This document provides an overview of innovations in caring for older adults across the continuum of care in Canada. It introduces the Acute Care for Elders (ACE) strategy, an integrated care model shown to deliver better outcomes for patients and the healthcare system. The document describes how Mount Sinai Hospital in Toronto implemented an ACE strategy through interprofessional teams and programs across inpatient, outpatient and home-based settings. Evaluations show the ACE strategy at Mount Sinai reduced length of stay, increased rates of patients returning home, and improved patient satisfaction and staff experience with geriatrics care.

1. Canadian Innovations in
Caring for Older Adults
Across the Continuum of Care
Samir K. Sinha MD, DPhil, FRCPC
Director of Geriatrics
Mount Sinai and the University Health Network Hospitals
Assistant Professor of Medicine
University of Toronto and the Johns Hopkins University School of Medicine
Research Affiliate
Oxford Institute of Ageing
Nuffield Trust Health Policy Summit
1 March 2012

2. Presentation Objectives
 Provide the Canadian context that demands
innovations in caring for older adults.
 Demonstrate how current care delivery paradigms are
problematic and require an elder friendly approach.
 Introduce the Acute Care for Elders (ACE) Strategy
as an integrated care model that can deliver better
patient and system outcomes.

3. Canadian Healthcare 101
 We have a universal health care system that is
independently administered by 13 provincial and
territorial governments.
 Hospitals are independently governed authorities with
a public mandate
 Ontario is the largest HMO in North America with a
budget of 47.1 B and population of 13.3 M

4. Ageing and Hospital Utilization
in Central Toronto
Number Age <65 Seniors 65 + % Seniors 75+
Total Population 1,142,469 87% 14% 49%
Emergency Room Visits 321,044 79% 21% 62%
Acute Hospitalizations 78,025 63% 37% 64%
w/ Alternate Level of Care Days 4,263 17% 83% 76%
w/ Circulatory Diseases 10,361 32% 68% 65%
w/ Respiratory Diseases 5,928 43% 57% 73%
w/ Cancer 6,743 53% 47% 54%
w/ Injuries 5,809 58% 42% 71%
w/ Mental Health 6,161 87% 13% 59%
Inpatient Rehabilitation 3,368 25% 75% 66%
Toronto Central LHIN

5. Ontario Inpatient Hospitalizations
Age Discharges Total LOS Days ALOS
Population Total 945,089 6,075,270 6.4
Population 65+ 370,039 (39%) 3,516,006 (58%) 9.8
65-69 6.9% 7.9% 7.3
70-74 7.7% 9.8% 8.2
75-79 8.5% 12.5% 9.4
80-84 7.9% 13% 10.5
85-89 5.3% 9.4% 11.4
90+ 2.8% 5.3% 12.2
Canadian Institutes for Health Information (CIHI)

6. Ageing and Hospital Utilization in the 70+
Inconsistently High Users Consistently High Users
4.8%
6.8%
42.6%
24.6%
Consistently Low Users No Hospital Episodes
 Only a small proportion of older adults are consistently
extensive users of hospital services (Wolinsky, 1995)

7. What Defines our Highest Users?
 Polymorbidity
 Functional Impairments
 Social Frailty

8. Why Hospitals often fail Older Adults

9. Conceptualizing Functional Decline
The Hazards of
Hospitalization
Hostile Environment
Depersonalization
Functional Acute Illness
Bedrest / Immobilty
Older + Possible
Malnutrition / Dehydration
Person Impairment
Cognitive Dysfunction
Medicines / Polypharmacy
Procedures
Depressed Mood, Delirium, Physical Impairment
and Negative Expectations and Deconditioning
Dysfunctional
Older
Palmer et al., 1998 (Modified) Person

10. Trajectories of Functional Decline
Baseline Admission Discharge
70+ Pts 57% Stable 45% Stable 65% Discharged
N=2293 N=1311 N=1039 with Baseline
Function
20% Recovery N=1494
N=455
12% Hospital Decline
N=272
35% Discharged
43% Decline 18% Fail to Recover with Worse than
N=982 Pre-Hospital Decline Baseline Function
N=402
N=799
5% Pre-Hospital and
Hospital Decline
Covinksy et al., J Am Geriatr Soc 2003 N=125

11. The Hazards of Hospitalization
THE COST OF FUNCTIONAL DECLINE (Palmer, 1995)
The loss of independent functioning during hospitalization
has been associated with:
 Prolonged lengths of hospital stay
 Increased recidivism
 A greater risk of institutionalization
 Higher mortality rates

12. The Dilemma
The way in which acute hospital services are currently
resourced, organised and delivered, often disadvantages
older adults with chronic health problems. (Thorne, 1993)

13. Developing an Elder Friendly approach

14. Acute Care for Elders (ACE) Strategy
 Redesigns or establishes new sustainable approaches
that seek to enhance and improve upon current service
models.
 Requires a shift in traditional thinking that currently
underpins the administration and culture of most
traditional care organizations.
 Is not adverse to identifying risk factors and needs and in
intervening early to maintain independence.

15. Geriatrics at Mount Sinai
 In 2010, Mount Sinai became the first acute care
academic health sciences centre in Canada to make
Geriatrics a core strategic priority.
 Our ACE Strategy is being operationalized through the
implementation of a comprehensive and integrated
strategic delivery model that utilizes an interprofessional
team-based approach to patient care.
 Our Strength relies on the partnership of our Geriatric
Medicine, Geriatric Psychiatry, Primary Care, Palliative
Medicine, and Emergency Medicine programs.

16. The Elder Friendly Hospital™ Model
These dimensions work together to minimize functional
decline, promote safety, and mitigate adverse social and
medical outcomes.
Social Behavioural Culture Physical Design
Policies and Procedures Care Systems, Processes
and Services

17. The Mount Sinai Geriatrics Continuum
Home-Based Geriatric
Primary/Specialty Care
Outpatient Geriatric
Program: House Calls
Medicine, Geriatric
Psychiatry and Palliative Temmy Latner Home-Based
Medicine Clinics Palliative Care Program
CCAC – Clinic Coordinator CCAC – Integrated Client
Care Project (ICCP) Site
Reitman Centre for
Alzheirmer’s Support and
Caregiver Training
Community and Staff
Education Programs
Geriatric Medicine,
Geriatric Psychiatry
and Palliative Medicine
Consultation Services
Orthogeriatrics Program ISAR Screening
ICU Geriatrics Program Geriatric Emergency
MAUVE Volunteer Program Management (GEM) Nurses
ACE Unit ED Geriatric Mental Health
Program
CCAC – ACE Coordinator
RED = New Programs Launched in FY 10/11

18. Evaluating ACE at Mount Sinai
LENGTH OF STAY (Age 65+)
FY 09/10 = 8.0 → 6.5 (Provincial Average = 9.8)
% RETURN HOME (Age 65+)
 FY 09/10 = 71.7% → 78.4% (Regional Average = 70.9%)
CATHETER UTILIZATION RATIO (Age 65+)
 FY 09/10 = 56% → 19%
READMISSION w/n 30 DAYS (Age 65+)
 FY 09/10 = 14.4 → 12.5%
PATIENT SATISFACTION (Age 65+)
 FY 09/10 = 95.9 → 96.8% (Regional Average = 93.5%)
STAFF EXPERIENCE w/ GERIATRICS
 FY 09/10 = 63 → 66.9 (Canadian Average = 56.2)

19. Evidence in Action

20. MSH/House Calls Partnership
 Provides ongoing comprehensive interprofesional home-
based primary/specialty care to frail, marginalized,
cognitively impaired, and house-bound elders who would
not otherwise have access to primary care.
 The first hybrid primary/specialty geriatrics model in
Canada that provides excellent training opportunities.
 GPs, Nurse Practitioner, Occupational Therapist, Social
Worker and Team Coordinator w/ Specialist Support.
 Initiation of primary care can occur within 48hrs.
 A Continuum of Care that spans Hospital and Home.

22. Evaluating the House Calls Program
 Average Patient Age at Enrollment is 87
 Average Daily Census is ~ 180
 Annual House Calls Program Budget = 480K/Year
 Average Nursing Home Cost/Client = 50K/Year
 37% of patients are referred after a hospital episode…
 Average (Age Adjusted) CCI/Mortality
= 3.7(7.9) = 1 Year 52%(85%) Mortality
 Unscheduled Readmissions at 30/90 Days vs (Usual Care)
= 12% (14%) and 22% (31%) for 65+
 67% of House Calls patients die at home.

23. Drawing Conclusions

24. Concluding Thoughts
 Whereas hospitalization offers older patients potential
benefits it also exposes them serious risks.
 Pursuing an ACE Strategy requires a shift in traditional
thinking.
 Programs only succeed through collaborations and
partnerships internally and externally.
 Implementing an ACE Strategy will allow providers to
remain leaders in the delivery of complex medical care.