North Simcoe Muskoka LHIN Aging at Home Strategy

Year Three - 2010-2011

Our Approach

Click here  for a link to the funded projects from 2008/09 and 2009/10

The Aging at Home Strategy was designed to enable seniors to live healthy, independent lives in their own homes by creating opportunities that reflect their lifestyle choices and how they truly want to live. These supportive opportunities for seniors also avoid the unnecessary loss of independence due to premature admission to higher care long-term care homes and/or hospitals.   The Aging at Home Strategy is of critical importance, both for its potential to improve the lives of Ontario seniors, and also because it will help ensure the sustainability of the overall health system.   

In 2010/11, NSM LHIN has approximately $4,200,000 to invest in seniors to support the provincial priorities, NSM LHIN’s Emergency Room and Alternate Level of Care (ER/ALC) Framework and the vision for an Integrated Seniors Health Program Report Recommendations.  

Provincial Priorities

The Provincial Priorities include:

• Improve access to emergency care by reducing the amount of time that patients spend waiting in the emergency department
• Improve access to hospital care by reducing the amount of time that patients spend waiting for a hospital bed
• Click here for Assistant Deputy Minister Deane's memo to LHINs related to 2010-2011 Aging at Home - "Investments and Expected Outcomes"

NSM ER/ALC Framework

In order to address the issue of access to care, the NSM LHIN will focus on improving emergency room wait times through focused strategies that 1) reduce demands for Emergency Department services, 2) build capacity and improve efficiency within Emergency Departments, and 3) allocate patients to levels of care that are most appropriate for their conditions so that patients that require inpatient beds can access them readily.  These three goals care are aligned with provincial goals and, if targeted appropriately, can successfully improve ER wait times. 

The target populations identified as the most likely to visit an emergency department and/or be admitted to hospital when they visit an ER are:

• seniors at risk,
• individuals who experience mental health challenges,
• people with multiple and complex chronic diseases and
• falls including orthopedic trauma.

Integrated Regional Seniors Health Program

The North Simcoe Muskoka Local Health Integration Network (NSM LHIN) recognized the importance of seniors in our health care landscape and, since its inception, has taken active steps to support system planning for this population.  The Seniors Health Regional Action Group has completed a report on A Vision for an Integrated Regional Seniors’ Health Program for North Simcoe Muskoka.    The report recommends an integrated system approach to seniors care.Click here for a link to the full report.

In recognition of the need to strategically fund services, NSM LHIN will be allocating the 2010/11 AAH investment to two Strategic Directions; Supportive Housing and Primary Care.

Supportive Housing

Enhanced Community Care (Building community based services)

To enhance the range of home care services for seniors to avoid unnecessary ER visits, ER and hospital admissions, and support timely discharge of seniors. 

The findings of the NSM Balance of Care Project (May 2009) demonstrated that there is considerable potential to support older persons “at risk” of loss of independence, safely and cost-effectively in the community. The overall divert rate from LTC for NSM is 27%. Between a quarter and half of those waiting for residential LTC could potentially continue to live in the community if given appropriate community-based supports. To achieve the full potential of Home & Community Care (H&CC), greater capacity is required in NSM LHIN.  

The Ontario Ministry of Health and Long-Term Care defines Supportive Housing by the 24-hour availability of personal care and homemaking services (2000). Rather than emphasizing discrete services, supportive housing is an integrated housing model with access to comprehensive and coordinated packages of services and programs necessary to support individuals to maintain their optimal level of health and well-being. 

NSM LHIN will build on existing resources to develop local models for supportive housing across our five geographic planning regions. NSM LHIN will explore new models for supportive housing that include both traditional multiplex housing in social congregate seniors’ settings (building focus) and an outreach approach that includes ready access to flexible support.   

The target population will include high risk seniors. Ministry research suggests that high risk seniors require medium to high levels of support. These medium to high levels of support will focus on the triggers for LTCH admission and ER visits. Providing effective supportive housing services has been shown to make a downward substitution for LTCH for high risk seniors to more cost effective community solutions such as supportive housing. 

Primary Care

To provide enhanced nursing assessment and treatment services in any home setting (e.g. home, LTC home, Supportive Housing) targeted outreach service towards high risk seniors who comprise high ER volume or high volume of ALC patients. 

The Geriatric Care Team at the Algonquin Family Health Team has shown considerable success in optimizing the health, independence and quality of life for at-risk seniors in Muskoka by increasing the capacity for geriatric care. This is an interdisciplinary team that uses a consultative shared-care model and incorporates a CCAC-led Intensive Case Management program (funded in 2008/09 AAH) to support the Family Health Team.  Under the leadership of Dr. Andrea Moser, a Care of the Elderly Family Physician the Geriatric Care Team and the Intensive Case Management Program has demonstrated the ability to avoid unnecessary hospitalization and Emergency Room visits.

Outcomes to date include:

• Decreased Alternative Level of Care admissions for clients referred in the community by allocating patients to levels of care that are most appropriate for their conditions;
• Increased geriatric knowledge in community; and
• Increased capacity for geriatric care

NSM LHIN will expand and replicate this model in order to establish high functioning interdisciplinary Seniors’ Health Teams in each of the LHIN’s five geographic regions. With a common foundation, each team would be encouraged to evolve uniquely to best support local community needs.  The target population for these teams will be high risk seniors. The mandate of these teams is to reduce the demand on local Emergency Departments, Reduce Alternate Level of Care by allocating patients to levels of care that are most appropriate for their conditions and support seniors to ‘Age in Place’.  

Transportation

An inventory of organizations within the NSM LHIN that provide or use transportation services was conducted to identify the state of transportation services in the LHIN.  To read the full report, please click here.

Expert Panels

Two expert panels will make recommendations on which groups will be invited to submit a proposal for 2010/11 AAH. The Seniors Health Regional Action Group (SHRAG) will evaluate the proposals submitted and make recommendations to the ER/ALC Steering Committee and the LHIN Leadership Council. The ER/ALC Steering Committee and the LHIN Leadership Council will review and endorse the proposals to be submitted for NSM LHIN’s Board approval. 

Two expert panels have been created one for Primary Care and one for Supportive Housing. The expert panels consist of key stakeholders that included:

• Emergency Department Nurse Leads
• Care of the Elderly Physicians
• Geriatric Advanced Practice Nurses
• Representatives from the Emergency Room/Alternate Level of Care Steering Committee
• Community Support Services Sector
• Supportive Housing Sector

Focus Groups

Community focus groups will be held to gain advice and guidance from our key stakeholders on developing a system approach to delivering integrated care to our seniors in NSM LHIN. Key stakeholders include:

• Supportive Housing Providers
• NSM Community Care Access Centre
• Community Health Centres
• Family Health Teams
• Physicians
• Hospitals
• Community Support Services
• Addictions and Mental Health

Timelines: