Re-designing a Population-based Region-Wide Central Intake and Navigation Strategy for Older Adults who Live with Complex and Chronic Health Conditions

Older adults with health complexities (e.g., frailty, dementia) and their care partners often have difficulty accessing the specialized geriatric services (SGS) they require. It is also difficult for primary and acute care providers to determine the best supports for their patients. We need navigation solutions that help these older adults access appropriate resources in a timely manner. Regional population-based navigation strategies that facilitate fluid and timely navigation to SGS can help. Developing these strategies, however requires collaborative efforts that actively involve the thinking and resources of diverse stakeholder communities (e.g., older adults and care partners; primary care, acute care and SGS providers; support organizations and programs in the community). In 206, the North Simcoe-Muskoka (NSM) SGS developed a population-based region-wide central intake and triage service (CIT). This service has had much success in helping older adults and families access SGS services. However, this service must continue to evolve to respond to changing population and health resource complexities in the region. NSM-SGS took on a collaborative co-design effort to better achieve efficiencies by leveraging regional (inter-agency, cross-sector) resources and expertise. The aim of the initiative is to co-evolve the CIT service into an integrated regional navigation strategy.

Approach: Description of the original NSM-SGS CIT service comprehensive referral process to SGS and interim educational supports for families in crises system navigators who work one-on-one with older adults, families, and providers effective, collaborative and coordinated referral pathways for referring organizations dissemination of information between and across organizations Collaborative Re-Design Process: We embarked on a collaborative co-design process to evolve CIT into a broader regional navigation strategy. To begin we conducted a series of focus groups with key stakeholders to gain their perspectives about what works what are the challenges and ideas for moving forward. The results were analyzed and presented to members of a co-design working group. The working group used this information to host a series of collaborative workshops to further operationalize a strategic plan to evolve a regional navigation strategy with action steps at micro (within the CIT team), meso (between organizations), and macro (regional systems) levels. Several distinct change initiatives have evolved out of this work that are currently being implemented (and evaluated).

Results: We are evaluating the co-design process and tracking the outcomes of change initiatives. We want to assess whether the co-design initiative helps:- bring key stakeholder communities together to meaningfully and actively engage in problem solving, solution finding, and equitable co-design activities- identify change initiatives that can be undertaken at micro, meso and macro levels- encourage joint ventures for co-production of new navigation resources and pathways- support a community asset-based approach to navigation for this population- develop new infrastructures (e.g., policies, networks, technologies) to support the development of regional cross-sector navigation pathways- realize changed navigation experiences for older adults, families, and providers In our presentation we will describe the co-design process (including the results of our focus group study), the emerging regional navigation strategy (implementation of new change initiatives) and the results of our ongoing evaluation.

Implications: By taking on this co-design process we hope to build stronger partnerships (and learn from and with each other) to achieve integrated efficiencies and leverage the resources and expertise that already exist in our region to improve system navigation for older adults who live with health complexities and their care partnersThrough the development and maintenance of strong partnerships, we have significant opportunity to work together to achieve efficiencies and leverage the resources and expertise that already exist in our region to improve system navigation for older adults who live with health complexities and their care partners.