Theme 7. Clinical innovations keeping people at home and out of the hospital
Presentation Materials (members only)
Aging at Home Indicator Management
Learning Objectives
Our Aging at Home program’s focus is to provide interdisciplinary home care to seniors and reduce unnecessary emergency department visits. We will share our experience with team building, physician engagement as well as collaboration with CCAC and Joseph Brant Hospital. Our team were participants in the IDEAS program. We will discuss how the resources made available assisted in developing tangible goals and performance indicators and how this carried over into our QIP. The goal for our presentation is to have the attendees benefit from our learnings in:
- Program Development
- Team Building
- Internal and External Collaboration
- Embedding QI into a program.
Summary
The LHIN’s Aging at Home Strategy identified that a wider range of homecare and community support services will be needed. They project that the population of seniors will double in the next 16 years. Approximately 40% of the population of Burlington is over the age of 50. For our aging population, the Burlington Family Health Team has developed a program through clinical innovations to keep seniors at home and out of hospital. The Aging at Home program aims to reduce preventable emergency department visits and helps to promote optimal health for our patients in the community. This is achieved through assessment and intervention by the FHT Occupational Therapist and Nurse Practitioner for patients who have difficulty accessing services, and who are at high risk for repeat emergency department visits and hospitalizations. Several aspects of the program will be highlighted, including monthly rounds with physicians and members of the interprofessional team as well as ongoing monitoring of emergency department data for quality improvement purposes. A key feature of the program is the ongoing collaboration and integration with our local CCAC and Joseph Brant Hospital. The Burlington FHT will also continue to build on our close relationship with Burlington Health Links. Future goals include utilization of emergency department data to screen for high risk patients who may benefit from the program.
Presenters
- Burlington FHT:
- Shawna Cronin, Occupational Therapist
- Theresa Hubley, Nurse Practitioner
- Caitlin Grzeslo, Program Coordinator
Authors and Contributors
- Joanne Pearson, Executive Director, Burlington Family Health Team
- Courtney Field, MD, Burlington Family Health Team