Optimizing Health Outcomes for Older Adults Living with Complexity through a Regional Hub & Spoke Network Model

Background: Older adults across regions can experience varied levels of care and services.  This is especially challenging for older adults who live with health complexities  (e.g., frailty, dementia) as inequity in access and quality can negatively affect health outcomes and health care resource utilization.  More important, it can diminish their overall health and wellbeing.  These older adults and their care partners require a suite of services and supports (enabled through collaborative partnerships) to address interrelated physical, mental and social health issues. Over the past ten years, the North Simcoe Muskoka region of Ontario, Canada has attended to this need by advancing a single regional integrated Specialized Geriatric Services (SGS) program.  A whole-system response was mobilized to improve patient outcomes, build system capacity and foster system change. 

Approach: Through early co-design work (that engaged older adults and their care partners, clinicians, administrators, and regional health authorities), a unique hub-and-spoke network model of SGS services and supports was developed and implemented across our region.  Our presentation will describe how this novel regional, integrated care approach was developed and how it facilitates the flow of SGS knowledge, resources and leading practice in and across sectors (e.g., primary care, acute care, long-term care), layers (e.g., primary, secondary, tertiary) and domains (e.g., physical, mental, social health) of care.  We will describe how we use our spheres of influence (e.g., leadership, advocacy, clinical practice, education) to accelerate change and how compassionate, collaborative and dynamic leadership has helped advance outcomes.

Results:  Our SGS program hub-and-spoke network model is leading to care delivery redesign as well as cross-organizational service delivery and action.  It is inspiring changes in funding, practice and policy across the region.  More care is being delivered in alignment with leading practices and we are witnessing an increase in the number and type of services available across the region.  In creating an operating network of intertwined services and supports, we are better leveraging regional relationships, assets and resources.  Through this integrated care approach, we are improving population health at a regional level. 

 

Implications:  The hub-and-spoke network model has applicability to other regions and services.  In our presentation, we will describe how model components operationalize a regional integrated system of care for a target population. To illustrate the model, we will present a case example focused on our regional Behaviour Success Agent project.  Using early findings from this ongoing evaluation study, we will explain how the model has contributed to improved patient outcomes and system capacity by expanding the reach, depth, spread, and scope of SGS services for older adults who experience behavioural symptoms of dementia across six acute care hospital sites. We will share key learnings from the implementation of the model and identify next steps related to a conceptual analysis we will be undertaking to illustrate how the model enables an integrated and population health approach.