Senior’s Health Wellness ASSIST Model CSS – Building by trf16073

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									  Senior’s Health & Wellness
        ASSIST Model
CSS – Building Community
 Capacity to Deliver Care
Conference, June 26, 2007
         Raymond Applebaum
               Peel Senior Link
        “Helping seniors live independently”


       Mississauga/Halton LHIN
Integration Priorities & Enabling Strategies

                           Mississauga/Halton LHIN - IHSP


                                  Improving System Performance

                                                                               Enabling
                                                                               Strategies:
           Local Solutions for                   Integrating
           Provincial Priorities:                                              • Information and
                                                   Mental                          Technology
          • Alternate Level of Care               Health &                         Solutions
          • Surgical Throughput                  Addictions                    •   Human Health
          • Critical Care Capacity                                                 Resources
          • Wait Times                                                             Planning
                                  Preventing &                 Strengthening   •   Promotion and
          • Long-Term Care
                                   Managing                    Primary             Prevention
            Placement Time
                                    Chronic                    Health Care     •   Education and
          • Quality of Care –      Conditions                                      Knowledge
            Patient Perception                                                     Sharing
          • Readmissions for Acute               Enhancing                     •   Easy Movement
            Myocardial Infarction                 Seniors                          Through the
                                                  Health &                         System
                                                  Wellness



                                                     Page 2
                    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 3
    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 4
 The Road Today…….
Jan 2005   Hospitals meet and agree      Nov 2005     Regional Geriatric
           to work together on a                      Advisory Task Force
           regional geriatric model                   formed (RGATF)
           with DHC

                                         Jan 2006     Price-Waterhouse-
May 2005   CCACs join and “White                      Coopers engaged to
           paper” written to identify                 support the RGATF in
           the challenges and                         developing an integrated
           current resources.                         model of senior’s health
           Recognize we need                          delivery
           broader community input.      .
                                         March 2006   Vision Day
Oct 2005   “A Call to Action”

                                         April 2006   Final Report


                                        Page 5
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 6
The GATF Core Team Members Organizations




                     Page 7
Page 8
               Vision, Mission

           Vision
•Working together for seniors’
         good health
           Mission
     •Maximizing health and
independence in seniors through
an integrated and comprehensive
        continuum of care

                      Page 9
 Guiding Principles



            Evidence
Dignified    Based       Choice
            Practices

Continuum
             Inter-      Easy
    of
          disciplinary   Access
  Care

 Joint
Account- Sustainable Passionate
 ability




              Page 10
Building Blocks of ASSIST for MH LHIN


                   Vision, Values/Principles, Goals

    Population            Size of Population          Points of Access
    Definition        (Catchment vs Residence)             / Entry
                                                        Consistency
    Scope of Services             Approach to
                                                           of Care
   Provided within Model          Assessment
                                                        Classification

    Linkages to and Fit within              Information Requirements
         the Continuum                              and Flow

                            Performance
  Accountability                                       Coordination
                            Management

                                  Page 11
“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 12
           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 13
ASSIST Model (Client can enter at any point)

    Family                                             Adult Day
                                       GPs or
  Health Team                                           Centre
                                      Specialist
                    Seniors
                 Health and                            Long Term
                                                                      Tertiary
                                                                       Care
                Wellness Centre                          Care

                Care Coordinator(s)
                Exact Services TBD                      Respite      Quaternary
                                                                       Care
   GPs
                                      Central            Acute,
                SHWC             Information and       Specialists
  FHT
                                     Referral                         Teaching
                                                                       Centres
                                                       Community
   GPs
                                                       Services &
                SHWC                                    Agencies
  FHT                                                  Emergency
                                                        Room/           RGP
                                                        Urgent
   GPs                                                   Care
                SHWC
                                                        Family
   FHT                                                  Support

                                             Page 14
                                                                        Mississauga
                                                                                                        Community
                                                                         Halton
                                                                                                         Advisory
                                                                          LHIN
                                                                                                        Committee
                                                                          Board




                                     Health Care
                                       Leaders                          Integration
                                     Collaborative                       Advisory
                                                                          Group




                                                               Health
                                                               Human              e-Health
                                                              Resources           Steering
                                                              Advisory           Committee
                                                               Group




                                                             Transportation




                                                                                                                    Integrated                 MH&A
Rapid    DPA Team      DPA Team          DPA Team      DPA Team         DPA Team                      DPA Team                   DPA Team
                                                                                         LTC Action                    Care                    Rapid
Action   Action Plan   Action Plan       Action Plan   Action Plan      Action Plan                   Action Plan                Action Plan
                                                                                           Group                    Pathways                   Action
Team          2             1                 2             3                1                             1                          1
                                                                                                                      Action                   Team
                                                                                                                      Team




                                                                     Existing Networks




                                                                              Page 15
                         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 16
                       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 17
           INTEGRATION

Stick with the vision


Focus on the needs of the patient/client


What is the function of my organization
within an integrated system?



                   Page 18
Working together for seniors’ good health




 ASSIST MODEL




          www.peelseniorlink.com

								
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