December 22, 2020
Given the ongoing pressures experienced by the acute care system during the ongoing pandemic, the Ministry of Health (MOH) and Ontario Health have signalled an urgent need to develop or expand existing services for those patients with high intensity needs. These patients may include older adults with complex health concerns who are currently admitted to hospital or who are in the community and need support to return home or to avoid acute care admission. In response to these pressures, the Provincial Geriatrics Leadership Office (PGLO) consulted leaders in clinical geriatric services from across Ontario to highlight opportunities for collaboration with specialized geriatric services (SGS). “Our health services are focused exclusively on older persons’ living with complex health concerns” said Kelly Kay, Executive Director of the Provincial Geriatric Leadership Office (PGLO). “There are more than 2500 clinicians working in approximately 440 SGS programs across Ontario. We know we can help with scalable, evidence-based, high yield clinical services” said Kay.
Kay noted there are numerous community-based or community-focused SGS programs and services with expertise that could be leveraged and resourced to create integrated solutions for the short-term and longer term. There are also several existing models of integrated care specific to older adults living with complexity that can serve as exemplars. Results of a recent environmental scan of SGS in Ontario have identified programs that contribute to good experiences for older persons living with complex health concerns include:
- interventions that address integrated physical, mental, social and substance use issues;
- involvement of family/friend caregivers in planning and care processes;
- community and home-based interventions;
- comprehensive assessment and care planning;
- cross-sector/interdisciplinary teams;
- integrated specialized geriatric expertise; and self-management support.
SGS Leaders have compiled a partial list of eleven SGS programs, and related services and innovations that could be resourced and leveraged quickly to contribute to the desired outcome of increased care at home for older persons with complex health concerns. All programs meet the criteria expressly identified by Ontario Health of initiatives that can be implemented in the short term and that build on prior and proven approaches. View the list here
For more information about effective clinical models of older persons care, review the PGLO’s related resources. Questions and comments can be directed to firstname.lastname@example.org.