1. VIHA Leader: TLAB Site Leader: SARIN Site Leader: Project Manager: Facilitators: Evaluator: December 2010 Marianne McLennan Fiona Sudbury Mark Blandford Jeanie Stann Tammy Dewar Dave Whittington Lesley Bainbridge

2.  Vancouver Island Health Authority context  The Lodge At Broadmead Site/Intervention  Seniors At Risk Integrated Network Site/Intervention  Hopes 2

3. 3

4. Population ~ 750,000 (17% of the BC population) Employees ~ 17,000 Physicians ~ 1,700 Facilities 138+: Acute /Rehabilitation Beds ~ 1,500 Residential Beds/Assisted Living Units 6,200 *Community Addiction Beds 386 * Community Mental Health Beds 646 Volunteers ~ 3,600 volunteers provide over 260,000 hrs. annually VIHA Context 4 *owned and operated by VIHA

5.  18 % of Population over 65 years increasing to 28% by 2030-  VIHA strategic direction - Seniors Service Excellence  BC Health Reform -KRA#3 Community Integration (GPs, IHNs, HCC, PH, Community MH) 5

6. 6 Site - The Lodge at Broadmead (TLAB)  Victoria, BC  Non-profit residential care [complex care]  Committed interdisciplinary team  Learning organization  Home to 225 people  Worksite for 300 people

7. 7  Frail older adults with multiple co-morbidities  Average age is 87 when people move in  People are often near the end of their life  60% are Veterans [higher percentage of men]  75% have Cognitive Impairment  100% have families  Complex and ambiguous illness trajectory The Lodge at Broadmead (TLAB)

8. 8 TLAB Intervention  Enhance Staff collaboration  Maximize team effectiveness through NP role clarity  Document processes/tools used to share with others

9.  1 of 25 IHNs demonstration projects initiated 2008  Purpose: Improve community care of frail elderly with 2 or more co-morbidities, Improve patient/family experience, Enhance provider satisfaction/confidence in system, Reduce system costs.  Integrated staff from 6 VIHA Programs (matrix), align HCC case managers to GP Practices. 9

10. 10  Partnership programs with community agencies e.g. Alzheimer Society, Victoria Hospice and Recreation Centers.  Actively engage patient/family in health/care planning.  2,100 patients in 41 physician practices in South Island.  All Physicians are “Fee For Service”, some group/solo practices, variety of locations/information systems, etc.  Physicians attend bi-monthly meetings with Clinical team  Some physicians part of KRA#3 activities, some are not –impacts of changes to this mixed IHN are unclear. Seniors at Risk Integrated Health Network (SARIN)

11.  Position team for meeting future changes  Identify challenges/opportunities to enhance team functioning & physician engagement  Develop roadmap for SARIN/Physician alignment  Document processes/tools used to share with others 11

12. What do we want to achieve? What are we doing? Improved health outcomes for people How are we doing it? Working Relationships (expectations) New Model of Practice Facilitate Successful Change in Complex Systems 12

13. Project Hopes  Create environments that enable collaborative practice learning & improvement which result in improved health outcomes.  Share learnings & gain new ideas through the community of practice network.  TLAB – enhance staff effectiveness through NP role clarity.  Improved understanding of the current clinical team members views on collaborative practice.  Insights in to what is working well  SARIN – Develop an 18 month roadmap to enhance team functioning & GP engagement. 13