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Regional Geriatric Programs and Specialised Geriatric Services

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Title: Regional Geriatric Programs and Specialised Geriatric Services


1
Regional Geriatric Programs and Specialised
Geriatric Services
Mr. Cal MartellDirector, Ottawa-Carleton
Regional Geriatric Assessment Program
  • OHA - November 23, 1999

2
Specialised Geriatric Services Context
  • Responding to the needs of an aging population
    will likely be the single most significant
    challenge facing our health system, and is cited
    as a major factor in health system
    restructuring
  • HSRC recommended all hospitals take measures to
    further develop their geriatric capabilities

3
Specialised Geriatric Services Role
  • Fundamental Assumption
  • Much of the disease, disability and dependency in
    old age is preventable, treatable, or manageable.
  • Diagnostic Difficulties (co-morbidity,
    atypical presentation)
  • Loss of health and independence sometimes
    associated with inaccurate diagnoses resulting in
    inappropriate treatment.

4
Specialised Geriatric Services Role
  • Comprehensive Geriatric assessment, short term
    treatment, rehabilitation and management for
    older adults with complex health problems.
  • Consultation advice to older adults, their
    families, physicians and other caregivers
  • Promote high quality geriatric care through
    education, research and evaluation
  • A resource for more successful aging to
    reduce unnecessary the human and financial
    burden of population aging

5
Specialised Geriatric Services Description
  • Inpatient
  • Geriatric Assessment Unit
  • Geriatric Consultation Service
  • Geriatric Rehabilitation Unit
  • Ambulatory /Outpatient
  • Geriatric Outpatient Clinic
  • Geriatric Day Hospital
  • Geriatric Outreach Service

6
Geriatric Assessment Units
  • Function Comprehensive geriatric assessment,
    care and treatment.
  • Location Acute Care
  • Target Older hospitalised patients with complex
    health care problems requiring full range of
    geriatric and therapeutic services.
  • Team Geriatrician-lead interdisciplinary team
  • Referrals Other hospital services, through
    consult team, and community.
  • Length of Stay 2-3 weeks
  • Discharge Community

7
Geriatric Rehabilitation
  • Function Geriatric Rehabilitation and
    reactivation
  • Location Complex Continuing Care or Acute
  • Target Frail individuals experiencing loss of
    independence following acute illness or injury,
    with multiple problems requiring individualized
    inpatient rehabilitation.
  • Team Interdisciplinary team.
  • Referrals Acute hospitals, some community.
  • Length of Stay 4-8 weeks.
  • Discharge Community

8
Geriatric Consultation Service
  • FunctionComprehensive geriatric assessment
    triage
  • Target High risk older patients in acute care
  • Team Geriatrician, CNS
  • Referrals Hospital.
  • Length of Stay 1 visit, occasional follow up.
  • Discharge (N/A) Existing service, triage to
    geriatric service.

9
Geriatric Outreach Teams
  • Function Multidimensional geriatric screening,
    assessment and triage.
  • Target High-risk elderly in their own homes.
  • Team Multidimensional geriatric assessors with
    physician support.
  • Referrals Community - Family physicians, CCACs,
    Families, Discharge planners.
  • Length of Stay 1 visit with some follow up.
  • Discharge n/a - Advice and referral to day
    hospital and other services.

10
Geriatric Day Hospital
  • Function Outpatient Comprehensive geriatric
    assessment and short term treatment and
    management
  • Location Acute or complex continuing care.
  • Team Geriatrician lead interdisciplinary team.
  • Referrals Family physicians - may be triaged
    through Outreach.
  • Length of Stay 4-8 weeks.
  • Discharge Community services as required.

11
Geriatric Clinics
  • Function Comprehensive geriatric medical
    assessment and consultation - may include follow
    up or be targeted e.g. falls, memory disorder,
    continence
  • Location Acute , continuing or long-term
    care....
  • Team Geriatrician, may include CNS.
  • Referrals Family physicians, discharge planners
  • Length of Stay 1 visit with some follow up.
  • Discharge Existing residence

12
Geriatric Rehabilitation Unit
Outpatient Clinics
Community Referrals
Hospital Referrals
Geriatric Assessment Treatment
Outreach Assessment Teams
Consultation Services
Geriatric Assessment Units
Day Hospitals
An Organised Delivery System for Seniors with
Complex Health Problems
13
Regional Geriatric Programs The Original
Network
  • Established in 1988
  • Seen as first step in province-wide
    comprehensive, integrated system for frail
    elderly.
  • Mandate for Specialised care, education,
    evaluation, research and program development.
  • Physician Alternate Payment Plan.
  • Academic Health Science Centres.
  • Regional Approach

14
RGPs Where Art Thou?
  • Hamilton Specialised Health Care for the Elderly
    Program
  • London Southwestern RGP
  • Toronto Metro Toronto RGP
  • Kingston Southeastern RGP
  • Ottawa Ottawa-Carleton RGAP
  • Provincial Survey 1998
  • 50 of Ontarios population 65 reside within
    primary catchment area of RGPs. (52 of 75).
  • 17 reside in other areas receiving clinical
    service from RGPs e.g. Renfrew, Pembroke, Moose
    Factory, Kenora, Dryden, Kirkland Lake,
    Manitoulin,

15
RGPs Where Are You Going?
  • Provincial Review
  • Enhanced accountability and consistency
  • Improved access to SGS
  • Distinguish network coordination role and funding
    of RGPs
  • Review approach to Alternate Payment Plan
  • RGP Strategic Planning
  • More integrated regional network of SGS (e.g.
    Dementia Networks)
  • Increase capacity of primary continuing care
  • More joint education / research initiatives.
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