TheGeriatrics, Interprofessional Practice and Interorganizational Collaboration (GiiC) Initiative: Enhancing Shared Care of Frail Seniors
The GiiC initiative is a collaboration of the Regional Geriatric Programs of Ontario located in Hamilton, Kingston, London, Ottawa and Toronto, the Centre for Education and Research on Aging and Health (CERAH) at LakeheadUniversity in Thunder Bay and the North East Specialized Geriatric Services (NESGS) Groupin Sudbury. CERAH and the NESGS Interest Group are affiliated with the Northern Ontario School of Medicine.
Acknowledgements
The GiiC Project is funded by theMinistry of Health and Long-Term Care through a HealthForceOntario, Interprofessional Care Education Fund and supports the Provincial Interprofessional Care Blueprint for Action. The willingness of Family Health Teams and Community Health Centres across the province to join our initiative is gratefully acknowledged as is the support of the Quality Improvement & Innovation Partnership, the Association for OntarioHealthCenters and the Arthritis Community Research and Evaluation Unit
GiiC Investigators
Dr.DavidRyan, PhD, CPsych, Project Director
Director of Education Knowledge Processes
Regional Geriatric Program of Toronto
Assistant Professor, Faculty of MedicineUniversity of Toronto
Dr.CherylCott, BPT, MSc, PhD
Associate Professor, Faculty of Medicine, University of Toronto
Director, Arthritis Community Research & Evaluation Unit
Dr.WilliamDalziel, MD, FRCPC
Chief, Regional Geriatric Program of Eastern Ontario
Dr.IrisGutmanis
Director of Evaluation & ResearchRegional Geriatric Program of Southwestern Ontario
Assistant Professor, Department of Epidemiology and Biostatistics,SchulichSchool of
Medicine & Dentistry, The University of Western Ontario
Mr.DavidJewell, MSW, MHSc
Administrative Director, Regional Geriatric Program of Central Ontario
Assistant Clinical Professor, Dept of Psychiatry & Behavioural
Neurosciences, McMasterUniversity, Hamilton
Dr.MaryLouKelleyMSW, PhD
Director, Centre for Education & Research & Aging & Health (CERAH),
Professor, School of Social Work & Northern Ontario School ofMedicine,
LakeheadUniversity, Thunder Bay
Dr.BarbaraLiu, MD, FRCPC
Executive Director, Regional Geriatric Program of Toronto
Assistant Professor, Faculty of Medicine, University of Toronto
Dr.JohnPuxty, MD, FRCPC
Medical Director, Regional Geriatric Program of South Eastern Ontario
Associate Professor & Chair, Division of Geriatric Medicine
QueensUniversity, Kingston
GiiC Initiative Steering Committee
Dr.NickKates,
Director of Programs, Hamilton Family Health Teams
Professor, Faculty of Medicine, McMasterUniversity
MsBrendaMcNeil
Executive Director, AnneJohnston Health Station, Toronto
Ms.MarleneAwad, BSCMHA
Director, Administration & Information Management
Regional Geriatric Program of Toronto
Mr.KellyMilne, BScOT
Program Manager, Regional Geriatric Program of Eastern Ontario
Ms. CatherineMatheson, BSW, MBA, CEC
General Manager, Community Development
City of Greater Sudbury
Ms.LindaPisco, BA, MA
Education Planner, Center for Research and Education in Ageing and Health
LakeheadUniversity
Kelly Simpson, M.A., Cert Ed
Regional Development & Education Coordinator, Specialized GeriatricServices
Regional Geriatric Program of Southwestern Ontario
Ms.MaureenVickers BScN
Director, Specialized Geriatric Services
Regional Geriatric Program of Southwestern Ontario
And
Dr.DavidRyan, Project Director
Dr. William DalzielDr. Cheryl CottMr.DavidJewell
Dr.IrisGutmanisDr.JohnPuxtyDr.MaryLouKelley
Dr.BarbaraLiu
The Project Evaluation Team
The Arthritis Community Research & Evaluation Unit
Dr.CherylCott, Director
Ms.NicoleDonaldson, Research Assistant
GiiC Consultants
DeannaAbbott-McNeil, BScPT
RGP Kingston
DarleneHarrison, RN, HBScN, GNC(C)
CERAH
Mary-Louvan der Horst, RN, BScN, MScN, MBA
RGP Hamilton
Lyne Marcil, BScOT, BA, Geriatric Assessor
RGP Ottawa
CatherineMcCumber, RN, BScN, MN, GNC(C)
RGP Ottawa
SusanneMurphy, BScOT, MSc
RGP Kingston
DonnaScott, RN, BScN, CHRP
RGP London
TanyaShute,MSW, RSW
CERAH
DeanaStephen, RSSW
NE SGS Interest Group
KenWong, BScPT, MSc
RGP Toronto
GIIC Project Overview
Introduction
Population aging presents significant challenges to the health care system in Ontario. Not the least of these is the fact that 82% of seniors have one or more chronic health conditions and 43% have three or more conditions. This later group of seniors is at risk of becoming frail. Frailty, characterized by complex bio-psycho-social and functional problems, is associated with increased health system usage and puts seniors at risk of loss of the capacity for independent living and lowered quality of life (Wolff et al, 2002). Within the aging demographic, frailty may be the fastest growing segment across the province and particularly in northern regions and outside high-density urban areas (Manuel & Schultz, 2001)
Ageing demographics will have a significant impact on human resource planning and development in all professions working in many health care contexts across the circle of care (McKnight et al. 2003). Providing care to the expanding population of frail seniors requires an both an increase in the numbers of care providers and development of our skill sets. Our skill sets require expertise in three broad competencies - geriatrics, inter-professional practice and inter-organizational collaboration. Competence in geriatrics is required because the clinical presentations of frail seniors are unique and include the ‘geriatric giants’ of dementia, delirium, falls, continence and poly-pharmacy often co-occurring in complex ways. Competence in inter-professional practice is required because the complexities of these clinical presentations are such that optimal care requires an interdisciplinary team. Inter-professional teamwork, as outlined in the recently published Health Force Ontario, Inter-professional Care: Blueprint for Action (Oandasan & Closson, 2007), is the care delivery method of choice in caring for frail seniors (Geriatrics Interdisciplinary Advisory Group, 2006). Finally, competence in inter-organizational collaboration is required because the management of frail seniors requires the sharing of care across many organizational boundaries from primary and community based care to emergency and hospital-based services. Table 1 provides an overview of these competencies.
On the need for training in the core competencies
Repeated surveys demonstrate that curriculum time devoted to geriatrics in the academic preparation of health professionals is insufficient. In our own surveys, for example, frailty-focused service ‘specialists’ in all disciplines tell us that they when they graduated they lacked the confidence and skill sets to care for frail seniors. They tell us that they required extensive continuing education that was acquired through informal ‘on the job’ processes, specific time-limited educational events and pilot projects though groups such as the RGPs of Ontario. These findings from the inter-professional geriatric ‘specialists’ appear independent of year of graduation (Ryan & Kirst, 2005). Limitations on geriatrics training are a challenge to the health systems capacity to meet the needs of an aging population.
The need for renewed focus on preparing health professionals for inter-professional practice has recently been documented in the Health Force Ontario, Inter-professional Care: Blueprint for Action (Oandasan & Closson, 2007). The blueprint argues that because inter-professional practice is an essential characteristic of health care delivery in the real world, preparation for inter-professional practice must be formally incorporated into the academic and continuing
education of health professionals. Simply putting people together to work does not necessarily create effective teamwork. In formative academic training health professionals must build
attitudes and expectations supportive of inter-professional practice that with appropriate support can be refined in the workplace to improve the quality of services to patients (Barr, 2000).
The Inter-professional Care: Blueprint for Action and the emergence of Local Health Integration Networks in Ontario also guide us towards the importance of inter-organizational collaboration in the delivery of effective health care. But, just as simply putting people together to work does not necessarily create effective teamwork, so simply requiring organizations to work together does not necessarily lead to effective shared care. Inter-professional practice and inter-organizational collaboration require ongoing coaching, support and facilitation. Resources to meet this ongoing need are seldom available in the workplace.
Between Specialized Geriatric Service providers affiliated with the Regional Geriatric Programs of Ontario, Community Health Centres and Family Health Teams who are and will increasingly be the primary source of care for the growing population of frail seniors, there exits a combination of skill sets and needs that can respond to the issues of human resource scarcity for geriatric care and the need to provide practice based training in inter-professional practice and inter-organizational collaboration as outlined in the Blueprint for Action.
Goals and objectives
Through this initiative we propose the development of a network of excellence in practice based interprofessional education and interorganizational collaboration in primary care that will support the academic initiatives outlined in the Health Force Ontario, Inter-professional Care: Blueprint for Action and help the province in managing the consequences of its ageing population.
The primary outcomes arising from this initiative are as follows:
1) The consolidation of a team of GIIC resource consultants situated within the RGPs of Ontario,
the Centre for Education and Research on Aging and Health at Lakehead University and the North East Specialized Geriatric Services Group in Sudbury totrain coach and mentor a provincial network of GiiC facilitators.
2) The development of a province-wide network of 200 GiiC facilitators situated in Family Health
Teams (FHT) and Community Health Centers (CHC) to assist their teams and organizations in
the delivery of collaborative shared care to frail seniors.
3) A set of GIIC teaching resources and facilitation tools with an online repository
4) An intersectoral and province-wide health services workforce with enhanced awareness and
knowledge of each other and higher levels of skill in the three competencies
6) A sustainability plan for each network hub consistent with each group’s specific needs and
leveraging existing resources and skill sets
7) Improved shared health care for seniors and especially frail seniors
Table 1. A framework of competencies for health human resource development
The Geriatric clinical core competencies for frailty focused services
1. The nature of frailty
2. Dementia, delirium, depression, falls, continence, polypharmacy – the Geriatric Giants
3. Context specific geriatric assessment tools
4. Specialized geriatric services and their processes
5. Senior friendly environments and seniors safety.
6. Geriatrics and models of geriatric care giving
The Inter-professional core competencies
Assessment competencies include the ability to:
1.Assess the culture of a working team
2.Assess the characteristics of a team’s development
3.Understand the formal and informal influence processes on teams
4.Understand individual styles of behavior and problem solving
5 Assess team meeting behavior
6. Identifying the correct locus of decision-making
Intervention competencies include:
1.Create consensus on a best practice
2.Engage formal and informal opinion leaders
3.Small group facilitation
4. Communication, confrontation and conflict resolution
5. Manage task and process needs
6 Edumetrics – measurement procedures that teach
7 The ability to engage patients/clients and their families as team members
8. Inter-professional mentoring and coaching
9. Inter-professional ethics
Developing inter-organizational core competencies
Inter-organizational assessment competencies include:
1. Recognizing teams within teams
2. Network analysis and system pragmatics
3. Assessment of boundary functions
4. Organizational culture and power analysis
5. Understanding expectancy dynamics
6. Privacy, confidentiality and inter-organizational collaboration
7. The colleges, theskill sets and cognitive maps ofthe health professions
Inter-organizational intervention competencies include:
1. Network building and support
2. Managing change in a networked environment
3. Inter-organizational human resource facilitation
4. Diversity management
5. Inter-organizational negotiation and issues management
Selected References
Allen, M, Ryan, D. & Sibbald, G. (2002). Information Technology & CME: Learning in Communities of Practice, Presented at the Annual Meetings of the Canadian Association of Continuing Health Education, Halifax.
MacKnight, C, Beattie, BL, Bergman, H, Dalziel, WB, Feightner, J, Goldlist, B, Hogan, DB, Molnar, F & Rockwood, K. (2003) Response to the Romanow Report: The Canadian Geriatrics SocietyGeriatrics Today: Journal of the Canadian Geriatrics Society 6 (1), pp. 11-15
Wolff JL, Starfield B, Anderson G. (2002) Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. JAMA, 162: 2269–2276.
Geriatrics Interdisciplinary Advisory Group (2006) Interdisciplinary Care for Older Adults with Complex Needs: American Geriatrics Society Position Statement. Journal of the American Geriatrics Society, 54(5), 849-852.
Ryan, D. & Kirst, J. (2005) Core Competencies for Specialized Frailty Focused Services. Presented at the Annual Meetings of the Ontario Gerontology Association, Toronto 2005.
Ryan, D., Cott, C. & Robertson, D. (1997) A conceptual tool-kit for thinking about inter-teamwork in clinical gerontology. Journal of Educational Gerontology, 23, 651-668.
Ryan, D. (1996) A history of teamwork in mental health and its implications for teamwork training and education in gerontology. Journal of Educational Gerontology, 22(5), 411-431.
Oandasan, I, Closson, T. (2007) Health Force Ontario, Inter-professional Care: Blueprint for Action. Online at
Oandasan, I, Reeves, S. (2005) Key elements of interprofessional education. Part 2. Factors, processes and outcomes Journal of Interprofessional Care 19 (Suppl.1), 39-48
Manuel, DG, Schultz, SE (2001) "Adding years to life and life to years: life and health expectancy in Ontario. ICES Research Atlas, January
Barr, H. (2000) Working together to learn together: learning together to work together. Journal of Interprofessional Care, 14(2) 177-179.
Clark, PG, Puxty, J. & Ross LG (1997) Evaluating an interdisciplinary geriatric education and training institute: What can be learned by studying processes and outcomes? Educational Gerontology 23(7), 725-744.
On the role of GIIC facilitators
Congratulations on being nominated to the role of GiiC facilitator within your organization.
Across the province the network of GIIC facilitators will comprise health professionals from many backgrounds. It will be an interprofessional team itself. So far, we have had physicians, advanced practice nurses, nurses, social workers, and occupational therapists nominated to represent their Family Health Team or CommunityHealthCenter.
The key selection criteria we suggested for recommending FHT/CHC facilitators were personal interest, breadth of clinical experience, acceptance by your colleagues and, perhaps ideally, the qualities of an informal opinion leader. Informal opinion leaders are individuals to whom others often turn for advice – they like answering questions, seem to stay up to date on a wide range of topics and communicate in a down to earth and humanitarian way. So congratulations once again, you must be a very special health professional.
We will provide you with 16 hours of training with our team of GiiC consultants and expert local faculty. Each of you will have a regional GiiC consultant who will support you when you return to your organization for a period of 3-4 months and, we hope, longer. We will invite you to a follow-up meeting to share your experiences with us and as well, we will invite you to the annual meetings of the staff of the Regional Geriatric Programs of Ontario, held in Toronto in the Spring, in order to build bridges to the provinces specialized geriatric services.
We will provide you with a GiiC toolkit in an electronic version. The toolkit will provide a range of tools on 18 dimensions of geriatrics and on interprofessional practice and interorganizational collaboration. For each dimension there are Quick Facts, Practice Aids, Practice Algorithms, Quizzes, Patient Handouts, Teaching Case Studies, Slide Materials and Reference materials, designed to help you in the facilitator role. The GiiC facilitator website is available for you at It is a secure resource and once you have opened a membership, you can download the GiiC resources, discuss issues with each other and with your GiiC consultant.
But what specifically is required of you . . . ?
We know that there are no two FHTs or CHCs the same and that each organization responds to the needs of its frail seniors in diverse ways. Similarly, we anticipate that there will be a range of opportunities for you to implement GiiC processes in your organization. Some of you are working in organizations that want to introduce big changes in the care of frail seniors, while many of you will be working in organizations that are already going through significant developmental change. For you, GiiC might lead you to be able to find the right tool to better serve one of your teams seniors. Whether big or small, we will consider each instance a significant success. We know that big things often come from small beginnings and that it is hard to tell ahead of time which small beginning that might be.
We will be evaluating the project and part of the evaluation, having your team complete a perceptions of teamwork survey and network analyses of your team and its interorganizational collaborations, will itself be an intervention to help your team in these areas. We call this approach to measuring and teaching ‘edumetrics’.
With all of this in mind your GiiC facilitation might include some or all of the following activities:
Clinical geriatrics activities
Informal opinion leadership on geriatrics issues
Periodic reviews of geriatric practices
Coaching of clinical knowledge to practice activities
Liaison with formal geriatrics experts
Able to recommend context specific assessment tools
Inter-professional practice activities
Annual survey of team member perceptions of the team
Coordination and facilitation of quarterly team process meetings
Facilitate reflection on issues of team performance
Facilitate teamwork problem solving
Coordination of inter-professional mentoring for new staff
Inter-organizational collaboration activities
Annual inter-organizational network analysis and expectation surveys
Identification of inter-organizational boundary management functions
Facilitation of annual and ad hoc meetings of the inter-organizational network
Network feedback process analyses for quality improvement initiatives
Problem solving inter-organizational issues and concerns
But most of all keep in mind, that we are very grateful for your interest in our project. We will work hard to help you and for us success can come in both large and small initiatives.