Home VIVE Dr. Jay Slater

A Day in the Life

Mandate Provide comprehensive quality care to frail elderly patients in their homes as an alternative to residential care “Patients who are unable on a consistent basis to get out for medical care and/or whose current Family Physician can’t consistently provide home visits” Respect patient / family wishes regarding the direction and goals of their health care (including advance care planning)

Goals Maintain or improve function Maintain independence / safety Manage chronic diseases Avoid or delay hospitalization for acute issues Avoid or delay residential care admissions

Goals Focus on quality of life (not necessarily quantity) Reduce symptoms Reduce caregiver burden Patient / Family – specific goals

Home VIVE / VIVE Plus 5 half-time MDs, 1 very part-time MD 3 RN/Case Managers 1.5 Physiotherapists 2 Rehab Assistants 1 Occupational Therapist 1 Secretary

Home VIVE / VIVE Plus Extended Team Home Care Nursing Home Support Workers Home Care OT and PT Case Managers Geri Triage RN’s (ER)

Home VIVE / VIVE Plus Virtual Team Mobile Lab Mobile Podiatry, Optometry, Dentistry Palliative, Mental Health Programs Geriatric Day and In-Patient Programs (STAT, Geri Med) Adult Day Programs Etc.

Model “Full-service” Family practice with integrated Nursing and Rehab components Longitudinal primary care (vs. episodic, intermittent care), proactive Chronic disease management, monitoring Acute interventions (but not an emergency service) Intensive case management, linkage with other community services and supports

Frailty DisabilityCo-morbidity

Does It Work?

Reduced reliance on acute services Reduced or delayed admissions to Residential Care Enhanced quality of life for patient and caregiver Cost effective

Challenges Demand outpaces capacity Triaging referrals Complex patient needs, intensive support City-wide program Lack of equipment programs Communication across various systems

The Office

Questions?