Seniors Strategic Aim
Improving health care for seniors, also referred to as older adults, continues to be a top priority of the Central East LHIN as the senior population continues to increase and their complex health care needs require more resources and attention.
With the overarching goal of Living Healthier at Home - Advancing integrated systems of care to help Central East LHIN residents live healthier at home, the Central East Local Health Integration Network (Central East LHIN) 2016-2019 Integrated Health Service Plan (IHSP 4) will guide, direct and inspire health system change.
Through the engagement process for the LHIN's 2016-2019 Integrated Health Service Plan, patients, caregivers and providers identified where improvements to the health care system are required as the system continues to support frail older adults to live healthier at home by spending 20,000 fewer days in hospital and reducing Alternate Level of Care days for people age 75+ by 20% by 2019.
Who is this Priority Population?
The Central East LHIN has the largest number of seniors (65+) in the province. This priority population is growing and impacting the demand for health care services:
- over 16% of Central East LHIN’s population are seniors aged 65+ (up from 14% in 2011);
- by 2021 seniors will account for 18% of the Central East LHIN’s population;
- Central East LHIN has the highest waitlist and 2nd highest long-term care (LTC) demand rate in the province - 118 of every 1000 seniors aged 75+ are living in, or waiting for LTC, up 10% from IHSP 3
- the LTC bed supply has decreased for the 75+ population from 90.1/1000 to 82.9/1000 since 2010;
- over 40% of the 85+ population live alone in the community;
- by 2016, over 1000 community-dwelling people with dementia will experience ALC hospitalization in the
- Central East LHIN; and,
- by 2020, an estimated 32,700 Central East LHIN residents will be living with dementia, the second highest in
- Ontario (Alzheimer Society of Canada).
Focusing on Frailty
Frail seniors are those older adults whose complex health concerns threaten their independence and function. A highly coordinated system response, that strives to understand and then deal with root cause(s) of their health care needs, is required to better serve this population.
Building on Key Accomplishments
Integral to achieving the aim and improving seniors’ health is the Seniors Care Network, formed and funded by the Central East LHIN to improve the organization, coordination and governance of specialized geriatric services (SGS) for frail seniors in the Central East LHIN. Making a direct contribution to reducing hospitalization and promoting the ability for frail seniors to remain at home and, by working collaborative-ly with a range of health system providers, specialized geriatric services enhance care, improve quality and advance system coordination and integration.
The following are some of the specialized geriatric services and investments which have contributed to and will continue to contribute to achieving our Seniors Aim:
- inter-professional hospital and community-based teams providing comprehensive assessments, care plans, and provide home-based care, optimizing function and independence
Geriatric Emergency Management (GEM) (Implemented)
- nurses and nurse practitioners in caring for frail older adults, in LHIN’s Emergency Departments (ED) who conduct assessment and provide support to frail older adults experiencing acute health concerns
- reducing unnecessary hospital admissions
Home First (Implemented)
- a collaborative approach between hospitals, the CCAC and community agencies to improve hospital bed utilization
- facilitates the timely and safe return home of every individual who enters the hospital
Nurse Practitioners Supporting Teams Averting Transfers (NPSTAT) (Implemented)
- nurse practitioners, working in teams, support staff in all 68 long-term care homes (LTCHs) in Central East LHIN, avoiding preventable resident transfers to hospital EDs
- specially trained health professionals work in LTCHs and in the community supporting people living with challenging behaviours and their families
Assess and Restore (A&R) (Implemented)
- extend the functional independence of frail older adults
- reduce the burden on caregivers
- help health service organizations and health care professionals adopt effective evidence-based clinical processes and interventions
- exercise classes to improve and maintain functional performance
- falls prevention classes provide instruction on reducing the risk of falling
Assisted Living Services for High Risk Seniors (Implemented)
- service hubs address needs of high risk seniors to support living at home
- scheduled and non-scheduled personal support, homemaking, security checks and 24/7 reassurance services
Adult Day Programs –Seniors (Implemented)
- services for patients and family caregivers (often includes respite) in a congregate setting, includes planned social and recreational activities, meals, assistance with the activities of daily living and health care assistance for both individuals with dementia and frailty
- collaborative hospital initiative to improve seniors’ health and prevent physical and cognitive decline in hospital including delirium
Memory Services (In development)
- primary care based regional program enhancing capacity for timely detection, diagnosis and treatment of dementia
Seniors’ Physician Lead (In development)
- will provide the Central East LHIN with clinical expertise and physician clinical leadership to support practitioners in caring for frail older adults and inform system planning, design and quality improvement
- developing the dementia strategy for the LHIN and participating in the provincial dialogue towards development of a provincial dementia strategy
To achieve the strategic aim of continuing to support frail older adults to live healthier at home by
spending 20,000 fewer days in hospital and reducing Alternate Level of Care days for people age 75+ by 20% by 2019, the Central East LHIN will continue to provide ongoing alternatives for home and specialized care that helps older adults to remain living healthier at home and in their community.
By continuing to support existing initiatives, expand community-based services and implement new strategies related to dementia, the LHIN, its Health Links and other partners in Health Link communities, will continue to work together so that patients will only have to stay in hospital as long as they need the intensity of care that hospitals are designed to provide. The effective use of Coordinated Care Plans will better support patients being admitted to or discharged from hospital as they benefit from improved communication among providers in an integrated system of care. Providing seniors with the appropriate care to enable them to stay in the community as long as possible will also ensure that the limited LTC resources will be optimized and available to those individuals who need it most.
To track the system's ongoing progress against this Strategic Aim, please visit the Central East LHIN Performance page.
For more information on these accomplishments, please contact the LHIN at firstname.lastname@example.org or any LHIN-funded Health Service Provider.