Abstract
Seniors in Canada now outnumber children for the first time in history. This trending is echoed globally as the number of older persons is growing faster than all other age groups. The growth of the senior population is faster in Asia and Oceana than Canada, but the social and economic implications are similar. Creating innovative, integrated and sustainable delivery models for senior health care is a global and local imperative.
A significant challenge in developing population-based approaches for frail persons has been the persistent disconnect between health and social services planning and delivery. While the barriers and benefits of coordinating health care services alone are significant, they fall short of addressing the holistic needs of seniors and caregivers. Often, wellness and preventative services, housing, caregiver supports, and other social needs are overlooked – further compounding risks to patients and caregivers, such as sub-optimal quality of care, health loss, personal and family stress and mental health, financial risks, and a poor overall health experience. .
There is growing interest among international health care experts on the need to implement integrated community based primary health care (ICBPHC) initiatives that will assist frail and complex seniors in maintaining their independence while remaining in home as long as possible. ICBPHC is focused on meeting the needs of medically-socially complex patient groups through intensive case management, interprofessional practice, and a chronic care model that integrates primary and specialty care, as well has health with social services.
Carefirst Seniors and Community Services Association, a 40 year old non-profit organization servicing largely the Asian population in the greater Toronto area, made a strategic decision to implement its own ICBPHC solution, called INTEGRATE©. INTEGRATE© is a comprehensive chronic care model that provides a full range of services to meet the unique needs of the patient and their caregivers. This includes intensive case management anchored in Carefirst’s Adult Day Programs and a state of the art One Stop Multi-Services Centre in Scarborough, Ontario, Canada. The strengths of the Carefirst INTEGRATE© model has made it an effective partner with the local hospital in providing centre and home based restorative care , transportation, short-stay transitional beds, virtual ward, and specialized geriatric team-based services.
Preliminary data about patients participating in this INTEGRATE© model of is promising: . Client satisfaction is higher while visits to hospital emergency department, readmissions and patients experiencing falls appear lower than comparative data. In recognition of this success, Carefirst has received several provincial and national distinctions, and hosted national and international visitors to showcase INTEGRATE© in practice. .
We see INTEGRATE© as internationally applicable to other regions looking to successfully support the health needs of an increasing older adult population. Our presentation aims to share key components and lesson’s learned of the INTEGRATE© model. We will also present the model’s future evolution – including the development of complimentary payment models, and the innovative promotion of its spread locally and internationally.