Abstract
Background: The North Simcoe Muskoka Specialized Geriatric Services (NSM SGS) program in Ontario, Canada was established in 2016 to improve quality of care and health outcomes for older adults living with complexity and/or frailty and their care partners. As our regional program was developing, so too was a new provincial program called GeriMedRisk (GMR), a virtual clinical service connecting prescribers with geriatric specialist physicians and pharmacists to optimize medication use among older adults. A series of events brought our two teams together and we began to explore how to integrate our complementary provincial and regional resources to build capacity and improve population health, with a specific focus on medication management.
Approach: As specialists in the care of older adults, both teams understood the impact of medication complications on the health and well-being of older adults and our health care system. We also recognized that by working synergistically, we could enhance medication management outcomes and improve access to resources for our patients, organizations and health system. Each team contributes funding to a joint pharmacist position, creating a bridge between the specialty teams. This position provides clinical care and education, builds partnerships and programs, and supports system planning. Through this partnership, NSM SGS leverages the expertise and resources of the provincial GMR program to improve our quality of care and build our regional capacity; in turn, GMR leverages the resources, structures and the hub-and-spoke network model of NSM SGS to extend its reach, depth and spread.
Results: The impact of our cross-region approach to integrate care exceeded expectations. For patients, the partnership with a provincial remote consult service improved regional access to medication specialists delivering evidence based patient care. As an embedded member of our interdisciplinary NSM SGS team, the pharmacist increased team skills through education and mentoring, including training in the completion of best possible medication histories. Within the region, partners have benefitted from the creation of a Geriatric Pharmacy Community of Practice, education events, and an annual virtual geriatric pharmacotherapy conference. GMR has benefitted as initiatives started within our region have influenced provincial, national and international work.
Implications: This integrated care strategy - informed by the experience of clinicians, leading practices and design input from older adults, community partners and leaders – offers a model for integrated care that can be replicated in other regions and clinical service areas. Our model offers insight into the value and opportunities in building partnerships across geographic regions. In this session, the audience will learn how organizations with a shared vision and purpose can work synergistically to influence population health by improving service and workforce capacity. We will share lessons learned and explore key factors lending to our success, including the building of relationships and the breaking down of silos through mutually beneficial partnerships.