life to years: life and health expectancy in Ontario. ICES Research Atlas, January Barr, H. (2000) Working together to learn together: learning together to work together. Journal of Interprofessional Care, 14(2) 177-179. Clark, PG, Puxty, J. & Ross LG (1997) Evaluating an interdisciplinary geriatric education and training institute: What can be learned by studying processes and outcomes? Educational Gerontology 23(7), 725-744.

On the role of GIIC facilitators Congratulations on being nominated to the role of GiiC facilitator within your organization. Across the province the network of GIIC facilitators will comprise health professionals from many backgrounds. It will be an interprofessional team itself. So far, we have had physicians, advanced practice nurses, nurses, social workers, and occupational therapists nominated to represent their Family Health Team or Community Health Center. The key selection criteria we suggested for recommending FHT/CHC facilitators were personal interest, breadth of clinical experience, acceptance by your colleagues and, perhaps ideally, the qualities of an informal opinion leader. Informal opinion leaders are individuals to whom others often turn for advice – they like answering questions, seem to stay up to date on a wide range of topics and communicate in a down to earth and humanitarian way. So congratulations once again, you must be a very special health professional. We will provide you with 16 hours of training with our team of GiiC consultants and expert local faculty. Each of you will have a regional GiiC consultant who will support you when you return to your organization for a period of 3-4 months and, we hope, longer. We will invite you to a followup meeting to share your experiences with us and as well, we will invite you to the annual meetings of the staff of the Regional Geriatric Programs of Ontario, held in Toronto in the Spring, in order to build bridges to the provinces specialized geriatric services. We will provide you with a GiiC toolkit in both hard copy and electronic versions. The toolkit will provide a range of tools on 18 dimensions of geriatrics and on interprofessional practice and interorganizational collaboration. For each dimension there are Quick Facts, Practice Aids, Practice Algorithms, Quizzes, Patient Handouts, Teaching Case Studies, Slide Materials and Reference materials, designed to help you in the facilitator role. The GiiC facilitator website is available for you at . It is a secure resource and once you have opened a membership, you can download the GiiC resources, discuss issues with each other and with your GiiC consultant.

But what specifically is required of you . . . ? We know that there are no two FHTs or CHCs the same and that each organization responds to the needs of its frail seniors in diverse ways. Similarly, we anticipate that there will be a range of opportunities for you to implement GiiC processes in your organization. Some of you are working in organizations that want to introduce big changes in the care of frail seniors, while many of you will be working in organizations that are already going through significant developmental change. For you, GiiC might lead you to be able to find the right tool to better serve one of your teams seniors. Whether big or small, we will consider each instance a significant success. We know that big things often come from small beginnings and that it is hard to tell ahead of time which small beginning that might be.

We will be evaluating the project and part of the evaluation, having your team complete a perceptions of teamwork survey and network analyses of your team and its interorganizational collaborations, will itself be an intervention to help your team in these areas. We call this approach to measuring and teaching ‘edumetrics’. With all of this in mind your GiiC facilitation might include some or all of the following activities: Clinical geriatrics activities Informal opinion leadership on geriatrics issues Periodic reviews of geriatric practices Coaching of clinical knowledge to practice activities Liaison with formal geriatrics experts Able to recommend context specific assessment tools Inter-professional practice activities Annual survey of team member perceptions of the team Coordination and facilitation of quarterly team process meetings Facilitate reflection on issues of team performance Facilitate teamwork problem solving Coordination of inter-professional mentoring for new staff Inter-organizational collaboration activities Annual inter-organizational network analysis and expectation surveys Identification of inter-organizational boundary management functions Facilitation of annual and ad hoc meetings of the inter-organizational network Network feedback process analyses for quality improvement initiatives Problem solving inter-organizational issues and concerns

But most of all keep in mind, that we are very grateful for your interest in our project. We will work hard to help you and for us success can come in both large and small initiatives.

Dr. David Ryan, PhD CPsych GiiC Project Director Tel. 416.480.6100 x3369 Email

Table of Contents GiiC People GiiC Overview On the role of GiiC facilitators The GiiC Toolkit Frailty A Framework for the Assessment of Frail Elderly with Co-Morbidities in Primary Care Advance Care Planning Quick Facts on Preparing Advance Care Plans Clinical Assessment Tools and Algorithms  Process Guide to Advance Care Planning  Advance Care Planning Mnemonic Guide Patient/Client/Family Handouts  An Advance Care Planning Brochure for Families  Advance Care Planning Terms in Use Teaching Slides on Advance Care Planning Teaching Slides on Engaging Families in Advance Care Planning Advance Care Planning Knowledge Quiz Capacity Assessment Capacity Assessment Toolkit Overview Capacity Assessment Quick Facts Clinical Assessment Tools and Algorithms  An Aid to Capacity Evaluation (ACE)  A Teaching Case Study on the Use of ACE  Pocket Guide to Determining Decision Making Ability  A Patient Capacity Risk Assessment Framework  A Risk Assessment Worksheet Capacity Assessment Teaching Case Study 1 & 2 Teaching Slides on Capacity Assessment NICE Tool on Capacity Assessment Caregiver Support Caregiver Support Knowledge and Practice Tips Caregiver Support Provincial Contacts Clinical Tools and Algorithms  The Zarit Burden Structured Interview Patient/Client Handouts  Caregiver Support Handout  Checklist for Caregivers  Caring for a Loved One with Dementia Teaching Slides on Caregiver Support Caregiver Support Reference List

Table of contents (cont) Delirium Causes of Delirium in Primary Care Delirium Quick Facts for Primary Care Clinical Tools and Algorithms  The Confusion Assessment Method (CAM) for Primary Care  The Delirium Decision Tree for Primary Care  Delirium + 2Ds Comparison Table for Primary Care  Delirium and Medications Overview for Primary Care Delirium in Primary Care Teaching Slides Delirium in Primary Care Teaching Case Study The Best Practice Blogger on Delirium Dementia Screening and Assessment Overview Flowchart with Provincial Resources Patient/Client/Family Pre-Assessment Forms  Informant Questionnaire on Cognitive Decline (Short Form)  Lawton-Brody Modified Physical Self-Maintenance Scale Clinician Tools and Algorithms  Target Symptom Checklist  AD8 Informant Interview, Scoring and Interpretation Guide  Montreal Cognitive Assessment Test  Montreal Cognitive Assessment Test Normative Data  Folstein Mini-Mental Status Questionnaire (Bilingual version)  Folstein ‘Copy Drawing’ stimulus  Folstein Interpretation Guide Dementia Screening and Assessment Teaching Slides and Dementia Quiz Late Life Depression Late Life Depression Fact Sheet Depression Pocket Guide Late Life Depression Poster Late Life Depression Patient/Client/Family Pamphlet Late Life Depression Teaching Slides and a Quiz Driving Capacity Driving Capacity and Dementia Facts Clinical Tools and Algorithms  The Dementia and Driving Checklist – Screening Tool  The Dementia and Driving Screening Summary Sheet  Trail Making Tests  Driving and Dementia Decision Algorithms  Driving Cessation – Talking with Seniors about Driving  How to report to The Ministry of Transportation Patient Handouts  License Renewal After 80  Dementia and Driving Dementia and Driving Capacity Teaching Slides

Table of contents (cont) End of Life Care Physical and Mental Comfort at the End of Life Overview On Bereavement and Grieving Pain Management Quick Tips – The WHO Analgesic Ladder Patient/Client/Family Handouts  When a Family Member is Dying  When a Family Member Has Died  Food For Thought  Other Handouts/Poster The Compassionate Care Benefit Teaching Case Study on End of Life Care Teaching Slides on End of Life Care Teaching Slides on Working With Families Falls An Introduction to Falls in Primary Care Quick Reference Sheets Clinical Tools and Algorithms  A Framework for Falls Management in Primary Care  A Falls Algorithm  The Timed Up and Go Test  Falls Evaluation for the Initial Visit  American Geriatric Society Falls Evaluation Checklist Patient/Client Pre-Assessment Forms  Falls Description  Home Safety Questionnaire  Falls Focused Medical History Patient Handouts from Key Associations and Agencies Teaching Slides on Falls References Incontinence An Introduction to Urinary Incontinence in Primary Care Quick Reference Sheets Clinical Tools and Algorithms  Initial Management of UI in Women, Men and Frail Elderly  Secondary Management of UIO in Frail Elderly  Urinary Incontinence Evaluation Form Patient Pre-Assessment Forms  Incontinence Patient Information Form  International Consultation on Incontinence Questionnaire  Patient Incontinence Impact Questionnaire  Bladder Diary Patient Handouts on UI from Key Associations and Agencies References Teaching Slides on Incontinence

Table of Contents (cont) Oral Health Oral Health Quick Facts Oral Health for Older Adults in Primary Care Resource Kit Tips Facts and Myths on Oral Care in the Community Oral Pathology Basics Clinical Tools and Algorithms  Oral Health Assessment Tool for Primary Care  Oral Health Impact Profiles  Oral Health Audit Tool for Primary Care Medications that Impact Oral Health in Primary Care Special Topics on Oral Health  Cancer Care-Mucositis, Dementia Care, Denture Care  Managing Oral Care for the Elderly Diabetic Patient  Dry Mouth and Managing Xerostomia, Dysphagia, Gum Disease  Palliative End Stage Oral Care, Renal Disease and Oral Health  Root Caries, Swallowing, Stomatitis, Keeping Teeth for a Lifetime  Caregiver Handout on Oral Health and Dementia The Best Practice Blogger on Oral Health Teaching Slides on Oral Health References Osteoporosis Osteoporosis and Bone Fracture Risk Assessment Risk Assessment Instrument – Pocket Reference Teaching Case Study on Osteoporosis and Bone Fracture Teaching Slides Best Practice Blogger on Bones Pain An Overview of Pain in Primary Care Clinical Tools and Algorithms  Pain Assessment Algorithm  Pain Assessment Algorithm for Non-Verbal Patients  History and Physical Findings – Pain  Pain Follow-up Flow Chart Patient Pre-Assessment Forms  Pain History  Persistent Pain – Follow-up Questionnaire  Daily Pain Diary and Instructions for Use  Geriatric Depression Scale (Short Form) Patient Handouts on Pain Teaching Slides on Pain in Primary Care References

Table of contents (cont) Periodic Health Exam Introduction to Geriatric Periodic Health Exam in Primary Care Quick Reference Sheets Clinical Tools and Algorithms  Clinical Process Overview  Periodic Health Exam Flowchart  Geriatric Periodic Health Exam Tracking Form  Geriatric Periodic Health Exam Interprofessional Screen Patient Pre-Assessment Forms  Geriatric Periodic Health Exam Patient Form Patient Handouts Teaching Slides on the Geriatric Periodic Health Exam References Polypharmacy Facts and Figures on Polypharmacy and the Elderly Practice Tips on Safe Prescribing for the Elderly The Beers Criteria for Possible Unsafe Medication Use Canadian Guidelines on Inappropriate Prescribing Practices for the Elderly Clinical Tools and Algorithms  Improved Prescribing for the Elderly Tool  Medication Review Worksheet Patient Handouts  Medication Tips: Keeping Your Medications in Check  Warfarin References Interprofessional Practice The Dimensions of Teamwork Survey Informal Roles Analysis The Stages of Team Development The So Short Styles Exercise Overview The So Short Workshop Materials Build-a-Case for GiiC Trauma Care Provides a Snapshot of the History of Health Care Teamwork Teaching Slides on Interprofessional Teamwork in Health Care Annotated Bibliography of Recent Interprofessional Practice References Interorganizational Collaboration Thinking Through Interorganizational Collaboration in Health Care – An Overview Stages of Team Development and Collaboration Checklist Interorganizational Boundary Function Review Outcome expectation Worksheet Teaching Slides on Practice in a Networked Health System Teaching Slides for a Workshop on Interorganizational Collaboration