GiiC Overview

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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 to train 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, the skill sets and cognitive maps of the 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 Society Geriatrics 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 http://www.healthforceontario.ca/upload/en/whatishfo/ipc%20blueprint%20final.pdf

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.