SPECIALIZED GERIATRIC AND PSYCHOGERIATRIC SERVICES IN …

SPECIALIZED GERIATRIC AND

PSYCHOGERIATRIC SERVICES IN

THE CENTRAL EAST LHIN: AN

ENVIRONMENTAL SCAN 2011

PREPARED BY:

PATTI REED

DISTANCE LEARNING GROUP

MAY 2011

Specialized Geriatric and Psychogeriatric Services Environmental Scan 2011 Page 2

SPECIALIZED GERIATRIC AND PSYCHOGERIATRIC

SERVICES IN THE CENTRAL EAST LHIN: AN ENVIRONMENTAL SCAN 2011

ACKNOWLEDGEMENTS

This Environmental Scan project was led by Ontario Shores Centre for Mental Health Sciences (Ontario

Shores) in partnership with the Central East Local Health Integration Network (Central East LHIN). The

author would like to thank Sheila Neuburger, Vice-President at Ontario Shores and Carol Anderson, Lead

SGS Planner at the Central East LHIN, for their assistance in determining the scope of the project and in

their recommendations and advice throughout.

Special thanks go to the many key informants who gave of their valuable time and shared their

experience and knowledge to ensure that the Environmental Scan was comprehensive and complete.

A full list of people who supported this work can be found in the Appendix.

DISCLAIMER

The author has made every effort to ensure that the information collected during the timeframe of the

project is accurate. However, neither Ontario Shores Mental Health Sciences Centre nor the Central East

Local Health Integration Network can accept responsibility for any errors or omissions. It is up to the

reader to consult with the original program source for more detailed service descriptions.


CONTENTS

Acknowledgements 2

Disclaimer 2

Executive Summary 5

Purpose and Scope of the Project 6

Limited Scope 6

Methodology 8

Priority Populations and Scope 8

Key Informant Interviews and site visits 8

Stakeholder Consultation 8

Seniors Demographics in the Central East LHIN 9

Specialized Geriatric Services (SGS) 12

Defining the Population 12

Description of Core Components of SGS 13

Inpatient/Hospital Functions 13

outpatient services 14

The Lay of the Land 15

Inventory of specialized Geriatric Services 16

Scarborough 16

The Scarborough Hospital (TSH) 16

Rouge Valley Health System (RVHS) 19

Durham 21

Lakeridge Health (LH) 21

Peterborough, Kawartha Lakes, Haliburton, Northumberland 24

Peterborough Regional Health Centre (PRHC) 24

Ross Memorial Hospital (RMH) 25

Northumberland Hills Hospital (NHH) 26

Haliburton Highlands Health Services (HHHS) 27

Campbellford Memorial Hospital (CMH) 27

Specialized Geriatric Services in Central East LHIN 28

Psychogeriatric Services 33


Defining the Population 33

Description of Core Components of Psychogeriatric Services 34

Inpatient/Hospital Functions 34

Outpatient Services 34

Inventory of Psychogeriatric Services 36

Scarborough 36

The Scarborough Hospital (TSH) 36

Rouge Valley Health System 37

Durham 39

Lakeridge Health 39

Peterborough, Kawartha Lakes, Haliburton, Northumberland 41

Peterborough Regional Health Centre (PRHC) 41

Ross Memorial Hospital (RMH) 43

Central East LHIN-Wide Psychogeriatric Services 44

Ontario Shores Centre for Mental Health Sciences (Ontario Shores) 44

Specialized Psychogeriatric Services in Central East LHIN 45

Stakeholder Consultation Feedback 49

Key Challenges to Care 49

Promising Practices 52

Final Thoughts 54

References 56

Appendix 57


EXECUTIVE SUMMARY

Under the leadership of Ontario Shores Centre for Mental Health Sciences in collaboration with the

Central East Local Health Integration Network (Central East LHIN), the purpose of this project was to

complete an environmental scan of geriatric and psychogeriatric services available within and in close

proximity to the Central East LHIN.

Through a combination of in-depth key informant interviews and broad stakeholder consultation with

specialized geriatric health service providers serving frail older adults with complex needs, it was found

that the Central East LHIN currently offers a patchwork of specialized supports with islands of isolated

excellence. The environmental scan offers a complete inventory and brief description of existing

specialized geriatric and psychogeriatric service within the scope of the definitions provided.

Services are found supportive for those that can access them but the range of available services is often

fragmented, hard to negotiate and inflexible. Some services overlap to offer a duplication of resources

while leaving some needs completely unaddressed. This means that depending on where one lives in

the Central East LHIN, one may have a very different patient experience. The environmental scan

identifies some key challenges in the provision of specialized geriatric services and psychogeriatric

services in the Central East LHIN.

Over the years, health service providers in the Central East LHIN have worked to improve the care for

the frail elderly population while making the best use of limited resources. The environmental scan

found some excellent best practice examples of partnerships between the hospital and community

health and long term care home service providers. Recent investments made by the Central East LHIN

have led to a broader mix of resources available to assist frail older individuals with chronic and

complex conditions. The environmental scan identifies some of these promising practices in the

current provision of specialized geriatric services and psychogeriatric services.

We know that targeted care for frail seniors with chronic and complex health conditions improves

health outcomes. The environmental scan, along with expert stakeholder opinion, concurs that the

array of specialized geriatric services and supports available fail to address the need for a

functioning, integrated service delivery system. To be most successful and achieve best

outcomes for this vulnerable population requires that a regional framework for the coordinated

delivery of specialized geriatric and psychogeriatric clinical services be put into action in order to

improve access to the appropriate level of quality care that will best meet their ongoing needs.


PURPOSE AND SCOPE OF THE PROJECT

The fundamental premise of specialized geriatric services (SGS) is that much of the disease, disability

and dependence associated with aging are preventable, treatable or manageable. SGS services have

been shown to decrease the length of stay in hospital, maintain functional abilities and improve patient

outcomes.

The Central East LHIN recognizes that limited capacity to provide specialized geriatric and

psychogeriatric clinical services for high risk frail elderly people living in the community creates barriers

to accessing care and to the quality of care people receive. As a result, the Central East LHIN has been

strategically investing in services that are aimed at supporting the needs of the frail elderly population

with a vision to integrate new funding with existing services and establish a LHIN-wide program of highly

coordinated specialized geriatric and psychogeriatric services.

Under the leadership of Ontario Shores in collaboration with the Central East LHIN, the purpose of this

project was to complete an environmental scan of geriatric and psychogeriatric services available

within and in close proximity to the Central East LHIN.

The objectives of this project were:

To gain a better understanding of the full range of specialized geriatric and psychogeriatric

services (a ‘big picture’ scope of services and supports) and how they are currently organized

and delivered to meet the needs of the frail elderly population;

To determine what and where health-funded specialized geriatric programs/services are

currently delivered; and

To determine what and where health-funded psychogeriatric programs/services are currently

delivered.

A significant number of older adults receive health services as a result of the general population profile.

This environmental scan is focused on those services that are dedicated resources with advanced

expertise working in interdisciplinary teams to serve the smaller percentage of older adults as a special

population who present with complex care needs due to frailty in combination with interrelated

biomedical, psychological, social, functional and environmental needs.

LIMITED SCOPE

Specialized geriatric services are available to all older adults and their families/caregivers;

however, not all older adults require this intensity of service. Older persons with complex

health problems are at a greater risk of physical and/or mental health frailty and present with

specific and unique challenges for accurate assessment and diagnosis. It is this 10-15% of older

adults that require specialized geriatric expertise to manage their care that were the focus of

the environmental scan.


Specialized geriatric services are just one piece of a much larger system of care. Although

outside the scope of this project, it is important to acknowledge the integral role of community-

based services for frail older adults and their caregivers in both preventative care and in

supportive discharge from hospital, to maintain individual quality of life and functioning in their

own homes and to reduce the overall need for SGS. Access to primary health care (e.g., family

physician, nurse practitioner) and community support services (e.g., adult day programs,

personal support services, family support and respite, meals on wheels and congregate dining,

security checks, emergency response systems) can delay admission to a long term care home

for several months or even years. In fact, optimal care in SGS depends on the linkages and

relationships with the other parts of the continuum that include illness prevention, primary care and

post-acute care to successfully maintain and support frail seniors living in the community. Although

health and social services within the broader service delivery system for seniors are beyond the scope of

this project, it will be critical to engage these partners in future planning discussions in order to develop

a coordinated, integrated system of care.

The environmental scan does not include:

Any services for seniors/older persons that are not defined as SGS; for example, inpatient

hospital services serving seniors within the general population of the hospital (including

medicine, surgery, complex continuing care and rehabilitation, mental health, etc.) or outpatient

specialty clinics (e.g. falls, osteoporosis, diabetes); or community support agencies that provide

a range of services to all older adults (e.g. adult day programs, meals on wheels, supportive

housing, foot care, chronic disease management);

Any services for seniors/older persons that are not defined as specialized psychogeriatric

services; for example, community mental health and addiction agencies that serve adults,

including seniors with mental illness and/or addiction issues within the general population;

Individual clinicians or geriatric specialists who are not part of a specialized geriatric

interdisciplinary team (e.g. geriatric psychiatrists working within the acute care mental health

unit to support seniors within the general population of the entire unit); or

Recommendations for investments in current service delivery components.

The environmental scan will be used to complement and inform current planning processes in moving

towards a coordinated regional geriatric service approach to improve patient outcomes and to create a

better future for the frail elderly population in the Central East LHIN.


METHODOLOGY

PRIORITY POPULATIONS AND SCOPE The project was managed in parallel with the SGS regional organization and governance project in the

Central East LHIN. To that end, the Regional Geriatric Advisory Committee Expert Panel defined the SGS

target population and advised on what core components of specialized geriatric and psychogeriatric

services to include in the environmental scan (see full report: Specialized Geriatric Services in the Central

East LHIN: Options for Coordinated Delivery, Organization and Governance). In the process of

developing this report there was ongoing dialogue between the two project leads to ensure that the

work of the Expert Advisory Panel was consistent with the goals of the environmental scan and that

there was no duplication of effort across the two projects.

KEY INFORMANT INTERVIEWS AND SITE VISITS Information on the current context for the investigation of this report was collected through key

informant interviews and site visits. In February, March and April 2011, interviews were conducted with

twenty-five providers with expertise and experience in the provision of specialized geriatric and

psychogeriatric services in the Central East LHIN. (See Appendix A for list of key informants and site

visits.) Interview questions pertained to specific information including:

What type of service/program do you provide?

How many units of service/beds do you offer?

What are the referral sources and intake processes? What, if any, are the exclusion criteria?

Is service provided by an interdisciplinary team? If yes, what professions are represented on the

interdisciplinary team?

What is the average length of service?

Do you carry a waitlist? If so, how long is it?

What services/programs do you partner with to facilitate discharge?

What are the key challenges to providing health care to this population?

What are the promising practices that you would like to promote going forward?

The key informants were provided the opportunity to vet the service descriptions for accuracy.

STAKEHOLDER CONSULTATION The two projects hosted joint stakeholder consultation sessions midway through the project; one in the

northeast (Peterborough) and one in the southwest (Ajax) of the Central East LHIN. Over ninety

participants provided feedback on the information gathered on the inventory to date and on the

proposed regional specialized geriatric governance and funding model.


SENIORS DEMOGRAPHICS IN THE CENTRAL EAST LHIN

The aging of the population is occurring at a rapid rate. At present older adults (age 65 and over)

represent 13.75% of the population in the Central East LHIN or 200,000 seniors. By 2030 the number of

seniors is expected to grow to represent over 20% of the total population in the Central East LHIN.

Seniors over the age of 85 are growing at a rate that is four times faster than any other age cohort in

Canada. The life expectancy at age 65 in the Central East LHIN is higher than the rest of Ontario at 85.3

years of age versus 84.6 years of age. As people live longer it is likely that there will be an increasing

number of people with age-related neurodegenerative disorders such as dementia and mental illnesses

such as depression.

The majority of older adults is able to manage independently within the normal physiological changes of

aging and can access the health care that they need. However, an estimated 10 to 15% of the

population is considered to be frail older adults with multiple co-morbidities requiring specialized

geriatric expertise to manage their care (approximately 20,000 to 30,000 older adults currently residing

in the Central East LHIN).

An estimated 3 to 5% of the population requires specialized geriatric psychiatry services (representing

approximately 8,000 older adults currently residing in the Central East LHIN). The risk of suicide

significantly increases with age. The incidence of suicide in men 80 years of age and older is the highest

of any age group (at 31 per 100,000 people)1. Conservative estimates put the rate of addiction among

older adults at 10%2. However, if one includes less severe disorders, substance abuse and age-related

disorders such as dementia in the estimate of the population that require specialized psychogeriatric

services than the prevalence of mental health problems among older adults is between 17% and 30%

(up to 60,000 people in the Central East LHIN).

Typically, the prevalence of chronic diseases and associated disabilities is highest among the oldest age

groups (those 75 years of age or older) which is also the age groups that are more likely to require

hospitalization and remain in hospital for a longer length of stay. Eighty-two per cent of seniors have

one or more chronic health conditions and 43% have three or more chronic health conditions.

According to 2009 data from the Institute of Clinical and Evaluative Studies, seniors aged 75+

represented 6.5% of the general population in the Central East LHIN, yet they constituted 12.7% of all

emergency room visits, 45% of all acute inpatient bed days and 70% of all ALC days3.

As the older senior population increases (those aged 85+), so does the number of people living in long

term care homes. Older adults entering long term care homes tend to be at an advanced age with more

1 Special Senate Committee on Aging First Interim Report: Embracing the Challenge of Aging, Sharon Carstairs and Wilbert Keon, March 2007. 2 See COPA website: www.copacommunity.ca. 3 Anderson, C. and Regional Geriatric Advisory Committee Expert Panel (2011). Regional Specialized Geriatric Services in the Central East LHIN: Options for Coordinated Delivery, Organization and Goverance.


complex health care needs resulting in a disproportionate number of residents in long term care homes

with mental disorders. In Ontario today, dementia is the leading cause of admission to long term care.

Research shows that eighty to ninety percent of long term care home residents with some form of

dementia, depression, delirium, adjustment disorder, personality disorder, and psychosis or anxiety

disorder are common4.

The Central East LHIN is the second most populated area in Ontario with over 1.5 million people5. It

contains a wide range of demographics in terms of age structure, urban and rural, socio-economic

status, language and ethnicity. A significant proportion of the population lives in the Scarborough and

west Durham areas and there is a largely dispersed rural population in its northern and eastern regions.

The proportion of seniors that live within the boundaries of the Central East LHIN is comparable to other

regions in the province. However, the distribution of the population of seniors within the Central East

LHIN is disproportionate, as seen in Figure 1. The highest proportions of seniors live in the north and

eastern predominantly rural communities of Peterborough, Haliburton, City of Kawartha Lakes and

Northumberland.

Figure 1: Percentage of Central East LHIN Residents Aged 65+ by Region

The population of seniors (age 65+) is forecasted to increase steadily and double in numbers by 2029. It

is generally accepted that the presence of frailty increases with advanced age. Research suggests that a

more accurate method to measure the prevalence of frailty is a stratified method based upon age

categories; i.e. 7% of those aged 65-74 years, 17.5 % of those aged 75-85 years, and 36.6% of those 85

years and older. The significant projected growth by 47.1% in the “old-old” seniors’ population in the

Central East LHIN will dramatically shift the estimated number of frail seniors to 42,449 by 2019.6

4 CMHA Network Magazine, Winter 2007 “Minding Our Elders: Mental Health in Long Term Care”. Nicole Zahradnik at www.ontario.cmha.ca/network_story.asp?cID=7439 downloaded 31/03/2011. 5 Statistics Canada, 2009. 6 Anderson, C. and Regional Geriatric Advisory Committee Expert Panel (2011). Regional Specialized Geriatric Services in the Central East LHIN: Options for Coordinated Delivery, Organization and Governance, p. 8.

http://www.ontario.cmha.ca/network_story.asp?cID=7439


On average, Alzheimer’s Disease or related dementia affects one in ten seniors over 65 years of age and

one in three seniors over 85 years of age. By 2016 it is projected that there will be about 25,000 people

over age 65 with dementia living in the Central East LHIN, and that the number of people with dementia

is increasing at a faster rate than the total population of seniors growth rate7.

With the forecasted change in the seniors population demographics, mood disorders (i.e. anxiety,

depression) followed by substance use and dementias will be the biggest drivers in the demand for

psychogeriatric services in the Central East LHIN. When combined, these three disorders will account for

80% of the growth in the number of older adults affected by mental health and addiction disorders over

the next twenty years.

7 Hopkins, R., Hopkins, J. (2005). Projected Prevalence of Dementia: Ontario’s Local Health Integration Networks, Kingston, ON.


SPECIALIZED GERIATRIC SERVICES (SGS)

DEFINING THE POPULATION

For the purposes of this report it is necessary to define the population who will most benefit

from specialized, comprehensive (and more resource intensive) geriatric services. Age is a

primary factor in defining this population but the uniqueness of this group is best described by

their frailty in combination with complex and interrelated biomedical, psychological, social,

functional and environmental needs.

SGS are hospital and community-based geriatric medicine services that diagnose, treat and

rehabilitate frail older individuals with chronic and complex conditions that cannot be

addressed in the regular health care system. With the complex interaction of chronic conditions

and the physical, social, and functional consequences, frail older adults frequently present with

atypical symptoms of disease and are difficult to diagnose.

SGS provide a range of services to support older individuals with chronic and complex

conditions including: specialized geriatric assessment, consultation, short-term treatment,

rehabilitation and short-term specialty case management. The goal of SGS is the reduction of

disability, the identification and treatment of reversible conditions, and the optimization of

chronic care.

Geriatric services require a high degree of collaborative and interdisciplinary care due to

multiple co-morbidities and the functional and social impact of illness on frail seniors.

Specialized geriatric services are delivered by interdisciplinary teams with expertise in the care

of the elderly, including geriatric medicine and geriatric psychiatry services, and have specialty

physicians (geriatricians or geriatric psychiatrists) as part of the team. Other team professionals

include (but are not limited to) physicians, nurse practitioners, nurses, social workers,

physiotherapists, occupational therapists, nutritionists, speech and language pathologists and

psychiatrists.

SGS are a specialized backup resource and support to primary and secondary care providers.

SGS rely on other services to be effective and are delivered in a variety of home, ambulatory,

long term care homes and in-patient hospital settings. SGS can significantly contribute to a

(frail) older persons’ ability to remain in their home.


DESCRIPTION OF CORE COMPONENTS OF SGS

The following services are typically associated with Specialized Geriatric Services.

INPATIENT/HOSPITAL FUNCTIONS

Acute Geriatric Medical Unit/Acute Care of the Elderly (ACE)

ACE Units are inpatient general medicine units for acutely ill older adults who require an admission to an

acute care hospital and the ongoing expertise of a specialized geriatric team. Individuals are admitted

directly from the emergency department. These acute care beds are situated in one unit for older adults

who require short term diagnostic investigation and treatment and are at high risk for a prolonged

hospital stay due to frailty, multiple complex medical, functional, psychosocial problems and/or recent

functional decline. An ACE Unit is not equivalent to an ‘ALC’ or an ‘Assessment’ unit.

Geriatric Assessment and Treatment Unit (GATU)

GATU inpatient units are typically short- stay, non-acute care units specifically designed to meet the

needs of older adults and managed by multidisciplinary specialized geriatric teams. Specialized

equipment is available to promote safety and independence. Patients stay from 4-6 weeks up to three

months.

Geriatric Rehabilitation Unit (GRU)

Geriatric Rehabilitation Units are for older frail persons who require the expertise of a geriatric team

and individualized assessment and rehabilitation program in order to regain or maximize function and

independence. These units are often located in Complex Continuing Care and the client is typically

admitted for a period of one to three months.

Internal Geriatric Consultation Team

A specialized geriatric multidisciplinary team provides in-hospital consultation and assessment for frail

older patients throughout the acute care in-patient beds in the hospital. Consultation teams support the

development of care teams in hospital through education and capacity building. In some situations the

teams participate in ‘case finding’ for ACE Units or Geriatric Rehabilitation Units to facilitate the

seamless transfer from an acute care bed to the most appropriate setting.

Geriatric Emergency Management (GEM)

GEM staff is specialized geriatric health professionals (most often a clinical nurse specialist with

gerontology training) that provide a comprehensive geriatric assessment for frail older adults identified

as high-risk who present at the emergency department of the hospital. The assessment involves the

identification of medical, psychosocial and environmental factors; older adults may present at

emergency with falls, cognitive decline, polypharmacy, incontinence, complex medical conditions or

recent changes of functional status that place them at risk of hospitalization.


Following the initial screening and assessment the GEM Nurse will either divert an admission to hospital

by establishing community and primary care linkages and at-home supports for the client, or facilitate

and support an internal admission to an acute inpatient bed. The GEM Nurse also provides education

with emergency room staff, patients and families.

OUTPATIENT SERVICES

Geriatric Day Hospital

Hospital based ambulatory programs provide diagnostic, rehabilitative and therapeutic services to

persons living at home who have complex needs and require the expertise of the geriatric

interprofessional team for a period of several months. Many clients have been recently discharged

home from hospital and have specific individualized needs to regain or maximize function to continue to

safely reside in the community. Short-term counseling and education is also provided to patients and

their families.

Geriatric Outpatient Clinics

These are Clinics (most often led by a Geriatrician) used to assess, treat and monitor the health of

elderly persons who can travel and referrals are received from both hospital and community. Clinics may

provide comprehensive geriatric assessment or they may be highly specialized; i.e. memory,

incontinence, falls. (Memory Clinics are dedicated to the early diagnosis and treatment of Alzheimer’s

disease and related dementias.)

Geriatric Outreach Teams

Geriatric Outreach Teams provide comprehensive assessments for identified at-risk individuals that are

conducted in the person’s home or long-term care home by one or two health care professionals in

geriatric medicine, nursing, social work, psychiatry, physiotherapy or occupational therapy. Other health

professionals may be called up to assist with specific care management concerns (i.e. pharmacy,

dietician, speech and language, etc.). Geriatric Outreach Teams may also offer short-term case

management to assist individuals to access longer term supports.


THE LAY OF THE LAND There are three quite distinctive demographic profiles that have significant implications for health

system planning in the Central East LHIN. These three clusters include:

Scarborough: An urban area comprised of the former city of Scarborough with a highly diverse

population; poverty rates that are twice the CENTRAL EAST LHIN average; a lower percentage of

older adults but a higher absolute number;

Durham: A suburban region comprised of the Region of Durham with a younger population than the

LHIN average; and

HKPR: A set of rural counties in Haliburton, Peterborough, Kawartha Lakes and Northumberland

Hills (alternatively “HKPR”) in the north and east parts of the region with a significantly lower

population density than the Central East LHIN average and the highest proportion of older adults

(but a lower absolute number than the urban areas).

Although clients/patients and their families may access services anywhere within the Central East LHIN,

the delivery of specialized geriatric services and psychogeriatric services typically reflect services that

have been developed around the local hospitals that operate within one of the above three geographic

clusters. This is largely due to the historical evolution of programs and services’ trying to address local

demand as funding has been made available and to the working relationships between agencies that

have been built over several decades – long before the provincial LHIN boundaries were established.

Therefore, the environmental scan looks at the inventory of services at both the Central East LHIN as a

whole and it takes a more in-depth look at services within the three geographic (sub-LHIN) areas.


INVENTORY OF SPECIALIZED GERIATRIC SERVICES

SCARBOROUGH

THE SCARBOROUGH HOSPITAL (TSH)

TSH offers a wide range of geriatric services at two hospital sites located in Scarborough; the General

Campus (Lawrence Avenue East) and the Birchmount Campus (Birchmount Road) plus satellite

outpatient clinics that include the Community Outreach Programs (Kennedy Road) and the Community

Mental Health Outpatient Program (Eglinton Avenue).

ACE Units: TSH has provision for up to ten beds for acute care for the elderly at each campus. The inpatient beds are consolidated on one medicine unit but they are not “protected” beds; they are imbedded into the general medicine beds and utilized as required. There are no direct admissions to the ACE unit; referrals are from TSH in-patients or the emergency department for older adults with recent functional/cognitive decline that are expected to be discharged home within a maximum of ten days. The interdisciplinary team includes medicine, nursing, physiotherapy, occupational therapy, social work, pharmacy, nutrition, and speech and language pathology as required. Geriatric Rehabilitation Unit: TSH does NOT have any rehabilitation or complex continuing care beds. TSH has a formal partnership with Providence Hospital that deploy a full-time Patient Flo Coordinator on-site who attends bullet rounds, facilitates patient transition from acute care to rehabilitation, etc. Internal Geriatric Consultation Team: Internal consultation and assessment for frail seniors is provided at both hospital sites by physicians with specialized geriatrics training (2) and clinical support from the ACE Unit; there is not an internal team in place. Physician consultations may “case-find” patients for the ACE Unit; internal transfers from in-patient services to the ACE Unit are supported by a Nurse Practitioner. GEM: TSH has one FTE GEM Registered Nurse in the emergency department during regular business hours (Monday to Friday) at each hospital site. Geriatric Day Hospital: Not available at TSH. Geriatric Outpatient Clinic: TSH operates a Geriatric Outpatient Clinic that is managed by a Geriatric Physician two days/week at each hospital campus. Referrals for assessment and treatment planning are received from community physicians, emergency room physicians and internal hospital physicians. The Clinics also provide post-discharge follow-up care from the ACE Unit. TSH also operates one of the four regional GAIN Clinics (see general description in box below) for urgent/emergent care. The GAIN Clinic is located in the emergency department at the General Campus but it is available to inpatients/outpatients across both hospital sites and the community. The TSH GAIN Clinic operates 6 days per week with extended hours (11 a.m. to 9 p.m.). Referrals are accepted from the ER, family physicians, nurse practitioners and community agencies; the Clinic will also support


people being discharged from hospital. The GAIN Clinic will assess, treat and discharge home non-acute, medically stable seniors straight from the emergency department and thus avoid a hospital admission. Geriatric Assessment and Intervention Network (GAIN): The GAIN Geriatric Clinic at TSH is led by a Nurse Practitioner and the interprofessional team consists of social work, pharmacy, physiotherapy and occupational therapy with consultation from hospital physicians with specialized geriatrics training and emergency department physicians when required. The GAIN Clinic includes full-time CCAC Health Career Case Managers to facilitate timely in-home supports to ensure the person can remain at home until his/her next appointment. The team works collaboratively with the GEM Nurse and other professions within the ER to identify appropriate clients.

Geriatric Outreach Team: Not available to community. Nurse Practitioners Supporting Teams Averting Transfers (NPSTAT): TSH operates one of the three regional NPSTAT teams that provide outreach to long term care homes. The NPSTAT teams are Nurse Practitioner led teams that provide assessment and intervention for frail seniors who reside in long term care homes (LTCHs). NPs travel daily to see LTCH residents in their home whenever acute, episodic illnesses and injuries arise that require immediate assessment, diagnosis, treatment and intervention at the bedside. The Team works with the LTCH to reduce avoidable hospital visits and to facilitate earlier discharge from hospital back to the LTCH. Each NP remains carries an on-call cell phone and tries to attend the LTCH on the same day as called. Other Specialized Geriatric Services: Geriatric Activation Program (GAP): GAP is an activation program for elder friendly care and best practices for patients across the general medicine program. The GAP interprofessional team identifies the need for enhanced therapy services to prevent functional or cognitive decline, prevent falls or manage wound care. The Team includes occupational therapy, physiotherapy, social work and recreation therapy. The focus is on early intervention for frail seniors upon admission to hospital. VALUE Volunteer Program: TSH recently implemented the Volunteers Assisting Leisure Interests to Meet Unique Needs (VALUE) program (March 2012). Volunteers are trained to provide 1:1 support to maintain functionality for older adults that are inpatients on general medicine or in the ACE Unit. The VALUE

Geriatric Assessment and Intervention Network (GAIN Outpatient Clinics)

The four GAIN Clinics in the Central East LHIN are urgent/emergent care clinics located at hospital sites

and house Nurse Practitioner led multidisciplinary teams that complete a comprehensive assessment and

treatment plan for people who live at home with multiple complex medical, functional and psychosocial

problems. Referrals are received from hospital emergency department, the GEM Nurse, hospital in-

patient to facilitate discharge of stable geriatric patients, family physicians and community agencies. The

GAIN Clinics have access to the inpatient Acute Care for the Elderly (ACE) beds when a hospital admission

is required. The GAIN Clinics are currently administered by a regional administrator under the

sponsorship of Lakeridge Health with a goal to ensure access to urgent care for residents regardless of

where they live in the region.


program is intended to support frail elderly patients to get out of bed and dressed and active (not just sitting in a chair). Home at Last: An outside agency facilitates earlier in the day discharges from hospital and provides settlement support in the transition back home for frail seniors. Home First: TSH works in collaboration with Central East CCAC and community support service agencies to facilitate the patient’s timely return home from hospital or from the emergency department.

Regional Geriatric Programs (RGPs)

There is no RGP in the Central East LHIN. The Regional Geriatric Program of Toronto

provides information, educational resources, advocacy support and a limited degree of

consultation to health professionals involved in the care of older persons to four hospitals

located in the Central East LHIN: Lakeridge Health, Peterborough Regional Hospital, Rouge

Valley Health System, and The Scarborough Hospital as well as Ontario Shores Centre of

Mental Health Sciences.


ROUGE VALLEY HEALTH SYSTEM (RVHS)

RVHS offers geriatric services at two hospital sites; one is located in Scarborough (Centenary site - RVC);

and one is located in Ajax-Pickering (west Durham Region -RVAP).

ACE Unit: RVHS does not have a designated unit for acute care for the elderly; patients are admitted to

“virtual beds” in general medicine.

Geriatric Assessment and Treatment Unit (GATU): The RVC site has 25 post-acute beds for frail elderly

patients. Fifteen beds are designated for the comprehensive geriatric assessment and intervention of

frail elderly patients who have sustained significant illness or injury. Another ten beds are termed the

Functional Enhancement Unit with a focus on low intensity reactivation programming to optimize

functional abilities of patients who have experienced a recent loss of function and require slower-paced

therapeutic interventions. The GATU is led by a Geriatrician and the interdisciplinary team includes

occupational therapy, physiotherapy, pharmacy, social work, dietary, and speech and language

pathology.

The RVAP site recently opened a 20 bed post-acute Transitional Restorative Care Unit in collaboration

with the Central East CCAC and the Home First program. The program focuses on functional activities

individually and in group sessions to restore strength and stamina to prepare patients of any age for

transition from hospital to home. Referrals are accepted from RVAP inpatients only. The average length

of stay is 45 days with a maximum stay of 90 days.

Internal Geriatric Consultation Team: In the past RVHS sponsored an internal geriatric consultation

team led by the Geriatrician but it is no longer in practice.

GEM: RVHS has one FTE GEM Registered Nurse in the emergency department during regular business hours (Monday to Friday) at both hospital sites. The GEM Nurse at the RVC campus works closely with a Social Worker and Physiotherapist in an interprofessional team approach to develop a comprehensive assessment for seniors in the emergency department. The RVC GEM Nurse is currently providing nursing services to the GAIN Clinic. The GEM Nurse position at the RVAP campus has remained vacant for several months due to a sick leave. Geriatric Day Hospital: Not available at RVHS. Geriatric Outpatient Clinic: RVC operates a Memory and Outpatient Clinic that is managed by a Geriatrician (Dr. J. Peto) at the Centenary campus. Referrals for assessment and treatment planning are received from community physicians, emergency room physicians and internal hospital physicians. Geriatric Assessment and Intervention Network (GAIN): RVHS also operates one of the four regional GAIN Clinics for urgent/emergent care. It is located in the emergency department at the Centenary campus but it is available to inpatients/outpatients across both hospital sites and the community. The GAIN Clinic operates 5 full days (Monday to Friday) and 6 hours on Saturday.


Other Services: General Internal Medicine Outpatient Clinic (GIM): The GIM Clinics are new ambulatory clinics that provide follow-up to geriatric patients in the community after hospital discharge. There is a GIM Clinic at each RVHS campus and it is led by a physician with a specialty in geriatrics. Home at Last: An outside agency facilitates earlier in the day discharges from hospital and provides settlement support in the transition back home for frail seniors. Home First: RVHS works in collaboration with Central East CCAC and community support service agencies to facilitate the patient’s timely return home from hospital or from the emergency department.


DURHAM

LAKERIDGE HEALTH (LH)

Lakeridge Health offers a wide range of services at several sites throughout the Central East LHIN region

with the specialized geriatric inpatient and outpatient programs are delivered across two primary

hospital sites (Oshawa and Whitby).

ACE Unit: Lakeridge Health has provision for eighteen beds for acute care for the elderly at the Oshawa

site. There are no direct admissions to the ACE unit; referrals are from the GAIN Clinic or the emergency

department for older adults with recent functional/cognitive decline that are expected to be discharged

home within a maximum of ten days. The interdisciplinary team includes medicine, nursing,

physiotherapy, occupational therapy, social work and pharmacy.

Geriatric Assessment and Rehabilitation Unit: The LH Whitby site has 25 post-acute specialized

geriatric rehabilitation beds for frail older persons who cannot tolerate the intensity of regular stream

rehabilitation programs and require the assessment and management of geriatric conditions that limit

the ability to return home independently. The Unit takes a team/shared care Nurse

Practitioner/Physiatrist with Geriatric Specialty led approach and includes: Medical Doctors, Nurse

Practitioners, Nurses, Occupational Therapists, Physiotherapists, Social Workers, Speech-Language

Pathologists, Pastoral Care, Therapy Assistants and Therapeutic Recreationists with consultation from

Neuropsychology and Psychiatry as required. Referrals are accepted from in-patient as well as

community. The average length of stay is 30 – 45 days.

Internal Geriatric Consultation Team: LH does not have an internal geriatric consultation team.

GEM: LH currently has two FTE GEM Clinical Nurse Specialists in the emergency department during regular business hours (Monday to Friday) at the Oshawa and Bowmanville site and is currently recruiting a 3rd GEM Nurse. The Oshawa GEM Nurse works closely with the GAIN Clinic in an interprofessional team approach. Geriatric Day Hospital: The LH Day Hospital operates as an ambulatory geriatric rehabilitation group

program. Referrals are typically for post-acute older adults who have experienced an illness or injury

and attend to increase their strength and functionality. Treatment planning must include the family

physician/nurse practitioner. This service is being integrated into the Ambulatory Rehabilitation Centre

(ARC).

Geriatric Assessment and Intervention Network (GAIN): LH Oshawa operates a GAIN Geriatric Clinic that is led by a Nurse Practitioner and the interprofessional team consists of social work, pharmacy, physiotherapy and occupational therapy with consultation from hospital physicians with specialized geriatrics training. The GAIN Clinic includes full-time CCAC Health Career Case Managers to facilitate


timely in-home supports to ensure the person can remain at home until his/her next appointment. The team works collaboratively with the GEM Nurse and other professions within the ER to identify appropriate clients. Referrals are received from the emergency department, post hospitalization and from community-based physicians or nurse practitioners. Note: LH does not have a Geriatrician and are in the process of trying to recruit. The Chief of

Rehabilitation and Geriatrics and Medical Director of the Post-Acute Specialty Services (Dr. Jim Park) is a

Physiatrist with specialized geriatric training from the Toronto RGP.

Geriatric Outreach Team: LH does not provide Geriatric Outreach Services. (Prior to the opening of the

GAIN Clinic the Nurse Practitioner would conduct follow-up home visits as required through the SAFE

Clinic; however, it is now closed for GAIN.)

Other Services:

Geriatric Resource Program (GRP): The GRP is led by an experienced CNS/APN in gerontology who

works with an interested group of professionals in the hospital to provide education and training that is

focused on bedside staff behaviours and patient outcomes at the unit level.

Home at Last: An outside agency facilitates earlier in the day discharges from hospital and provides settlement support in the transition back home for frail seniors. Home First: TSH works in collaboration with Central East CCAC and community support service agencies to facilitate the patient’s timely return home from hospital or from the emergency department. ______________________________________

Other SGS Services in Durham Region:

Village of Taunton Mills – Geriatric Outreach Team: The Village of Taunton Mills provides the NPSTAT

team to LTCHs in the Durham region. The NPSTAT teams are Nurse Practitioner led teams that provide

assessment and intervention for frail seniors who reside in long term care homes (LTCHs). NPs travel

daily to see LTCH residents in their home whenever acute, episodic illnesses and injuries arise that

require immediate assessment, diagnosis, treatment and intervention at the bedside. The Team works

with the LTCH to reduce avoidable hospital visits and to facilitate earlier discharge from hospital back to

the LTCH.

The Village of Taunton Mills also operates a NP-led clinic that is well located in the middle of a retirement community. The Clinic focuses on serving frail seniors over age 70 that do not have a primary care physician. (The majority of their patients are women over age 85.) The NP will meet individuals in the Clinic or in their own home. The Clinic has successfully maintained people in their retirement home and averted placement to long term care.


Brock Community Health Centre (Brock CHC) – Geriatric Outreach Team: The Brock CHC runs a Nurse

Practitioner led geriatric outpatient clinic to assess and support frail elderly people in the community.

Referrals are received from community physicians and from the CHC. Brock is an underserviced rural

area with only 2.5 family physicians. The Clinic operates from a dedicated space in a LTCH in Beaverton

and the NP may meet individuals at the Clinic or at their home. The Clinic is a partnership between

Lakeridge Health (provides OTN video equipment), RGP of Toronto (consultation, education), Durham

Region (provides the space) and the Brock CHC (provides the program). The OTN equipment is used to

access a consulting Geriatrician to support the NP in developing a treatment plan.

Ontario Shores Centre for Mental Health Services - Geriatric Outpatient Clinic: Ontario Shores operates a Memory Outpatient Clinic 1.5 days per week with an interdisciplinary team that includes a Geriatrician (Dr. J. Ingram) at the hospital site. Referrals for assessment are accepted from family physicians.


PETERBOROUGH, KAWARTHA LAKES, HALIBURTON, NORTHUMBERLAND

PETERBOROUGH REGIONAL HEALTH CENTRE (PRHC)

PRHC provides both local and regional programs from its base site in Peterborough.

ACE Unit: PRHC has provision for four beds for acute care for the elderly in one unit at its Peterborough

site. The beds are closely tied to the GAIN Clinic.

Geriatric Assessment/Rehabilitation Unit: PRHC has physical space allocated for GATU beds (12 beds);

however it is unfunded and not in operation. The unit currently houses interim long term care patients.

Geriatric Emergency Management: PRHC employs 2 FTE GEM Nurses at its Peterborough site.

Geriatric Day Hospital: Not available at PRHC. Geriatric Outpatient Clinic: PRHC operates one of the four regional GAIN Clinics for urgent/emergent care at its Peterborough site. The GAIN Geriatric Clinic at PRHCis led by a Nurse Practitioner and the interprofessional team consists of social work, pharmacy, physiotherapy and occupational therapy with consultation from a Geriatrician when required. The GAIN Clinic includes full-time CCAC Health Career Case Managers to facilitate timely in-home supports to ensure the person can remain at home until his/her next appointment. The team works collaboratively with the GEM Nurses and other professions within the ER to identify appropriate clients. Geriatric Outreach Team: Not available at PRHC. However, PRHC has sponsored a Psychogeriatric Outreach Team (Psychiatric Assessment Services for the Elderly – PASE) for twenty-five years (see full description in Psychogeriatric Services below). Other Services: Home First: PRHC works in collaboration with Central East CCAC and community support service agencies to facilitate the patient’s timely return home from hospital or from the emergency department.

Home at Last: Program provides help to aging adults to help them settle at home safely in a timely

manner after hospital discharge; partnership between hospital, CCAC and community support services.

Memory Clinic: There is one private Memory Clinic operated in Peterborough by a Geriatrician (Dr. Jenny Ingram). The Clinic is available to residents throughout the HKPR region. Dr. Ingram provides leadership as the consulting physician with the interprofessional team at the PRHC GAIN Clinic.


ROSS MEMORIAL HOSPITAL (RMH)

RMH provides services from its base site in Lindsay.

ACE Unit: RMH does not have an ACE unit.

Geriatric Assessment/Rehabilitation Unit: RMH has a 22 bed Geriatric Engagement and Reintegration

Unit (GERI) within the Continuing Care program. The goal of the program is activation and socialization

to maintain function and mobility for older adults with chronic complex conditions with an average

length of stay of 30 to 60 days. The Unit operates with an interdisciplinary team that includes nursing,

rehabilitation assistant and recreation therapy – however, RMH does NOT employ a Geriatrician or

Physician with specialized expertise in geriatrics.

Internal Geriatric Consultation Team: RMH has a “GERI Acute Team” that functions as an in-hospital

interdisciplinary tem that screens medically acute patients that are over age 75 at risk for de-

conditioning and functional decline due to hospitalization. The team focuses on early mobilization and

the coordination of activation activities while in the hospital. The interdisciplinary team is lead by APN

gerontology (.5 FTE) and includes physiotherapy, rehabilitation assistant and recreation assistant. The

continuation of this program is pending ongoing funding for 2011/12.

Geriatric Emergency Management: RMH employs 1 FTE GEM Nurse during business hours (Monday to

Friday) in the emergency department. The GEM Nurse links with the GERI Acute Team, physiotherapy,

occupational therapy and mental health services in the hospital.

Geriatric Day Hospital: Not available at RMH. Geriatric Outreach Team: Not available at RMH.


NORTHUMBERLAND HILLS HOSPITAL (NHH)

NHH is a rural hospital that provides acute care inpatient services and twenty ambulatory care clinics on

an outpatient basis from its site in Cobourg.

ACE Unit: RMH does not have an ACE unit.

Geriatric Assessment/Rehabilitation Unit: NHH recently opened a 16 bed Restorative Care Program to support older adults who no longer require acute care but are not yet able to return home. The program focuses on optimizing an individual’s capacity to maximize their level of independence in order to return home. Geriatric Emergency Management: NHH has a full time GEM Nurse who provides geriatric assessment and treatment within the ER and collaborates with inpatient units and community services to provide continuity of care. Internal Geriatric Consultation Team: NHH does not have a Geriatrician or Physician with a specialty in geriatrics or internal team. Geriatric Emergency Management: NHH employs 1 FTE GEM Nurse in the ER. The GEM Nurse works closes with the Central East CCAC Case Manager and community support services. Geriatric Day Hospital: NHH does not have a geriatric day hospital. Geriatric Outpatient Clinic: NHH hosts several outpatient clinics that are disease or injury-specific; there is not a clinic specifically to serve older adults. Geriatric Outreach Team: NHH does not sponsor an SGS outreach team; however, a collaboration has been established with NPSTAT re: outreach to LTCHs to prevent unnecessary admissions to NHH and to ease transition from hospital back to the long term care home. Other Services: Home First: NHH ensures early involvement with Central East CCAC Case Managers and community support services to support seniors; NHH provides offices space on the units for the Case Managers who attend discharge planning rounds and family meetings to facilitate discharge home. Home at Last: Program provides help to aging adults to help them settle at home safely in a timely

manner after hospital discharge; partnership between hospital, CCAC and community support services.

The Hospital Elder Life Program (HELP): The HELP program relies on trained volunteers to work with geriatric patients to prevent and reduce delirium by providing a range of therapeutic activities. The program is led by one fulltime nurse (CNS Gerontology) and has initially started in one inpatient medical unit with a plan to spread throughout the hospital.


Geriatric Specialist: NHH hosts a part-time Geriatric Specialist (.2-.4 FTE APN in gerontology) to develop

and implement education and knowledge transfer for staff across teams and program areas that are

interested in gerontology as a core of their practice including mentoring staff at the bedside.

HALIBURTON HIGHLANDS HEALTH SERVICES (HHHS)

HHHS is a rural hospital that provides acute inpatient care (14 beds) and emergency services at its

Haliburton site and a 24/7 emergency services at its Minden site. HHHS also provides residential care at

a 30 bed long term care home at the Haliburton site; a 62 bed long term care home in Minden as well as

a supportive housing program in various apartment buildings.

HHHS serves a high percentage of seniors as part of their general population; however it does not

provide any specialized geriatric services as defined in this report. HHHS utilizes acute care services at

either Ross Memorial Hospital or Peterborough Regional Health Centre as back-up resources.

Geriatric Emergency Management: HHHS does not have a GEM nurse at either ER site. Rather than employ a GEM, HHHS advises that they would like funding to create an ER nurse role that provides an outreach function and assesses older adults in their own homes to prevent an ER visit. Home at Last: HHHS collaborates with outside agency community support services to facilitate earlier discharges from hospital and settlement support in the transition back home for frail seniors.

CAMPBELLFORD MEMORIAL HOSPITAL (CMH) CMH is a rural hospital that provides acute care inpatient (34 beds) and 24/7 emergency services at its location in Trent Hills. CMH also provides supportive housing in 49 apartment units on the hospital campus. CMH serves a high percentage of seniors as part of their general population. (In FY 2010/11 over 58% of ER visits were people over the age of 65 including 38% from people over the age of 85.) However, CMH does not provide any specialized geriatric services as defined in this report. ______________________________________

Other SGS Services in HKPR:

Central East CCAC – Geriatric Outreach Team: The Central East CCAC provides the NPSTAT team to

LTCHs in the north and east regions of the Central East LHIN. The NPSTAT teams are Nurse Practitioner

led teams that provide assessment and intervention for frail seniors who reside in long term care homes

(LTCHs). NPs travel daily to see LTCH residents in their home whenever acute, episodic illnesses and

injuries arise that require immediate assessment, diagnosis, treatment and intervention at the bedside.

The Team works with the LTCH to reduce avoidable hospital visits and to facilitate earlier discharge from

hospital back to the LTCH. The Nurse Practitioners work out of the local CCAC offices.


SPECIALIZED GERIATRIC SERVICES IN CENTRAL EAST LHIN

HEALTH SERVICE PROVIDERS


Geriatric Rehab Units/ Geriatric Assessment & Tx (non-acute)

Internal Geriatric Consultat’n Team



Geriatric Outpatient Clinic

Geriatric Outreach Team: Community

Geriatric Outreach Team: Long Term Care

Other Geriatric Services/ Programs

SCARBOROUGH – HOSPITAL SGS

The Scarborough Hospital

YES General: Up to 10 inpatient beds within 1 medicine unit Birchmount: Up to 10 beds within 1 medicine unit

X PARTIAL Not funded directly; access beds through formal partnership agreement with Providence Hospital for rehabilitation

X PARTIAL Physicians provide support at both hospital sites – not a team.

YES General: 1 FTE Birchmount: 1 FTE

X NO

YES General: 2 days/week GAIN Clinic (supports both sites) Birchmount: 2 days/week

X NO

YES NPSTAT

Geriatric Activation Program (GAP) VALUE Volunteer Program Home First Home at Last

Rouge Valley Health System

X NO

YES Centenary: 15 GATU beds 10 Functional Enhancement Unit beds Ajax-Pickering 20 bed Transitional Restorative Care Unit

X NO

YES RVC: 1 FTE RVAP: 1 FTE

X NO

YES RVC: Memory Clinic Dr. J. Peto GAIN Clinic

X NO

X NO

General Internal Medicine Outpatient Clinic (GIM) Home First Home at Last












SCARBOROUGH – COMMUNITY SGS

Central East CCAC

Manage the intake and discharge to Transitional Restorative Care Unit at RVHA Ajax-Pickering site

Each hospital ER has 1 full-time CCAC Case Manager to support discharge

There are 2 full-time Case Managers assigned to each of the GAIN Clinics (4 FTE)

CCAC manages the Home First in collaboration with TSH and RVHS hospital discharge planning for in-home supports

Memory Clinics

Yee Hong Centre (Chinese-speaking) Dr. Lessard (private)

Early diagnosis and referral to regional First Link program through Alzheimer Society Durham












DURHAM – HOSPITAL SGS

Lakeridge Health

YES Oshawa: 18 +/- beds within 1 medicine unit

YES Whitby: 25 GARU beds

X NO

YES Whitby: 1 FTE Oshawa: 1 FTE Bowmanville 1 FTE

YES Whitby

YES Oshawa: GAIN Clinic (serves all sites)

X NO

X NO

Geriatric Resource Program Home First Home at Last

Markham Stouffville Hospital (Uxbridge)

GOT Team serves Uxbridge (out of LHIN)

DURHAM – COMMUNITY SGS

Central East CCAC

GAIN Clinic 2 FTE Case Managers

Village of Taunton Mills

NPSTAT Outreach Team

NP-led Primary Care Clinic

Brock Community Health Centre

Brock Geriatric Assessment












Ontario Shores for Mental Health Sciences

Memory Clinic (Whitby)

HKPR – HOSPITAL SGS

Peterborough Regional Health Centre

YES 4 beds within 1 medicine unit

X NO

X NO

YES 2 FTE

X NO

YES GAIN Clinic

X NO

X NO

Home First

Ross Memorial Hospital

X NO

YES

X YES (pending continued funding)

YES 1 FTE

X NO

X NO

X NO

X NO

GERI Acute Team Home First

Northumberland Hills Hospital

X NO

YES 16 Restorative Care Program beds

X NO

YES 1 FTE

X NO

X NO

X NO

X NO Do have collaborative agreement with NPSTAT

HELP Home First












Haliburton Highlands Hospital

X NO

X NO

X NO

X NO

X NO

X NO

X NO

X NO

Home at Last

Campbellford Memorial Hospital

X NO

X NO

X NO

X NO

X NO

X NO

X NO

X NO

HKPR – COMMUNITY SGS

Central East CCAC

NPSTAT (3 office sites)

Memory Clinic

Dr. Jenny Ingram (private)


PSYCHOGERIATRIC SERVICES

DEFINING THE POPULATION

Psychiatry of the elderly is a branch of psychiatry and forms part of the multidisciplinary delivery of

mental health care to older people. The specialty is sometimes referred to as geriatric psychiatry, old

age psychiatry or psychogeriatrics. The specialty deals with the full range of mental illnesses and their

consequences, particularly mood and anxiety disorders, the dementias, the psychoses of old age and

substance abuse. In addition, the specialty deals with older people who developed chronic mental illness

at a younger age. Psychiatric morbidity in old age frequently coexists with the physical illness and is

likely to be more complicated by social problems. Seniors may also have more than one psychiatric

diagnosis. Many mental illnesses in old age can be treated successfully. Some, particularly the

dementias, are chronic and/or progressive8.

The above definition includes people with complex dementia or neurological/medical conditions with

associated or co-morbid psychiatric illness (for example; a person with late onset depression who suffers

a stroke, a person with chronic obstructive disease and anxiety disorder, or a person with Parkinson’s

disease and dementia).

As in other age groups, mental illnesses in older adults (aged 65+) affect approximately 20% of the total

population. Those individuals with a long-standing mental illness who grow old and do not have any age-

related issues (such as stroke, dementia, mobility problems) are best served by adult mental health

services and are not part of this environmental scan.

What is the relationship between SGS and Psychogeriatric Services?

There is a significant overlap between the delivery of specialized geriatric services and psychogeriatric

services which may cause some confusion among patients and their families or care providers. To

explain, the SGS interprofessional team routinely conducts a Comprehensive Geriatric Assessment which

includes the assessment of physical health, mental state and cognition of the frail elderly person. When

the assessment shows significant mental health issues and cognitive or behavioural issues then geriatric

psychiatric expertise is required to address the diagnostic, treatment and care needs of the patient (i.e.

psychogeriatric services)9.

8 Definition was downloaded from the International Psychogeriatric Association at www.ipa-online.net on February 10, 2011. 9 Anderson, C. and Regional Geriatric Advisory Committee Expert Panel (2011). Regional Specialized Geriatric Services in the Central East LHIN: Options for Coordinated Delivery, Organization and Governance, p. 7.

http://www.ipa-online.net/


DESCRIPTION OF CORE COMPONENTS OF PSYCHOGERIATRIC SERVICES

INPATIENT/HOSPITAL FUNCTIONS

Acute Geriatric Mental Health Unit

Mental health units are inpatient psychogeriatric beds for people experiencing acute mental illness and

require an admission for medical stabilization, short-term diagnostic investigation and treatment.

Mental health services provided in the mental health unit in a hospital require the expertise of a

geriatric psychiatrist and specialized geriatric health professionals who focus on older adults with a

serious mental illness and co-morbid health issues.

Internal Psychogeriatric Consultation Team

A specialized psychogeriatric multidisciplinary team provides in-hospital consultation and assessment

for older patients with mental illness and co-morbid physical illness throughout the acute care in-patient

beds in the hospital.

Tertiary Level Geriatric Mental Health Unit

Tertiary-level geriatric mental health services are highly specialized services provided at a psychiatric

hospital in support of primary (community) and secondary (acute care hospital) level service providers.

Services include assessment, diagnosis, and short-term treatment intervention for older adults with late-

onset mental illness, cognitive disorders and/or behavioural disturbances or individuals with long-

standing psychiatric disorders with age-related decline in physical or mental health. Patients may stay

for three to six months.

OUTPATIENT SERVICES

Psychogeriatric Outpatient Clinic

These are Clinics led by a geriatric psychiatrist used to assess, treat and monitor older adults with

complex mental health problems or dementia and challenging behaviours who can travel. Referrals are

received from both hospital and community sources.

Psychogeriatric Outreach Team

Psychogeriatric outreach teams provide a comprehensive mental health assessment and treatment plan

in the older person’s place of residence (own home, retirement home or long term care home).

Assessments are conducted by one or two professionals including psychiatry and nursing or social work.

Outreach programs also provide consultation; education and support. Services are time-limited and

geared toward the needs of the older adult experiencing serious difficulties due to complex mental

health problems. Referrals are received from community agencies or primary care; however family

physicians must agree to the referral and provide the follow-up and monitoring of the treatment plan.


Psychogeriatric Resource Consultants (PRCs)

PRCs are specialized staff that provides provincial curriculum training (PIECES, U-First, Enabler)and case-

based education, consultation and support to front-line staff who serve older adults with dementia or

with mental illness who exhibit challenging behaviours. PRCs work primarily in long term care homes

and they may also offer education and training to community support service agencies and CCAC.

Behaviour Support Unit

Behaviour support units (may be termed Behavioural Assessment and Management Unit) are typically

designated secure/locked units within a long term care home that are designed to ensure a safe and

therapeutic environment for residents whose behaviours could be detrimental to themselves or others

and who cannot be managed in a traditional long term care home setting. (Behavioural support units

may also be located in hospitals or as stand-alone residential programs.) Staff is trained in behaviour

management strategies and higher staff ratios allow for small group activities plus one-to-one

individualized care. The length of stay is based on response to treatment but is usually a minimum of six

months. Referrals are received from community and at discharge from hospital.


INVENTORY OF PSYCHOGERIATRIC SERVICES

SCARBOROUGH

THE SCARBOROUGH HOSPITAL (TSH)

Acute Geriatric Mental Health Inpatient Unit: TSH is the only Schedule 1 hospital in the Central East

LHIN that provides specialized geriatric beds that are separate from the general population in the

mental health unit. TSH provides 8-10 beds and an interdisciplinary team led by a geriatric psychiatrist.

The focus of inpatient services is acute stabilization of symptoms and active treatment. (TSH has a

submitted a capital proposal for 2011/12 to build a self-contained secure geriatric mental health unit

that has fully equipped washrooms, a separate dining area and its own lounge.)

Internal Psychogeriatric Consultation Team: TSH has an internal Psychogeriatric consultation team that

provides a psychogeriatric assessment to older adults in the medical units throughout the hospital. The

interdisciplinary team is led by a geriatric psychiatrist and includes 1 full-time specialized geriatric nurse

and 1 full-time occupational therapist.

Psychogeriatric Outpatient Clinic: TSH runs a psychogeriatric outpatient clinic. Referrals must be from a

family physician or a psychiatrist. The same team that provides the internal TSH psychogeriatric

assessments also works in the outpatient clinic (psychiatry, nursing, occupational therapy). Referrals

may be follow-up after hospital discharge but they are more typically from community physicians. The

Team also provides consultation to the TSH GAIN clinic and to the Home First program to support

discharge on request. (TSH has recruited a 3rd full-time geriatric psychiatrist who will start in August,

2011.)

Psychogeriatric Outreach Program: The TSH Psychogeriatric Outreach Program (POP) interdisciplinary

team provides consultation, assessment and treatment recommendations to manage residents in LTCHs

with challenging behaviours (including aggression, depression, psychosis, etc.) to avoid hospitalization.

The team includes a geriatric psychiatrist and mental health nurses. The POP team provides support to

twelve (12) of the 22 long term care homes located in Scarborough.

TSH does not provide POP to older adults in the community. TSH accesses the Psychogeriatric

Assessment Consultation and Education Clinics (PACE) community-based outreach teams operated by

CAMH.

Psychogeriatric Resource Consultant: The PRCs throughout Toronto report as a team to the Regional

Geriatric Program of Toronto and as individuals to the host organizations where they are based. TSH

augments the funding and hosts 1 full-time position (through its global budget). The PRC provides

training and case-based education to 10 of the 22 LTCHs in Scarborough and works in collaboration with

the TSH Psychogeriatric Outreach Team to conduct in-home assessments.


Other Services:

Seniors Crisis Access Line (SCAL): The Mental Health Mobile Crisis Line at TSH is working in partnership

with Saint Elizabeth Health Care Crisis Response Program, the Woodgreen Community Services Crisis

Outreach Service for Seniors and the Gerstein Crisis Centre to provide risk and safety assessments and

assistance in stabilizing age-related mental health and addiction crises. SCAL operates a telephone line

seven days per week (11.5 hours per day Monday to Friday and 8 hours per day on weekends). TSH staff

also participates on the mobile crisis response to go to people’s homes anywhere in Scarborough. (This

is a new program funded through the Toronto Central LHIN.)

ROUGE VALLEY HEALTH SYSTEM

RVHS provides emergency and outpatient mental health services at both the Centenary and the Ajax-

Pickering campuses. However, all mental health inpatient services and resources are consolidated at the

Centenary site only.

Acute Geriatric Mental Health Inpatient Unit: RVHS employs Geriatric Psychiatrists who work closely

with the Geriatrician to support individuals with age-related mental health and addiction issues;

however, in-patients are part of the general population on the mental health unit.

Psychogeriatric Outreach Program: The RVC Psychogeriatric Outreach Program (POP) interdisciplinary

team provides consultation, assessment and treatment recommendations to manage residents in LTCHs

with challenging behaviours (including aggression, depression, psychosis, etc.) to avoid hospitalization.

The team includes a geriatric psychiatrist and mental health nurses. The POP team provides support to

eight of the 22 long term care homes located in Scarborough.

RVHS does not provide POP to older adults living in the community. RVHS accesses the Psychogeriatric

Assessment Consultation and Education Clinic (PACE) community-based outreach team delivered by

CAMH in Scarborough and the Psychogeriatric Community Support Program (COPE) team delivered by

Community Care Durham in Oshawa.

Psychogeriatric Resource Consultant: RVHS is a paid member agency of the Regional Geriatric Program

of Toronto and may access educational support and outreach services on request.

Other Services in Scarborough:

Central East CCAC: The CCAC is the single point of access for the application, assessment and placement

of all residents in long-term care homes. There are 22 LTCHs in Scarborough with a total of 4,225 beds.

Thirteen of the homes contain secure units (total of 529 beds) with locked access to keep residents with

dementia or confusion in a safe environment without risk of wandering. One of the LTCHs (Bendale

Acres) operates 15 additional short-term beds for residents that cannot maintain a regular LTCH setting

due to complex mental health needs or challenging behaviours. However, there is a high demand for


specialized beds and limited turn-over and hospitals report that they rarely refer individuals due to long

waitlists and limited access.

Currently, there is no provincial mandate for CCACs to provide mental health services; it is up to each

agency to determine priorities based on the unique needs of the area it serves. Effective April 2011, the

Central East CCAC terminated the direct provision of in-home mental health services. The Central East

CCAC will facilitate referrals to local community mental health and addiction service providers.

CAMH - Psychogeriatric Assessment Consultation and Education Clinics (PACE): The Scarborough-based

PACE Clinic is a community-based outreach team that delivers assessment and psychogeriatric

consultation to seniors in their own home environment. Counseling, support, medication monitoring

and home visits are all components of the psychiatric follow-up. The clinic also provides crisis services

(during clinic hours); consultation to community agencies; advocacy, education and support to the

clients' family members; and community education.

COTA Health -Geriatric Mental Health (GMH) Case Management: The GMH Case Management service

provides individualized support to clients living with age-related dementia and clients over 65 living with

a serious mental illness. The case management team works hand in hand with RGP of Toronto to

prevent crises and avoid hospitalization. The team accepts referrals from the Seniors Crisis Access Line

to provide short-term case management and divert people from the hospital emergency department.

GMH Case Managers also work with hospital in-patient mental health staff to facilitate early discharge

home with supports. (COTA reports that there is a significantly reduced demand for long-term case

management services when intensive short-term brief services are made available.)

COPA – Community Outreach Programs in Addictions: COPA works with individuals 55 years and older

with addictions through outreach programs to people’s own home (including retirement homes and

long term care homes) or while they are experiencing homelessness. COPA uses a harm reduction

approach that does not require initial acknowledgement of an addictions issue. COPA Outreach workers

provide assessment, treatment and case management. The Geriatric Mental Health Crisis Outreach to

Long Term Care Homes program provides assessment and consultation by a Geriatric Addiction

Specialist to individual residents and staff education on addictions and mental health to all the LTCHs in

Scarborough.

Community Mental Health and Addiction Services

There are several health service providers that offer coordinated access to adult case management

services in the Scarborough area; however they are not identified in this report unless they offer a

program that is targeted to older adults with staff who have expertise in gerontology.


DURHAM

LAKERIDGE HEALTH

Lakeridge Health (Oshawa site) is a Schedule 1 hospital with a 39-bed inpatient mental health unit, a day

treatment program as well as outpatient services. The mental health program provides assessment,

diagnosis and short-term treatment for children and adults suffering from a mental illness. They do not

provide a specialized geriatric program.

Older adults residing in Durham receive specialized in-patient and out-patient psychogeriatric services

primarily at the Ontario Shores Centre for Mental Health Sciences (Ontario Shores) located in Whitby.

The Lakeridge Health Whitby and Oshawa sites are in close proximity to Ontario Shores and they have a

long-standing agreement that Ontario Shores geriatric psychiatrists will provide timely on-site

consultation and assessment to Lakeridge Health patients upon request.

Note: Lakeridge Health Pinewood Centre Addiction Services provides a range of services to substance

users and family members in Durham Region. Services include direct clinical, outreach, and consultation

within a harm reduction model. However, they are not further described in this report because they do

not offer a program specific to older adults with staff who have expertise in gerontology.

Psychogeriatric Resource Consultant: LH is a paid member agency of the Regional Geriatric Program of

Toronto and may access educational support and outreach services on request.

Other Services in Durham:

Central East CCAC: There are 19 LTCHs in Durham with a total of 2,780 beds. Ten of the homes contain

secure units with locked access (319 total beds) to keep residents with dementia or confusion in a safe

environment without risk of wandering.

Community Care Durham - Psychogeriatric Community Support Program (PCSP): The PCSP outreach

program is a community-based outreach team in collaboration with Ontario Shores that delivers

assessment and psychogeriatric consultation to high risk older adults in their own home environment in

Durham. The team is made up of one full-time Geriatric Psychiatrist (3 psychiatrists from Ontario Shores

share the one position) and a Nurse Clinician. Typically the Nurse Clinician will do the initial home visit

and conduct a psychiatric assessment and both the Nurse and the Psychiatrist will attend the second

home visit. Once a treatment plan is in place the PCSP will provide short-term case management and

link the individual to primary care providers and/or community case management services for ongoing

support; PCSP does not provide ongoing support. (For example, linkages are made with the Oshawa

Community Health Centre and the CMHA Primary Care Clinic for ongoing follow-up.)

Referrals are received from older adults’ self-referral and their families, CCAC, community agencies and

family physicians. In order to be admitted to the program the family physician must be supportive (to


manage patient monitoring and follow-up).(Individuals who already have a psychiatrist are excluded

from the program.) The referral process can be quite lengthy due to the extensive medical history

required from the family physician which creates a waiting list for service (up to four weeks). For those

individuals that are “in dire circumstances” the PCSP will refer individuals to the urgent care Prompt

Care Outpatient Clinic provided at Ontario Shores to access a Psychiatrist more quickly.

Ontario Shores Centre for Mental Health Sciences- Psychogeriatric Outreach Program: Ontario Shores

has worked in collaboration with Community Care Durham and the PCSP outreach team through a

contractual agreement for several years.

Special Service Program Outreach Team (SSPOT): Effective April 2011 Ontario Shores will deliver an

outreach program team (comprised of Geriatric Psychiatrist, Clinical Nurse Clinician, PRC, Rehabilitation

Therapist) to provide on-site comprehensive geriatric assessment and consultation Clinics for residents

of LTCHs (piloting with 12 homes). This program is based on best practices and the goal of the program

is to develop a care plan and assist the caregiver’s capacity to keep people with mental health needs or

dementia and challenging behaviours where they are living. The SSPOT will also assess the need for

admission to Ontario Shores. The Clinics will be set up 1 day/month in each LTCH and directly receive

referrals from the LTCH.

Ontario Shores also provides consultation and geriatric assessment to Schedule 1 hospitals on request.

Ontario Shores operates the multispecialty Mood Clinic for Seniors at the Whitby site two days/month.

The Clinic provides the assessment, diagnosis and treatment of older adults with severe depression. The

Mood Clinic provides medical management and follow-up; cognitive-behavioural group therapy; and

ongoing support and education for patients and their families.

Ontario Shores Centre for Mental Health Sciences - Psychogeriatric Resource Consultants: Ontario

Shores hosts the PRC Program for Durham and The City of Kawartha Lakes (formerly Victoria County)

with 2 full-time Consultants. They provide education and case-based learning to the health care staff

working with people with dementia and challenging behaviours in 28 LTCHs located in Durham and the

City of Kawartha Lakes.


PETERBOROUGH, KAWARTHA LAKES, HALIBURTON, NORTHUMBERLAND

PETERBOROUGH REGIONAL HEALTH CENTRE (PRHC)

PRHC is a Schedule 1 hospital with a 32-bed adult inpatient mental health unit, a day treatment program

as well as outpatient services for children and adults. The mental health program provides assessment,

diagnosis and short-term treatment for adults suffering from a mental illness. They do not have a

separate inpatient specialized geriatric mental health program. Upon discharge PRHC refers to the PASE

team when an older adult requires a comprehensive geriatric mental health assessment.

Geriatric Mental Health Assessment Unit: PRHC has the physical infrastructure to support a 12 bed

geriatric mental health assessment and stabilization unit to serve the northeast/HKPR area and are

looking for operational funding. PRHC currently has capacity with respect to geriatric psychiatrists to

provide psychiatric support to these beds when they potentially open. The beds are unfunded and not in

operation at this time. Currently, older adults with mental health issues are part of the general

population of the mental health unit.

Psychiatric Outreach Program and Outpatient Clinics: For the past 25 years PRHC has supported the

Psychiatric Assessment Services for the Elderly (PASE) program. PASE offers specialized geriatric mental

health services to older adults experiencing late onset mental health problems and their families living in

the counties of Northumberland, City of Kawartha Lakes, Haliburton and Peterborough. The PASE

interdisciplinary team includes psychiatry, nursing, social work and occupational therapy. PASE is funded

a funded community mental health and addictions program by the Central East LHIN and is a separate

vote program supported by PRHC Mental Health services.

PASE provides specialized assessment and consultation, care planning, short-term treatment and follow-

up to community residents in their own home if they are unable to travel to a clinic setting. Referrals are

received from older adults by self-referral and their families, CCAC, community agencies , LTCHs and

family physicians; in order to be admitted to the program the family physician must be supportive (to

manage patient monitoring and follow-up). Referrals are not accepted from clients without a primary

care provider (i.e. family physician). In an effort to manage the waiting list for service each referral is

triaged by the team as high risk, urgent or moderate risk (i.e. developing dementia) on a weekly basis.

The average wait for the initial visit depends on where a person lives in the catchment area and their

initial risk priority and is approximately four weeks on average.

PASE operates Monday to Friday during business hours. PASE satellite clinics are located in shared space

(borrowed sites) with community mental health, primary care or LTCHs in Brighton, Cobourg,

Campbellford, Lindsay (1 day per month), Minden, and Haliburton (1 day each bi-monthly)and at PRHC.

Approximately 65% of the service is provided to people living in the community. PASE also offers clinics

(monthly or bi-monthly) in 20 LTCHs (1,998 beds) located in Haliburton, Northumberland and

Peterborough Counties which represents approximately 35% of the total PASE service delivery. (Ontario


Shores serves the LTCHs – 675 beds - in the City of Kawartha Lakes.) PASE is staffed to serve

approximately 500 clients (50% of clients have Alzheimer’s Disease or related dementias) and their

families each year representing over 6,000 face-to-face/telephone visits.

PASE has limited resources with base funding for 7 clinicians (fulltime and part-time); 1.79 FTE nursing,

1.9 FTE social work and .50 FTE occupational therapy and sessional fees to purchase 1.2 FTE psychiatry

and .50 manager. Therefore, PASE does not provide internal psychogeriatric consultation to PRHC

although they work closely with the PRHC mental health services to ensure a seamless transition at

admission and discharge for clients on their caseload.

Psychogeriatric Resource Consultant: PASE is funded for 1.7 FTE to provide education and knowledge

transfer for staff in long-term care facilities and community agencies serving seniors with difficult

behaviours resulting from their dementia and/or mental health problems. PRCs work as capacity

builders and help primary service providers in their assessment skills; they do not conduct assessments

or develop care plans. (PRCs also support quality improvement activities and directly support the

Dementia Networks.)

In a unique effort to build capacity in the rural communities that PASE serves, the PRCs are also

members of the Outreach Team with combined responsibilities to provide education and case-based

education and clinical assessment. This is an innovative response to limited resources in a large

geographic rural area and builds on the already existing relationships that PASE has with the LTCHs.


ROSS MEMORIAL HOSPITAL (RMH)

RMH is a Schedule 1 hospital with a 15 bed adult inpatient mental health unit for assessment,

stabilization and short-term treatment and staffed by an interdisciplinary team. Older adults who are

medically stable with a serious mental illness are admitted as part of the general population to the

mental health unit.

Internal Psychogeriatric Consultation Team: RMH employs 1 FTE psychogeriatric nurse specialist who

works in partnership with the geriatric psychiatrist to provide hospital “in-reach” and outreach services

throughout the hospital. The geriatric mental health Clinical Nurse Specialist (CNS) and consulting

Geriatric Psychiatrist are available to all units for consultation and assessment with regard to delirium,

dementia or mental illness (e.g. depression) in conjunction with the internal Geri-Acute In-Hospital

Team. Any in-patient referrals take priority on the mental health program wait list. (There is

approximately a two to four week wait for an assessment appointment).

Psychiatric Outpatient Clinics: RMH offers an on-site day program that is specific for older adults with

mental health problems; it offers primarily group counseling using cognitive-behavioural therapy

approach (participants must be cognitively intact to attend). The clinic works with the older adult and

his/her family to provide comprehensive psychogeriatric assessment, treatment, consultation and

programming. Community or inpatient assessments are done by the psychogeriatric Clinical Nurse

Specialist as requested from family physicians or in-hospital.

The RMH Day Program has also established a Peer Counseling Group for older adults that operates as a

‘step-down’ from the active treatment group and is co-facilitated by a “graduate” from the program.

Psychiatric Outreach Program: The CNS and consulting Geriatric Psychiatrist that are available to the in-

hospital units also provide assessments prior to hospital discharge and/or in the patient’s home to

determine in-home support needs and follow-up with community service agencies. Referrals do not

require a family physician to receive services (although that is preferred). If the older adult living in the

community has complex mental health issues he/she is referred to the PRHC PASE program for further

assessment and follow-up. The RMH Mental Health Program has a Memorandum of Understanding with

the CMHA to provide case management services to support ongoing needs for older adults with a

serious mental illness.

Other Services in HKPR:

Central East CCAC – Long Term Care Homes: There are two LTCHs in Northumberland County (Port

Hope) with secure units (43 beds); three LTCHs in City of Kawartha Lakes (Lindsay) with secure units (105

beds) and three LTCHs in Peterborough with secure units (113 beds). There are no LTCHs with

behavioural support units in HKPR.


CENTRAL EAST LHIN-WIDE PSYCHOGERIATRIC SERVICES

ONTARIO SHORES CENTRE FOR MENTAL HEALTH SCIENCES (ONTARIO SHORES)

Ontario Shores is a stand-alone psychiatric hospital providing a spectrum of tertiary care specialized

assessment and treatment services to those living with complex and serious mental illness. The Special

Services Program provides specialized geriatric, psychiatric and neuropsychiatry rehabilitation services.

Services include assessment, diagnosis, treatment and rehabilitation provided by an interdisciplinary

team on-site in Whitby and in locations throughout the Central East LHIN.

Ontario Shores does not offer direct access emergency services. Patients are referred through

centralized intake (to all programs) from a Schedule 1 hospital, long-term care home or community

support agency for a planned admission to care. Ontario Shores does not provide acute care medical

services so applicants must provide a detailed medical history, laboratory results, CT/MRI or EKG (if

available), a social/family history, etc. Although a person may be medically complex, they do not accept

patients who are medically unstable.

Once patients have received treatment from Ontario Shores they may seek further treatment as

inpatients or outpatients. A patient may be transferred from a Schedule 1 emergency department on an

urgent basis.

Ontario Shores has two inpatient programs for older adults with mental health needs.

Seniors Mental Health Unit (SMHU): The SMHU is a 25 bed unit that provides specialized services to

meet the complex mental health needs of seniors (age 65+) with a serious mental illness including

refractory to treatment disorders. The majority of patients have been referred from long term care

homes. The average length of stay at Ontario Shores is two to four months; the unit has a 92-95%

occupancy rate and at the time of this report it had no wait list.

Seniors Memory Disorders Unit (SMDU): The SMDU is a 25 bed unity that provides specialized services

to meet the mental health needs of seniors (age 65+) with dementia and challenging behaviours. Again,

the majority of patients have been referred from long term care homes. The average length of stay at

Ontario Shores is three months; at the time of this report the unit had a 92-95% occupancy rate.

The inpatient units are managed by an interdisciplinary core team that includes the following disciplines:

geriatric psychiatry, neuropsychology, registered nurses (RNs and RPNs), occupational therapy, and

personal support workers. The inpatient team also consults with physiotherapy, recreation therapy,

social work, rehabilitation therapy, pharmacy, and dietary from other units in the hospital based on the

needs of the individual.


SPECIALIZED PSYCHOGERIATRIC SERVICES IN CENTRAL EAST LHIN Health Service Providers

Acute Geriatric Mental Health Inpatient Unit



Psychogeriatric Outreach Program

Psychogeriatric Resource Consultant


Other Psychogeriatric Services/ Programs

Scarborough – Hospital Psychogeriatric Services


YES 10 – 12 beds

YES Birchmount

YES

YES 12 LTCHs only

YES Host hospital for 1 FTE PRC with RGP

N/A

Seniors Access Crisis Line


X NO

X NO

X NO

YES 8 LTCHs only

X NO

N/A

Scarborough – Community Psychogeriatric Services

Central East CCAC

Bendale Acres LTCH 15 beds

CAMH - PACE

YES Community

COTA

Case Management

COPA

YES Addiction services

Case Management


Health Service Providers








Durham – Hospital Psychogeriatric Services

Lakeridge Health

X NO

X NO

X NO

X NO

X NO

N/A

Durham – Community Psychogeriatric Services

Central East CCAC

Designated 1 full-time Discharge Planner to OS

Community Care Durham

YES Community (in partnership with OS)

Work with hospital Home at Last and Home First programs

Ontario Shores

Mood Clinic for Seniors (2 days/month)

YES 12 LTCHs and Schedule 1 hospitals in Durham

YES 2 FTE serve 28 LTCHs (in Durham and City of Kawartha Lakes)










HKPR- Hospital Psychogeriatric Services


X NO

X NO

YES PASE - 8 locations in HKPR

YES PASE serves 20 LTCHs (excluding Kawartha Lakes) and community residents in-home in all HKPR

YES PASE – 1.7 FTEs to serve 20 LTCHs (excluding Kawartha Lakes)

N/A

Psychiatric follow-up with 2 LTCHs in Haliburton using OTN


X NO

YES 1 FTE CNS 1 PT Psychiatrist

YES Assessment and treatment Older Adult Therapy & Peer Counseling Groups

PARTIAL Hospital outpatients

X NO

N/A

Ontario Shores

YES 8 LTCHs and Schedule 1 hospitals in City of Kawartha Lakes

YES 2 FTE serve 28 LTCHs (in Durham and City of Kawartha Lakes)










LHIN-Wide Regional Psychogeriatric Services

Ontario Shores Centre for Mental Health Sciences

Provide consultation and assessment to five Schedule 1 hospitals on request

YES

YES Memory Clinic (located in Whitby) Mood Clinic for Seniors (located in Whitby) Outpatient clinics in 12 LTCHs (1 day per month)

YES PCSP in collaboration with Community Care Durham (serves Durham only)

YES 2 FTE (serve Durham and City of Kawartha Lakes only)

YES Seniors Memory Disorders Unit 25 beds

Seniors Mental Health Unit 25 beds Caregiver Support and Education Groups Prompt Care Clinic (urgent care)


STAKEHOLDER CONSULTATION FEEDBACK

Based on the facilitated focus group discussions at both of the stakeholder consultation sessions (held in

Peterborough and Ajax) there are significant issues that are common throughout the Central East LHIN.

A key issue identified in the stakeholder sessions was the lack of access to specialized geriatric services.

Of primary concern was that when a frail elderly person is screened as high-risk, perhaps in the

emergency department or at discharge from hospital, and receives a geriatric assessment that identifies

complex medical issues that require on-going supports and follow-up, that there is nowhere to refer for

help. It was suggested that this may be for a variety of reasons such as:

health service providers are unaware of the available services and supports in the LHIN;

service names/descriptions and who they serve are unclear (e.g. “GEM”, “NPSTAT”, “GAIN”);

service is too far from person’s home and the lack of transportation is an issue;

there are no standardized referral, intake or admission protocols to similar programs;

there are waitlists to access appropriate services;

the transitions from community to hospital and back to home are fragmented; there are no

system navigators and very limited long-term case management services for this population;

the lack of specialized geriatric human resources.

There was strong support for the regional coordination of dedicated resources (i.e. funding and health

human resources with geriatric expertise) through formal linkages across the continuum of care to

improve access to services for residents from all communities.

KEY CHALLENGES TO CARE

Ageism

Unfortunately, ageism and discrimination is alive and well in our health care system. Disability, illness

and chronic disease are seen as “senior’s issues” and older adults are often considered to be expensive

burdens to society. Seniors receive consistent messages about their weakness, their dependency, and

their need for medical and pharmacological intervention rather than senior-friendly messages of

psychosocial enablement and personal independence. The common myths that ‘old people can wait’,

‘old people decline gradually’, and that ‘old people only have one illness’ marginalizes the elderly

population. This means that when older adults see their health care provider they often do not get a

timely response and once attended to, they do not always get a comprehensive examination.

In discussion with hospitals and providers in the Central East LHIN there was an expressed concern that

there must be a major culture shift in thinking at all levels of the organization – from house-keeping to

medicine - to move to a truly senior-friendly hospital environment. Even the term “specialized


geriatrics” suggests that older adults require some type of specialist to provide health care and that

eldercare is therefore somehow exclusive and separate from general medicine. The comment was made

that “we need to make it *care for older adults+ non-specialized to serve all seniors well” and imbed

excellent geriatric care as an underlying philosophy within every department throughout the entire

hospital (or program).

Fragmentation and Inequitable Access

Historically, specialized geriatric and psychogeriatric services have evolved independently of

each other due to the separation of medicine from psychiatry, or body (physical health) from

mind (mental health). Divided scopes of practice and divided responsibilities for care becomes

reflected in the pockets of specialized expertise and available services in some areas within the

Central East LHIN and the same services as completely non-existent in another.

The highest proportion of seniors (and fastest growing demographic) live in the rural areas of

the Central East LHIN (Haliburton, Kawartha Lakes, Northumberland, Peterborough) where

there are the least amount of specialized geriatric services available.

There is no single point of entry or centralized referral and intake function for SGS in the Central

East LHIN. Although the premise is that “every door is the right door”10 to access care, the fact is

that frail older adults with complex and challenging needs (i.e. multiple co-morbidities,

behavioural issues, lack of social supports) are difficult to diagnose or treat and may have

difficulty finding help through any door because they don’t know where to find “the” door, the

door is far from their home, or the only way to access SGS is as a hospital inpatient.

It was found through the interviews and the stakeholder consultations that there are no

standardized assessments, treatment approaches or consistent protocols across the SGS or

psychogeriatric service components; and further, services may use the same nomenclature but

offer something quite different and vice versa, they may offer a similar program but call it

different names and collect different data – this causes confusion for the patient/client and their

family and among other health service providers.

Lack of Coordination

There is limited coordination, collaboration or knowledge transfer within large organizations or

between organizations that deliver SGS. For example, it was found that units within the hospital

typically work in isolation of one another (i.e. medicine is separate from rehabilitation is

separate from psychiatry); and further, hospitals have developed programs and practices in

isolation of other hospitals and as separate entities from the community. This results in

extremely limited continuity of care as people transition in and out of services.

10 MOHLTC, Every Door is the Right Door: Towards a 10-Year Mental Health and Addictions Strategy, July 2009.


The range of SGS that are available may not be known among providers (as was heard at the

stakeholder consultations) although the increasing complexity of client/patient conditions

requires interdisciplinary relationships that are organized around their changing care needs.

There are no long term specialized geriatric intensive case management services to support

high-risk frail seniors to navigate through the health system and to help them manage their own

care as their needs change. Often individuals get referred to an available service/program rather

than the most appropriate service/program.

Lack of Specialized Resources

There are only two acute care hospital-affiliated Geriatricians in the Central East LHIN (RVHS and

PRHC) and very few Geriatricians in the whole province (of the approximately 200 in Canada) so

it is difficult to find and recruit this valuable expertise. The comment was made that there are

foreign- trained Geriatricians working in other professional capacities in the Central East LHIN

due to the lower pay scale and lack of support Geriatricians experience in Ontario. [The

suggestion was made that physicians who take addition training in geriatrics should be

recognized for their expertise and remunerated accordingly.]

There are no Geriatric Outreach Teams supporting frail elderly individuals and their

family/caregiver in the community. It is imperative to provide SGS in the person’s home and

assist in accessing the in-home supports that they need if older adults are to remain out of

hospital and out of placement in a long term care home.

There are only 15 behavioural support unit beds (for older adults with challenging behaviours) in

the Central East LHIN (located in Scarborough). PRHC has designated GATU and GARU hospital

beds and a behavioural support unit in the new hospital design but they are not open due to

lack of funding.

Twenty percent of the frail elderly population that present at LH do not have a family physician

which therefore limits the ability to support and monitor post-acute care follow-up.

To access services from one of the Psychogeriatric Outreach Teams the applicant must have a

family physician to support the referral.

One of the challenges to service provision identified by RVHS is the number of patients who do

not have an appropriate discharge destination due to the lack of supported housing options

and/or homelessness of the patient. Some older adults that present at the emergency

department cannot possibly return home and they are admitted directly from the ER to an ALC

bed.


PROMISING PRACTICES

SGS and psychogeriatric service providers have developed a range of innovative approaches based on

best practices to support the frail elderly with complex needs population. Ideas are being tested and

new approaches are being initiated in an effort to improve the quality of care for patients/clients that

they serve. Some of these initiatives are highlighted below.

Interdisciplinary Teams and Knowledge Exchange

At RVHS the GEM Nurse is working with a Social Worker and a Physiotherapist as an

interprofessional team in the emergency department to conduct screening and comprehensive

assessment of frail elderly; looking ahead this is the kind of team that could work with family

physicians in prevention, early identification and early intervention.

TSH has developed team-based education modules entitled “Building Bridges to Great Elder

Care”. The series of modules are delivered to both clinical and non-clinical staff with the intent

to broaden the scope of eldercare expertise to general inpatient and outpatient units and

beyond “specialized” interventions.

PRHC PASE organizes an annual SGS Conference with invited speakers that is well-attended by

health professionals from the Central East LHIN and other parts of the province.

RMH has developed a 3D’s (delirium, depression, dementia) training binder for all

staff/volunteers to better understand and support patients with psychogeriatric needs.

Inpatient Supports

Evidence shows that the longer one stays in hospital the more likely one will experience deconditioning,

iatrogenesis and functional loss, and the reduced likelihood of maintaining independence and returning

home11. With this in mind, there are several initiatives currently in progress in the Central East LHIN,

including the following:

TSH has implemented the Geriatric Activation Program (GAP) to prevent functional or cognitive

decline and to ensure patients have an activation plan during hospitalization.

TSH has implemented the Volunteers Assisting Leisure Interest to Meet Unique Needs (VALUE)

which relies on trained volunteers to provide 1:1 therapeutic activities to keep people active.

11 See recommendations from the Central East LHIN Alternate Level of Care Systems Issues and Recommendations Report, June 2008.


NHH has implemented the Hospital Elder Life Program (HELP) which relies on trained volunteers

to work with geriatric patients to prevent and reduce delirium by providing a range of

therapeutic activities.

LH employs Personal Support Workers (PSWs) in the medical and rehabilitation programs to

work with patients diagnosed with dementia or delirium and challenging behaviours to engage

and interact with patients and de-escalate potentially unsafe situations; this also limits the need

for extensive security staff.

RMH has a “GERI Acute Team” that functions as an in-hospital interdisciplinary tem that screens

medically acute patients that are over age 75 at risk for de-conditioning and functional decline

due to hospitalization. The team focuses on early mobilization and the coordination of

activation activities while in the hospital.

Use of Technology

There are many new advances in the use of technology for telemedicine and remote access to limited

specialized resources. Opportunities to use technologies to bring SGS to frail seniors in their home (such

as remote monitoring and treatment compliance) are still largely unexplored and require further

investigation.

PRHC uses OTN to communicate with two rural LTCHs in Haliburton and is exploring OTN for

psychiatric assessment and consultation in their satellite clinics.

Brock CHC has partnered with LH to access OTN for access to a Toronto Geriatrician to support a

local Nurse Practitioner for SGS.

Early Identification and Linkages with Primary Care

An “upstream” needs-based model to build physician capacity was piloted by the Kawartha

Regional Memory Clinic and the Family Health Teams in the Central East LHIN with trained

nurses providing on-site dementia neurocognitive assessments in the physician’s office; results

indicated that providing the assessments was helpful and useful to physicians in counseling

families; in reducing referrals to specialists; in increasing referrals to community services (such

as the local Alzheimer Society); and to assist in their decision-making about patients.

Regional Model for Specialized Geriatric Services

Through its targeted investments, the Central East LHIN has initiated the beginnings of regional

approaches/protocols and standardization i.e. GAIN Clinics, NPSTAT, GEM, Home First, and

Home at Last. Sharing the concepts, plans and results of these initiatives within the community

of practice offers excellent opportunities to collaboratively address some of the key challenges

that health service providers are facing today and into the future.


There is an exciting opportunity to provide more highly coordinated care through one regional

(LHIN-wide) SGS and mitigate the key challenges with the adoption of the Specialized Geriatric

Services in the Central East LHIN: Options for Coordinated Delivery, Organization and

Governance, April 2011 report recently commissioned by the Central East LHIN.

FINAL THOUGHTS

The Central East LHIN currently offers a patchwork of specialized supports with islands of isolated

excellence. Over the years, health service providers in the Central East LHIN have worked to improve

the care for the frail elderly population while making the best use of limited resources. The

environmental scan found some excellent examples of partnerships between the hospital and

community health and long term care service providers, although they are typically isolated to one

hospital or to one geographic area. Recent investments made by the Central East LHIN have led to a

broader mix of resources available to assist frail older individuals with chronic and complex

conditions; however, together they do not address the need for a functioning, integrated

service delivery system.

Most of the SGS and psychogeriatric services have developed within the urban hospital settings. It was

found that within the hospital there continues to be a ‘great divide’ in the provision of care between

geriatric medicine and geriatric psychiatry, and between medicine and geriatric post-acute care for the

frail senior and their family. Similarly, geriatric services delivered in the community often function in

isolation of one another. For example, the nurse practitioner- led teams in the LTCHs (NPSTAT)

are not coordinated with the psychogeriatric outreach services to the LTCHs, and neither of

those specialized services is linked with the urgent care (GAIN) clinics.

Services are found supportive for those that can access them but the range of available services is often

fragmented, hard to negotiate and inflexible. Some services overlap to offer a duplication of resources

while leaving some needs completely unaddressed. As an example, there are no geriatric outreach

teams in the Central East LHIN to support individuals and their families to maintain

independence in their homes (and potentially prevent hospital visits). This proposes that

depending where one lives in the Central East LHIN, one may have a very different patient experience.


While it is important to identify the existing service gaps and challenges to accessing care, it is more

constructive to look at the big picture and build on the existing services to move toward an increasingly

integrated regional service delivery system of specialized care. There are two essential elements to build

upon the efforts of existing services to improve access, navigation and integration across the continuum

of care:

1. The necessary service components must be evenly present and accessible throughout the LHIN; and

2. Services must be regionally coordinated to ensure that individuals can easily move across the

continuum as their needs change.

In summary, we know that targeted care for frail seniors with chronic and complex health conditions

improves health outcomes. The environmental scan, along with expert stakeholder opinion, concurs

that there needs to be a regional framework for the delivery of specialized geriatric services. Through

the interviews and consultation sessions the feedback was loud and clear - the health service providers

are ready, willing and keen to get started to better serve this most vulnerable population.


REFERENCES

Anderson, C. and Regional Geriatric Advisory Committee Expert Panel (2011). Regional Specialized

Geriatric Services in the Central East LHIN: Options for Coordinated Delivery, Organization and

Governance, prepared for Central East LHIN, Ajax.

Butterhill, D. et al. (2009). From Hospital to Home: The Transitioning of Alternate Level of Care and Long-

stay Mental Health Clients, prepared for MOHLTC. CAMH, Toronto.

Carstairs, S. & Keon, W. (2007). Special Senate Committee on Aging First Interim Report: Embracing the

Challenge of Aging, Ottawa.

Central East LHIN Task Group (June 2008). Central East LHIN Alternate Level of Care Systems Issues and

Recommendations Report.

Day, P., Rasmusson, P. (2004). What is the evidence for the effectiveness of specialist geriatric services in

acute, post-acute and sub-acute settings? University of Otago, New Zealand.

Geriatric Working Group (2006). Canadian Collaborative Mental Health Initative – Geriatric Mental

Health Toolkit, Toronto.

Hopkins, R., Hopkins, J. (2005). Projected Prevalence of Dementia: Ontario’s Local Health Integration Networks, Kingston.

MacCourt, P. (2004). Seniors Mental Health Policy Lens, prepared for the BC Psychogeriatric Association, British Columbia. MOHLTC, (July 2009). Every Door is the Right Door: Towards a 10-Year Mental Health and Addictions Strategy, Toronto. MOHLTC Mental Health and Rehabilitation Reform Branch(2004). Specialized Geriatric Mental Health

Outreach Teams Program Policy and Accountability Framework, Toronto.

Policy Planning Inc. (2000). Summary Report of The Expert Panel on Specialized Geriatric Services,

prepared for MOHLTC, Hamilton.


APPENDIX

Face-to-face on-site (marked with an *) or telephone interviews have been held with the

following people:

Central East Local Health Integration Network

Kate Reed* Carol Anderson*

Team Lead, Integration/Implementation Lead for Regional Planning, SGS & Post Acute

Ontario Shores Centre for Mental Health Sciences

Sheila Neuburger* Sheryl Bernard*

Vice-President, Clinical Services Administrative Director, Special Services

Lakeridge Health Network

Dr. Jim Park* Michelle Acorn*

Physiatrist & Geriatric Specialist Nurse Practitioner, GAIN Clinic

Sue White*

Nurse Practitioner


Shailesh Nadkarni Gail Grant*

Program Manager, Mental Health, Sub-Acute Care Manager, PASE & PRC

& Nutritional Services

Dr. Jenny Ingram*

Internist & Geriatrician

City of Kawartha Lakes Memory Clinic, GAIN Clinic


Janice Cassels Beverlee Groves-Foley

Registered Nurse Manager Mental Health and Dialysis Program


Clara Tsang Glyne Boatswain

GEM Nurse Patient Flo Manager

Dr. John Peto*

Geriatrician



Nancy Veloso* Susan Engels

Manager Patient Care Director, Mental Health

Brock Community Health Centre – Geriatric Outreach Program

Ron Ballyntyne

Executive Director

Central East Community Care Access Centre

Laszlo Cifra Lisa Burden

Program Director, Aging at Home Program Director, Chronic Disease Mgmt

Community Care Durham - COPE Mental Health Program

Carolyne Pennell

Intake and Admission Coordinator

Psychogeriatric Community Support Program

COTA Health – Geriatric Mental Health Case Management

Paul Vanderlaar

Manager

Nurse Practitioners Supporting Teams Averting Transfers (npstat)

Linda Dacres*

Nurse Practitioner Clinical Director

Saint Elizabeth Health Care

Mary Compton

Director of Crisis Services

Village of Taunton Mills

Alison Trussel*

Nurse Practitioner, Wellness Clinic

Dr. Janice Lessard*

Geriatrician (Scarborough)

Documents

SPECIALIZED GERIATRIC AND PSYCHOGERIATRIC SERVICES IN …