1. An Introduction to IMPACT Sunnybrook Health Sciences Centre GiiC Knowledge-to-Practice Workshop Presenters: Susan Riddle & Jasmine Arellano

2. What it is Interprofessional Model of Practice for Aging and Complex Treatment A comprehensive model of: –Assessment –Care –Mentorship and training –Planning

3. What it is An interdisciplinary team works with patient, caregiver(s), and referring practitioner –Typical appointment covers a diverse range of medical, functional and psycho-social issues –Goal: ‘unpack’ the patient’s condition –Takes 2-3 hours –Complements family practitioners’ care

4. What it is Room to personalize process according to context –Builds on unique characteristics of the patient being assessed –Builds on unique characteristics of the team in place

5. IMPACT HCPs The team comprises: –Family physician –Family physician resident –Pharmacist –Occupational therapist –Physiotherapist –Community nurse –Social worker –Dietician

6. Patient on Screen Doctor Resident 2 Physio OT Pharmacist Social Worker Community Nurse Dietician Researchers Resident 1 HCP learner

8. The IMPACT patient Inclusion criteria –aged 65+ –5 or more long term medications –3 or more chronic disease requiring monitoring and treatment OR 2 chronic diseases when one is frequently unstable –minimum of 1 functional ADL limitation –not home-bound or institutionalized –patient and/or caregiver is willing and able to deliberate with a team –patient and/or caregiver are motivated to take action to improve patient’s health status and patient is emotionally/cognitively/socially equipped to do so

9. The IMPACT protocol Patient Selection & Invitation Group Discussion 1 Patient Welcome & Initial Patient Interview Group Discussion 2 HCP Assessments Team Deliberation Documentation & Debrief

10. Patient Selection & Invitation Selection based on inclusion criteria Invitation extended to patient/caregiver Patient Selection & Invitation Group Discussion 1 Patient Welcome & Initial Patient Interview Group Discussion 2 HCP Assessments Team Deliberation Documentation & Debrief

11. Group Discussion 1 Referring practitioner provides background info: –Brief history –Recent events –Current issues/concerns –Patient’s support systems –Rationale for bringing patient to IMPACT Patient Selection & Invitation Group Discussion 1 Patient Welcome & Initial Patient Interview Group Discussion 2 HCP Assessments Team Deliberation Documentation & Debrief

12. Patient Welcome & Initial Patient Interview Patient and caregiver greeted Patient and caregiver interviewed, team observes and gathers data on: –Current concerns, current function; patient and family goals and perspectives –Interviewer summarizes patient and family concerns Patient Selection & Invitation Group Discussion 1 Patient Welcome & Initial Patient Interview Group Discussion 2 HCP Assessments Team Deliberation Documentation & Debrief

13. Group Discussion 2 Interviewer debriefs team and priorities for visit are identified –Issues and concerns –Which HCPs will see patient and caregiver –Additional information needed? Patient Selection & Invitation Group Discussion 1 Patient Welcome & Initial Patient Interview Group Discussion 2 HCP Assessments Team Deliberation Documentation & Debrief

14. HCP assessments Relevant HCPs perform assessments of patient, caregiver –Social worker –Occupational therapist –Physical therapist –Nurse –Dietitian –Pharmacist Patient Selection & Invitation Group Discussion 1 Patient Welcome & Initial Patient Interview Group Discussion 2 HCP Assessments Team Deliberation Documentation & Debrief

15. Team Deliberation HCPs discuss situation in light of findings of team members’ assessments Investigation/treatment options discussed Care plan begins to take shape –What does the patient/caregiver want? –What can the patient achieve? Patient Selection & Invitation Group Discussion 1 Patient Welcome & Initial Patient Interview Group Discussion 2 HCP Assessments Team Deliberation Documentation & Debrief

16. Documentation and Debrief Dialogue with patient/ caregiver to ensure their needs and expectations have been met Patient plan of care negotiated with input from patient and caregiver/family Resources and patient to-do list provided Patient medical records completed Patient Selection & Invitation Group Discussion 1 Patient Welcome & Initial Patient Interview Group Discussion 2 HCP Assessments Team Deliberation Documentation & Debrief

17. Patient Follow-up Follow-up visit with FP and care plan review Community visits from IMPACT team members Ongoing team communication

18. Highlights of the IMPACT experience Very different from patients’ typical encounters with their family physician Group discussion, shared observation Final recommendations arrived at through a collaborative and interprofessional process Effectiveness –Real-time problem solving –Addressing patient and caregiver priorities –Avoids multiple referrals

19. Highlights of the IMPACT experience Shared knowledge and perspectives –Sharing of expertise, knowledge –Different professional and personal approaches –Opportunity to draw on expertise of entire team –“Interprofessional collaborative knowledge construction” Observation –Can see interactions – Referring FP sees patient in a “new light”

20. IMPACT Successes Appeal to patients and caregivers Patients feel better able to express themselves with longer appointments –“...so within the first 10-15 minutes, mom has a comfort level that she never had before and is more forthcoming than ever.” –Family member Patients feel that they are being listened to –“IMPACT is a huge improvement. They’re hearing the patient, finally they are, they have the time.” –Family member

21. Appeal to patients and caregivers Patients felt important and supported by the care team –“ Well, it was just wonderful. I felt taken care of… I felt um, I hate to say this, special” – Patient

22. Thank you! Questions?

23. "Frail older patients – unlike younger persons in the health care system or even well elders – require complex care. Most frail older patients have multiple chronic illnesses. Optimum care cannot be achieved by following the paradigm of ongoing traditional health care, which emphasizes disease and cure. Because no one health care professional can possibly have all of the specialized skills required to implement such a model of health care delivery, interdisciplinary team care has evolved.” –Dyer et al. Frail Older Patient Care by Interdisciplinary Teams. Gerontology & Geriatrics Education 2004;24(2): 51-62.