D1a -An Integrated Care Team for Older Adults: Embedding Geriatric Expertise in a FHT
Any questions regarding this presentation can be sent to adam.morrison@gmail.com
1. It takes a team: collaboration inside and out
- Release date:
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This webinar will be available for a limited time after the conference- don’t miss it on Wednesday October 12th during the conference!
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- Style: On-demand Webcast
- Focus: Balance between both (e.g. Presentation of a best-practice guideline that combines research evidence, policy issues and practical steps for implementation)
- Target Audience: Leadership, Clinical providers
Learning Objectives
- Learn about a pilot for an integrated care team that supports older adults living with complex and chronic health conditions in a FHT setting
- Observe an OHT-supported model of care based in primary care that includes interprofessional participation and geriatric expertise
- Understand the value of regional partnerships and inter-organizational relationship-building that includes specialized geriatric services as part of integrated care
- Receive resources and a roadmap for defining and measuring integrated care for older adults.
Summary/Abstract
This presentation describes the design, findings, lessons learned, and recommendations for a shared model of care that integrates specialized geriatric expertise into a team-based primary care setting. Attendees will receive tools and resources to consider how their FHT may adopt a similar shared model of care, with preliminary outcomes based on the quadruple aim framework. The Interdisciplinary Care Team (ICT) Pilot was developed as a primary care-based intervention to support older adults waiting to see a geriatrician. At the time of the pilot, the Geriatric Medicine Complex Care Clinic (GMCC) at St. Mary’s Hospital had a waitlist of 445 patients, with an average wait time of approximately 140 days. The ICT Pilot aimed to support older adults on the St. Mary’s GMCC waitlist by re-triaging them with the interRAI Check Up, a self-reported tool that supports risk stratification and management of older adults living with complex and chronic conditions. The ICT team met weekly to review patient information and Check Up outputs to develop care plans, initiate referrals, and support comprehensive geriatric assessment by a geriatrician. This approach favoured person-centred support of patients by identifying personal goals, managing symptoms, and advance care planning. The ICT Pilot Steering Committee confirmed the model of care, location (New Vision FHT), health human resources (from primary care, acute care, home and community care, community support services, community paramedicine, GeriMedRisk clinical pharmacology, and hospice) and workflow (how the diverse partners would work together as one team) for six weeks of operations in Winter 2022.
Presenters
- Dr. Sarah Gimbel, Family Physician, New Vision FHT
- Adam Morrison, Regional Project Lead, ICT Pilot, Canadian Mental Health Association Waterloo Wellington
Authors
- Dr. Éizabeth Côté-Boileau, Ontario Health Team Impact Fellow, KW4 OHT