29. Improving care for the older generation (Orals)

Home is where the HEART is: Humber Elderly Assess and Restore Team (HEART) journey towards restoring function and facilitating discharge home for frail older adults

HEART, a mobile service comprised of inpatient and outpatient components, operating 7 days/week, was implemented to optimize patient function, reduce length of stay, and facilitate home discharges. This session will share key success factors and benefits. HEART is comprised of 5.2 Full Time Equivalents of allied and nursing and serves a subset of high-risk seniors post acute event, with restorative potential and can benefit from assess and restore interventions. Patients are screened for eligibility, assessed upon admission, and followed to discharge and post-discharge promoting continuity of care and consistent follow-up. From September 2018 – June 2019, HEART has served 317 eligible patients with an average length of stay of 8.13 days saving 1572 bed days, the equivalent of 5.3 inpatient beds. Served patients had a 34% improvement in function on average, and 90% returned home to baseline living. This is a model to scale and spread.


Beatrise Edelstein – Humber River Hospital

Karimah Alidina – Humber River Hospital


A Pilot to Legislation: Increasing Family and Resident Engagement in Alberta’s Continuing Care

Seniors living in Continuing Care (CC) facilities are often unable speak for themselves. Resident and Family Councils (RFCs) in CC settings can be effective mechanisms to improve engagement and quality of life through partnership. This project developed a toolkit and tested its ability, along with networking meetings to promote successful councils. The toolkit was developed through a co-design process with residents, family members, researchers, rural and urban sites, patient relations and staff after conducting a survey of current practices.  Nine CC sites participated by receiving and testing the toolkit; completing surveys; attending meetings and participated in interviews. Participants found that the toolkit helped improve council function and networking increased council participation and a strong desire to have them available in the future. This impactful work resulted the Alberta Government’s Bill 22 – RFC Act in April 2018. Attendees will hear of the considerations when forming an effective resident and family council.


Anwar Haq – Covenant Health


A cross-sectoral group of leaders in southwestern Ontario have partnered with patients, families and communities to co-design a regional Strategy for Older Adults with Frailty  

An innovative approach to system transformation was undertaken in southwestern Ontario through consolidation of regional oversight for all initiatives focused on older adults. The regional committee struck to assume this oversight led a co-design process to identify strategic priorities for this strategy. Senior leadership representation on this committee allowed for mobilization of a rapid and robust co-design effort leading to a shared vision for the future and clearly identified priorities. A key learning that emerged is that while patients/families commonly identify the same system issues as healthcare providers, they often have different and critically insightful ideas about possible solutions. As the strategy moves forward within a changing healthcare landscape, the strength of co-designed priorities supports alignment with progressive system changes that prioritize improving the patient experience.


Kelly McIntyre Muddle – St. Joseph’s Health Care London

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