Designing a More Seniors-friendly Health Care System was the second in a Seniors Summit series produced by Health Sciences North. This event was held at the United Steelworkers Hall on Brady St. in Sudbury on Monday June 3, 2013. This presentation is a combination of the three presentations made by our keynote speakers: Sholom Glouberman, President of the Patients Association of Canada and Philosopher-in-Residence at the Baycrest Centre For Geriatric Care; Dr. Janet McElhaney, HSN Volunteer Association Chair in Geriatric Research, Medical Lead of Seniors Care at HSN and Senior Scientist at AMRIC and Dr. Jo-Anne Clarke, Geriatrician, Northeast Specialized Geriatric Services

1. patientsassociation.ca
4-Jun-13An Introduction 1

2. What Do Patients Want?
Designing a More Seniors-friendly
Healthcare System
Health Sciences North
June 3rd, 2013

3. patientsassociation.ca
Disclosure
The Patients’ Association of Canada has
received funding from the OMA, the CMA,
CIHR, CIHI, CHSRF, CFHI, Infoway, the
Health Council, the Change Foundation,
the Trillium Foundation, a large number of
hospitals, and some individual benefactors.
It is not our policy to accept funds from
pharmaceutical companies.

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A Brief History
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A Brief History of Our Health System
Before 1850 Longevity = 35-40
oLeading causes of death – infectious diseases
o Cholera, tuberculosis, small pox, typhoid fever, etc.
Major Innovations 1850-1880
o 1850 – Use of Ether as Anaesthetic
o 1867 – Joseph Lister & carbolic acid
o 1880-81 Robert Koch and Louis Pasteur discover cause
and vaccine for anthrax and other infectious diseases
Our Healthcare System Begins
o Hospitals, Medical Schools, Laboratories, Professionals
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Between 1880 and 1960
Rapid decline of % of death by acute infectious
diseases – success!
o Hospitals grow
o Doctors specialize
o Penicillin begins to save lives in WWII (1940-45)
o New surgeries are performed
o Medical science promises silver bullets
o Cures all around!
4-Jun-13An Introduction 6

7. patientsassociation.ca
Canadian Medicare:
o 1947 Saskatchewan Hospital Ins. Program
o 1957 A National Hospital Insurance Program
o 1962 Saskatchewan Hospital & Doctor care
o 1966 Medicare : A national program covers
o hospital care
o doctors
o 1984 Canada Health Act: Coverage for what
is medically necessary
4-Jun-13An Introduction 7

8. patientsassociation.ca
Our Current System
oCovers hospital care
oCovers Doctors fees
oDoes not cover drugs
oDoes not cover much non-medical treatment
oIt is:
o Highly specialized
o Body-part focused
o Very instrumental
o Increasingly Fragmented
4-Jun-13An Introduction 8

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Attempts to Link Silos Create More
o 1950s Quality (Shroud waving for Quality)
o 1960s Ethics (Because Clinicians need help to be ethical?)
o 1970s Clinical Directorates (Drs are not managers)
o 1980s Program Management (Sewer pipes for silos)
o 1990s KT ( Applying knowledge to particular cases)
o 2000s IPE (A new specialty in its own right)
o 2010s Lean (Industrial Methods for Human Systems)

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The 20th Century Healthcare System
oDoes amazing things to patients
oDoes wonderful things for patients
oDoes almost nothing WITH patients (to say
nothing about their families and caregivers)
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Disease Shifts: Acute > Chronic
Canada 2012
•89% of deaths due to chronic diseases
• Cancer , Heart Disease, Lung Disease, Diabetes
•<3% deaths due to acute infectious diseases
•49% of the population is on long term medication
•Everyone over 65 has at least 1 chronic condition
•2005 76% of people 65+ had taken medication
within 2 days
•More than 30% with chronic conditions have 2+
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12. patientsassociation.ca
Acute / Chronic Comparison
Acute diseases are simple or complicated
have clear diagnoses, can be “conquered”
with vaccines and respond well to
established procedures without much patient
participation
however…
Chronic conditions are complex, with many
causes & need patient & family collaboration

13. patientsassociation.ca
Types of Problems - Examples
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Simple Complicated Complex
Step by Step Recipe Building a Bridge Raising a Second
Child
Steps are critical Formulae are critical Formulae useful but
not alone
Steps are tested so
they work each time
Building 1 bridge
helps make sure the
next will be ok
Raising 1 child is no
assurance of success
with the 2nd
No particular
expertise needed
Expertise in many
fields required +
coordination
Expertise helpful but
not alone
Same results every
time
High certainty of
outcome
Optimism despite
uncertain outcome

14. patientsassociation.ca
How Patients and Families are Seen
4-Jun-13An Introduction to the Patients’ Association of Canada 14
With Acute Disease With Chronic Condition
Complicated Complex
Body to be treated Person with history
Individual – not linked to others Person with people close to them
Focus on disease or organ repair Resource on the health team
Try prescribed treatment Try different approaches or
options
OHIP card name Person with healthcare
experience as patient or caregiver

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The System is beginning to Respond
o “Patient centred care” is the current flavour
o McGill U Med School - more family docs
o Hospitals - patient and family advisers
o CIHR is including patients on its boards
o Cancer is recognized as a chronic disease
o Disease Charities “help now, hope later”
o St Mike’s “Hospital at Home”
o Mount Sinai and sexy geriatrics
4-Jun-13An Introduction 15

16. patientsassociation.ca
Who Are We at the Patient’s Assoc?
We bring a distinct patient and family
caregiver perspective to healthcare
• All providers have their own perspectives.
• They also speak on behalf of patients.
• As a result they do not always agree with each
other about what patients want.
• We are beginning to speak for ourselves and we
believe that this will make it easier for doctors
and other providers.
4-Jun-13An Introduction 16

17. We promote
patients and family
caregivers
as partners in
Canada’s
healthcare system
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Our Mission

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Our Vision
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Our Vision
Canadian patients and families will actively
participate in the transformation of the
Canadian healthcare system.
4-Jun-13An Introduction 19

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Making Patient Experience Count
oAll our work is based on patients’ experiences
oPublic Meetings to Receive Experiences
o Experimental methods to hear what patients have to say
oPatients’ Choice Awards (with OMA)
o Patients Nominate, Patient Jury Selects
oBring Patient Perspective to Advisory Boards
o Cancer Care Ontario, Infoway, OMHARN, CCPCRN, KTGRB

21. patientsassociation.ca
Our Process (ROKS)
1. Review from a patient & family perspective
o Your plans, achievements so far, current patient place
2. Orient Organization to Patient-Family
Partnerships
3. Help set Goals with experience based Key
Performance Indicators (KPIs)
4. Support participating patients & families
and staff groups
4-Jun-13An Introduction 21

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Review
oWhere are you in the process of partnering
with patients?
o Our experience with Patient Rights
o Focus groups
o Partial participations
o Areas of partnership
4-Jun-13An Introduction 22

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Orient Organization to Partnerships
o Orientation to Current Situation
o Partner with change champions
o Educational Sessions for Everyone
o Identify Opportunities for Change
o Surface Apprehensions and Difficulties
o Work with anxieties
o Develop a balanced approach
o Mediate difficult cases
o Institute local self development
4-Jun-13An Introduction 23

24. patientsassociation.ca
Key Performance Indicators of PFCC
o In ERs triage nurses are excellent at
distinguishing very sick from not very sick
o 90% of patients are not very sick, but most
are quite anxious
o Almost no triage nurses are trained to deal
with patient anxiety
o A KPI for ERs is that front line staff is
trained to respond better to worried people
4-Jun-13An Introduction 24

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KPIs
o Information Based KPIs
o Review of Primary are KPIs
o Review of Accreditation KPIs
o Review of System Performance KPIs
o Hospital Audit for KPIs
o KPIs for Chronic Care
o KPIs for Long Term Care
o KPIs for End of Life Care
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Support
oSupport patients and families
o Conferences
o Peer support
o Help line
o Support local champions
o Learning set
o Meet others facing similar issues
o Providing peer support
oSupport Organizations
o Problem solving
o Customized programs
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Patients Redesign Service Delivery
oAt Baycrest
oRedesign the Admission Process
o Especially the day of moving in
o Introduction of Family Member Mentors for New families
o Recognize and reduce anxiety of families as they move in
o Why patients and family caregivers are necessary
oAt Northumberland PATH
o Better transitions for older people in Northumberland
o Collaboration among 12 providers and patients and families
o We are responsible for preparing and helping bring the patient
perspective
4-Jun-13An Introduction 27

28. patientsassociation.ca
Patients Can Work with Providers
oAs Advisers
To bring the patient and family perspective to planning and policy
making.
oAs Mentors
To bring their experience to new patients and families and help
support them through difficult experiences
oAs Educators
To prepare organizations and individuals to create partnerships
with patients and their family caregivers
oAs Researchers
To bring a patient and family perspective to research
4-Jun-13An Introduction 28

29. patientsassociation.ca
Make Your Experience Count!
Join the Patients’ Association!
oHelp transform the Canadian healthcare system
o Become a Volunteer at the Patients’ Association
o Tell us your experiences as providers and patients
o Help us gain better insight into the provider perspective
oLearn to work with Patients
o Help train patients and family members to participate
4-Jun-13An Introduction 29

30. Join us!
It’s Free
Go to our website
patientsassociation.ca
THANK YOU!
W patientsassociation.ca
T @PatientsAssocCa
Facebook Patients Association of Canada
Make Your Experience Count

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4-Jun-13An Introduction 31

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4-Jun-13An Introduction 32

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4-Jun-13An Introduction 33

34. Aging with Vitality:
Partners in Care
Janet E. McElhaney, MD, FRCPC, FACP
HSN Volunteer Association Chair in Geriatric Research
Professor of Medicine, Northern Ontario School of Medicine
Health Sciences North and
Advanced Medical Research Institute of Canada
Sudbury, ON

35. Seniors’ Health: Adding Life To Years
60 70 80 90
Age
2000’s
1990’s
1980’s

36. Competence
Confidence
Connection
Determinants of Health

37. Risks Associated with Hospitalization:
United States 1993-1997
65+ population are hospitalized 3X more often than younger adults;
37% of discharges, 50% of inpatient days, and 60% of expenditures
65+ population – 80% have one chronic disease; 50% have two
At discharge, 33% are more disabled and one half never recover
5% die in hospital, 20-30% die in the year after hospitalization
Elixhauser A et al; AHRQ Pub. No. 00-0031, HCUP Fact Book No. 1, 2000
Covinksy KE et al; J Am Geriatr Soc; 51:451, 2003

38. Ageing and Hospital Use in the 70+
 Only a small proportion of older adults are consistently
extensive users of hospital services (Wolinsky, 1995)
42.6%
6.8%
4.8%
24.6%
Consistently Low Users No Hospital Episodes
Consistently High UsersInconsistently High Users
Seniors Strategy
Ageing and Hospital Use in the 70+
With Permission: Dr. Samir Sinha, MD, DPhil, FRCPC,
Provincial Lead Ontario’s Seniors Strategy

39. Changes in Level of Frailty:
Can we “see” it and what does it mean?
4
5
6
7
8 9
3
2
1
When reserve capacity is
decreased to a crucial
level, adaptive mechanisms to
stressors can no longer be
mobilized, leading to a breakdown
of homeostasis and crossing the
threshold to clinically manifested
frailty syndrome.

40. Acute Illness: Prevent or Minimize Disability
80 80 80 80 80
Age
Cardiovascular Disease
Diabetes
Osteoporosis
Chronic Lung Disease
Cognitive Impairment
Dynamic
Frailty
Usual
Aging
IADL
Frailty
ADL
Frailty

41. One presentation of dynamic frailty
Picture an 82 year old woman who presents in the ED with a possible
fracture from a fall while walking with her 3 K-a-day Club.

42. Dynamic frailty can be a mask
that limits our view of possible outcomes
Picture an 82 year old woman who presents in the ED with a possible
fracture from a fall while walking with her 3 K-a-day Club.

43. Learn to look behind the mask …

44. The Care Pathway: “48/5”
• Starts within 48 hours of hospital admission and
focuses on evidence-informed decisions about:
– Medication reconciliation/appropriateness
– Delirium / Cognition
– Functional mobility – “Every day is an activation day”
– Nutrition / Hydration
– Bowel / Bladder
• Interprofessional collaborative practice
• Mobility is the “fifth vital sign”

45. Acute Illness: Prevent or Minimize Disability
80 80 80 80 80
Age
Cardiovascular Disease
Diabetes
Osteoporosis
Chronic Lung Disease
Cognitive Impairment
Dynamic
Frailty
Usual
Aging
IADL
Frailty
ADL
Frailty

46. Summary
 Holistic care integrates evidence with a person’s goals and
values
 Optimize prevention strategies to maintain independence
 Goals of care: what would it mean if the quality of life were
the determinant of value in healthcare decision-making?

47. Improving Community-Based
Senior’s Care
Dr. Jo-Anne Clarke
Geriatrician

49. 14.6% of Canadians are 65 and older, yet account for
nearly half of all health and social care spending
(Census, 2011).
Canada’s older population is set to double over the
next twenty years, while its 85 and older population is
set to quadruple (Sinha, HealthcarePapers 2011).
Health care system developed when average of age of
a Canadian is 27 years of age
1500 hundred pediatricians, 125 geriatricians in Ontario
Health care system poorly adapted to the complexity of
managing and treating chronic disease, frailty and
dependence in an aging population
Decreased availability of family and caregivers

50. Amount of health care seniors receive is largely
driven by the number of chronic conditions
they have, not their age.
Seniors with 3 or more CCs have nearly 3x the
number of health care visits than those with no
reported conditions
Seniors with 3 or more CCs account for 24% of
the senior population, but account for 40% of
health care use

51. Older persons accumulate chronic illness as
they age
51
Age Number of chronic conditions
0 1 2 3+
40-59 44% 30% 14% 12%
60-79 20% 25% 25% 30%
80+ 12% 24% 22% 41%

52. It's more than Chronic Disease
Understanding Geriatric
Syndromes & Frailty

53. 53
1 Disease Many Symptoms 1 treatment
Pneumonia
Trouble
breathing
Fever
Short OB
Cough
Myalgias
Antibiotics

54. 54
Many Factors One Syndrome Multiple Interventions
Delirium
Inouye, NEJM 2006

55. As prevalent as chronic disease
In the HRS, 50 % of people > 65 had 1 or more
geriatric conditions
Commonly co-occur with chronic disease
more than 25% of older adults with chronic
disease have at least one geriatric syndrome
Strongly associated with functional decline
and disability
More likely than stroke to cause disaility
Top 3 predictors of “why cannot go home”
from hospital (mobility, incontinence,
cognitive impairment)
Incontinence
Pressure ulcers
Falls
Frailty
Delirium
Cognitive
impairment….
Examples

56. HRS Study - Association btw disease, geriatric
syndromes, and disability
Condition Risk of disability
Number of geriatric conditions
1
2
3+
2.1
3.6
6.6
Stroke
Diabetes
Heart disease
Cancer
3.0
1.3
1.2
1.0
Ann Intern Med 2007;147:156-64

58. One disease model does not work
Early identification, and management of
contributing and accumulating deficits
Requires integration of medical and social aspects
of care
 Medical and chronic disease management
 Strong primary care essential
 Enhancing physical activity, make it accessible and
available
 Senior friendly environment, proper nutrition
 Community supports and connections
 Formal and informal supports essential

59. Objective Target Population Initiatives Responsibilities
1
Maintain independence
prevent functional loss
HEALTH
PROMOTION
Primary
Care (1o Care)
2
Restore independence/
Reverse functional loss
Review and Intervene
UNFRAIL:
Diseases
Drugs
Deconditioning
Rehab
CCAC
+ Primary Care
+ Specialized Geriatric
Services
(SGS):OP
3
Identify and manage
conditions contributing to
frailty and functional loss
Screening for high risk to
return to ED
ED GEM, CCAC RISC
1o Care, and SGS
4
Identify and manage
conditions contributing to
frailty and functional loss
(10%)
ADMIT TO HOSPITAL
Screen for high risk by 48
hrs
 Prevent deconditioning/
Iatrogenesis
Geriatric consult unless
clear D/C plan
 Hospital Care Team
5
Return home or to lower
level of care (10%)
ASSESSMENT
Prior to ALC designation to
ensure NO reversibility
6
Reduce demand for
placement by optimizing
function for patients
referred (17%)
ACTIVATION and time (still
some “recoveries” possible)
6 Safety Nets
ALC UNIT
LTC PLACEMENT
ALC
Patient
FRAIL & NOW
SICK
ELDERLY IN ED
FRAIL & NOW SICK ELDERLY IN ED
FRAIL ELDERLY
HEALTHY ELDERLY
Changing the trajectory to Long term care: The key
to start early, target and treat
BEING
ADMITTED
SENT HOME

60. Prolonging Life
Optimizing quality of life
and function
AGE
A B C D
Osterweil D. 2007

61. Increased
primary care
coordination
Enhance care
coordination
and transitions
Mental Health
and Addictions
Access
Cultural
diversity
North East Local Health Integration Network
Seniors
remain in their
own home
longer
Integrated
Care
Generating
Knowledge
Specialized Geriatric Programs
Independence & Quality of Life
•Increased likelihood of living at home
•Improved physical & mental health
•Improved continuity of care
Clinical Efficiencies
•Reduced Hospital Days
•Reduced LTC Placement
•Cost Savings
Patient Outcomes
•Improved diagnosis
•Reduced loss of function in hospital
•Improved patient satisfaction
Geriatric Capabilities
•Improved Clinical Decision-Making

62. Program Goals
To provide specialized geriatric
assessment and treatment to
medically complex, frail elderly.
To provide education and
knowledge transfer promoting
best practices for geriatric care.
To increase capacity in geriatric
care throughout Northeastern
Ontario.
To be responsive to the needs
of the communities of
Northeastern Ontario

64. NESGS Clinical Team:
Geriatrician
Care of the Elderly Physician
Nurse Practitioner
Geriatric Nurse Clinicians
Occupational Therapist
Physiotherapist
64
Interdisciplinary:
• Cross trained in completing
comprehensive geriatric
assessments and supporting
treatment plans
Multidisciplinary:
• Providing professional specific
assessment and treatment

65. 65
26 Hospitals
1 CCAC
1 NEMHC
53 Long Term
Care Facilities
1,896 Retirement
Beds
+ community
support services,
FHT, CHC’s
Referrals Received to
Date: 2909
► clinics
► in-patient consults
► LTC consults
► Ontario Telemedicine
(OTN)
► Home visits
Cochrane
14%
Algoma = 3%
Cochrane 13%
Sudbury =
67%
Timiskaming =
3%
Nipissing = 2%
Parry Sound =
12%
DEMOGRAPHICS

66. 66
Geriatrician
Care of the
Elderly
Physician
Nurse
Practitioner
Geriatric Nurse
Clinician
Occupational
Therapist
Physiotherapist
Comprehensive Geriatric Assessment
&
Support Clinic
Physician Assessment
&
Treatment
Referral to multidisciplinary team
Intensive Case Management
Monitoring of side effects/conditions
Comprehensive Cognitive Testing
Functional Assessment
Home Modifications
Exercise
Gait
Mobility Aids
Continence Clinic
Bone Health Clinic
Frail to Fit Falls Prevention
Program

67. Geriatric Interprofessional and interorganizational collaboration
(GiiC)
Mini GiiC
Northern Geriatric Care Conference (biennial)
Next conference: September 18-20, 2013
Weekly calendar to all partners in care advising of educational
opportunities (OTN, rounds etc.)
Website
Physician education
Training
Medical students, medical residents, nursing students, allied health
students
PGY 3 – now available
Post secondary institutions/students

68. Development of Geriatric Programs
Geriatric Network in Sault Ste. Marie
Dr McElhany HSN STAT program, COACH teams
GEM programs (HSN, Parry sound, SSM)
Memory Clinic Training Program
Funded the involvement of 4 FHT across the
Northeast as well as research/evaluation
Geriatric Medicine Certificate Program
Development of a curriculum & evaluation

69. Integrated care model with CCAC Geriatric/
Complex Care Coordinators
Create standards of practice for all programs
supporting older adults i.e. GEM Nurses, Day
Hospitals
Work in partnership with NE LHIN, partners
in care, and our patients, to develop a
Regional Seniors Strategy
Support local communities to develop
Geriatric Networks and specialized
Geriatric Services along the continuum of
care

70. Ministry of Health and Long-Term Care and its LHINs should establish a
provincial working group of geriatricians, care of the elderly family physicians
and specialist nurses, allied health professionals, and others to help develop
a common provincial vision for the delivery of geriatric services and a
prioritization plan to guide local staffing and funding of care models as
resources become available.

71. Increase home care
More exercise classes and
falls prevention
Housing and supports
Connect every senior to a
Doctor
Better coordination
Hospital at home models
Improve transitions of care
Ontario wide geriatric care
Improved assessments
Improved training in geriatrics
Strengthen PSW work force

72. Improved
access to
primary care
One
common
assessment
One point of
access
Shared
information
Better
transition
from
hospital to
community
Accessible,
timely
services in
the home
Community
support
workers with
geriatric
expertise

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