Health Care Professionals Explore Possibilities to Improve Care for Frail Seniors at GAIN Day 

“What matters is what happens to the patient and outstanding performance takes teamwork,” said Victoria van Hemert, Executive Director, Central East Regional Specialized Geriatric Services (RSGS) at a recent gathering of health care providers focused on improving care for frail seniors in Central East Region.

van Hemert, who borrowed the quote from Dr. H. Krumholz’s essay “Listening to Those We Seek to Help,” outlined RSGS’ role in creating a regional system of integrated specialized geriatric services for frail seniors. RSGS supports the Central East LHIN’s strategic aim to reduce the demand for long-term care resulting in 320,000 more days at home in the community by 2016. One of the key priorities for RSGS is to identify opportunities to enhance safety, effectiveness, patient-centredness, timeliness, efficiency and equity in the delivery of care. Her remarks were built on the principle that truly exemplary performance in the care of frail seniors requires a diverse set of skills and contribution from a network of care across the community with shared performance measures.

Putting the patient first, taking care to the patient, working together and measuring shared success were just a few of the important themes that resurfaced throughout the day when more than 70 health care professionals who touch the lives of frail seniors gathered to share their expertise and identify new possibilities to support frail seniors living at home. Organized by Kelly Kay, Regional Manager for the LHIN’s Geriatric Assessment and Intervention (GAIN) Clinics, the event included GAIN teams including nurse practitioners, occupational therapists, pharmacists, physiotherapists, social workers and case managers, Geriatric Emergency Management (GEM) nurses, geriatric physicians and a host of other professionals and organizational representatives from across the Central East LHIN with a vested interest in improving the health care experience of our aging population.

Randy Filinski, a local LHIN resident and health care advocate started the day off by reminding participants that patient stories trump data and relationships trump stories. He noted that each participant had an opportunity to improve their relationships with each other and reminded them of the significance of their relationship with patients whose lives they touch each day.

“Today is an opportunity for us to explore opportunities to define excellence in geriatric assessment, explore possible interventions to support seniors living at home and identify opportunities for collaboration between partners in care,” said Kay in setting context at the event.

Each of the four largest hospitals in the Central East LHIN – Lakeridge Health, Peterborough Regional Health Centre, The Scarborough Hospital, and Rouge Valley Health System - have a GAIN clinic supported by interdisciplinary teams who partner with the Central East Community Care Access Centre case managers. Teams conduct comprehensive assessments and develop interventions and recommendations for high risk seniors who are living at home or in a retirement residence with multiple complex, medical, functional and psychological problems impacting their level of independence. Many hospitals are also now staffed with GEM nurses who have specialized knowledge of aging and understand common geriatric symptoms and atypical presentation patterns. ED staff can call on these professionals when an elderly patient meets the criteria for assessment.

The event included presentations from each GAIN team outlining their work in geriatric care and community outreach initiatives. As well, a panel presentation provided an opportunity to learn about the work of community partners who promote and support the principles of senior friendly care. This included a presentation from Jan Raine, Chief Nursing Officer, and Kerry Shudall, Discharge Planning with Campbellford Memorial Hospital; a presentation from Kim Lepine, Director COPE Mental Health and Specialized Geriatrics for Community Care Durham; and a presentation from Tarmo Uukivii, Chief, Northumberland County Emergency Medical Services. Most often as the first responders to seniors who call for help, Uukivii suggested there was an opportunity for paramedics to deliver geriatric-centred care through partnership with GAIN clinics based in the hospitals.

While the morning focused on identifying new possibilities for partnership and care, in the afternoon participants were treated to some thought-provoking presentations shared by geriatric experts including Dr. Irene Turpie from the Division of Geriatric Medicine, Department of Medicine, McMaster University who shared her insights on frail seniors. Karen Truter, a Clinical Nurse Specialist (Gerontology) with Northumberland Hills Hospital, provided a presentation on how to motivate those with cognitive impairment and their families to make positive health changes.

Dr. Turpie noted that most adults die from heart diseases, cancer or dementia but for the oldest old, the factor which limits their ability to live independently until death is muscle strength. “The definition and identification of frailty helps identify an at-risk population who may benefit from interventions,” she said. While a number of text book definitions exist, Dr. Turpie offered up a practical definition of frailty that focuses on asking the patient these questions: Can you do your own shopping? Can you walk up stairs? Can you tell what year it is? Can you lift your arms above your head? Do you have someone you can confide in? Do you feel safe at home?

She believes that frailty in seniors can be prevented by promoting environments that encourage exercise and social activity and by preventing diseases that are associated with frailty. In concluding her remarks, she reminded participants that the frail patient is someone who ultimately has lived a life and has a story to share, may have multiple diseases and disabilities and is a person we still need to know more about through research.

“Frailty is recognized but often its importance is not. Interventions can improve frailty and may be able to avoid frailty. The presence of frailty in a patient is an important indicator of disability and prognosis and communication between all people who are caring for the patient is very important,” she said.

Submitted by Jennifer Garland, Communications Lead, Central East Regional Specialized Geriatric Services (RSGS)