Authors:

Abstract

Introduction

The South West Frail Senior Strategy (SWFSS) is improving care for older adults and caregivers in Southwestern Ontario. Through literature review, clinical expert interviews, and engagement with over 500 providers, older adults, and caregivers, a priority that was identified was to integrate geriatric mental health and medicine providers into local cross-sectoral teams. These teams would have local coordinated intake and access processes and have agreements in place across organizations to support collaboration. Through local co-design, the aim of this work is improve access, outcomes and the experience of the health care system for older adults with frailty and their caregivers.

Aims Objectives Theory or Methods

The South West Frail Senior Strategy (SWFSS) is improving care for older adults and caregivers in Southwestern Ontario. Through literature review, clinical expert interviews, and engagement with over 500 providers, older adults, and caregivers, a priority that was identified was to integrate geriatric mental health and medicine providers into local cross-sectoral teams. These teams would have local coordinated intake and access processes and have agreements in place across organizations to support collaboration. Through local co-design, the aim of this work is improve access, outcomes and the experience of the health care system for older adults with frailty and their caregivers.

Highlights or Results or Key Findings

The local cross-sectoral team make-up across the region were similar with respect that they involved Alzheimer Society, Geriatric Medicine and Geriatric Psychiatry providers, however, varied in size, disciplines, employers, and level of integration. Preliminary data with the onset of these teams were collected.

The membership of the work groups to build these teams varied across the region based on existing partnerships, local priorities, and available resources. However, across all working groups it was critical to establish links with local priorities and the regional Steering Committee to ensure communication and alignment.

Challenges of this work include being adaptable to local priorities and securing commitment to prioritize system-level change alongside daily clinical commitments.

Next steps include complete implementation of collaboration agreements and coordinated intake and access processes.

Conclusions

By locally co-designing these integrated cross-sectoral teams within a regional strategy, the aim is for a more standardized approach to accessing specialty geriatric services. We anticipate improved outcomes and experiences for older adults and their caregivers, decrease in health care utilization costs, as well as increased provider satisfaction.

Implications for applicability/transferability sustainability and limitations

Despite variations in resources, it has been found that there is significant value in learning and sharing across the different regions. The approach of local co-design in order to integrate specialized geriatric care in the community across urban and rural geographies has high applicability for others.