Conduct asset mapping to understand what services are available for the population and wait times

• Provincial Geriatrics Leadership Ontario (PGLO) Provincial Asset Inventory
• 211 Ontario
• Rehabilitative Care in Ontario

Include patients and care partners as part of the care team

• Develop care plans and goals of care collaboratively with patients and care partners
• Implement an approach to measuring patient and care partner experiences and outcomes (e.g., using Patient Reported Experience Measures, PGLO Care Partner Experience Survey) 

Strengthen system capabilities and cross-sector partnerships to support care in the community and improve transitions in care  

Strategies can be deployed upstream (to prevent hospitalizations/ALC prevention) and/or downstream (to enable discharge/as part of ALC discharge management).  

• Early Identification and Risk Stratification
  • Provincial Geriatric Leadership Ontario (PGLO) and Ontario Collaborative for Aging Well provide recommended tools for both primary care and community care settings
  • Implement screening processes to identify patients at risk of loss of independence or in need of additional supports to remain safely in the community (including risks related to the social determinants of health such as housing instability, social isolation, caregiver strain, access barriers)
    • Frailty screening (Seniors Care Network)
  • Leverage OHT supported attachment initiatives to proactively identify individuals at risk of ALC (e.g. frailty, complex clinical and social needs) and connect them early to coordinate team-based care and services
• Proactive Comprehensive Assessment and Care Planning
  • Complete a comprehensive assessment addressing physical, cognitive, functional and psychosocial domains
    • Learn how through the Provincial Common Orientation to the Care of Older Adults
    • See the Competency Framework for Interprofessional Comprehensive Geriatric Assessment
  • Develop individualized care plans anchored in maintaining independence, achieving functional goals, achieving patient centered outcomes and reducing impacts of social drivers of decline
• Coordinated Interprofessional and Cross-Sector Care
  • Promote and support implementation of community-based integrated care models (interprofessional team-based care) 
  • Use the PGLO integrated care design elements and implementation rubric to help structure proactive coordinated supports (including primary care, community care providers, allied health and social supports)
  • Facilitate communication across sectors for coordinated interprofessional discharge models (hospital, home care, primary care, community providers, community paramedicine) and mobilize community and social supports early
• Promote evidence based preventative rehabilitation pathways 
  • Implement early intervention focused pathways:
  • ALC Leading Practices Guide
  • RCA/PGLO Framework for Rehabilitative Care for Older Adults living at risk of Frailty
  • RCA Post-Falls Pathway (ED and Primary Care)
  • RCA Direct Access Priority Access
• System Navigation and Linkages
  • Identify and connect with specialized geriatric services programs
  • Engage with Regional Geriatric Programs and Regional Specialized Geriatric Services
  • Strengthen linkages to ensure rapid access before a crisis occurs
  • Rapid mobilization of community supports post discharge

Across sectors, support patients with behaviours and those at risk of deconditioning 

• Embed evidence-based practices that prevent avoidable harm
  • Behavioural Supports Ontario
  • Senior Friendly Care implementation resources for delirium prevention
  • Senior Friendly Care implementation resources for mobilization
  • Delirium Aware Safe Health Care Initiative and Community of Practice

Transition patients requiring palliative care support back to the community

• Use evidence-based tools to identify individuals who would benefit from palliative care that supports timely identification, needs assessment, and connection to palliative care supports when indicated. 
  • Gold Standard Framework (GSF) Proactive Identification Guidance (PIG): The PIG is a practical guide for health care professionals enabling earlier recognition of decline for patients considered to be in their final year/s of life. Download the free GSF PIG and see page 2 that outlines disease agnostic clinical indicators.   
• Connect patients with identified palliative care needs, back to their community, should include timely assessment of needs, goals-of-care planning, all aimed to improve the quality of life and reducing crises and avoidable acute-care use as needs become more complex.
  • Step 1: Continue developing relationships with OH regional palliative care teams and regional palliative care clinical leads.
  • Step 2: Use and embed clinical indicators to identify those with palliative care needs.  
    • Palliative Care Toolkit: Best-practice tools that support health care professionals with palliative care delivery, organized into three steps: Identification, Assessment, and Plan and Manage.  
  • Step 3: Once identified, complete a holistic assessment of needs using validated tools and connect with an interdisciplinary palliative care team to support. Based on needs assessment outcomes, consider what, if any, referrals are needed to support the patient’s needs.  
    • Consider referral to Ontario Health atHome for care coordination and/or referral to palliative care specialist teams if shared care support is required.  
    • Model of Care: Adults Receiving Palliative Care in Community Settings: Refer to Recommendation #2 Intake, Comprehensive and Holistic Assessment, and Care Coordination and Recommendation #3 Interdisciplinary Team.  
    • Refer to Domains of Issues Associated with Illness and Bereavement to support completing comprehensive and holistic assessments (see page 5 of the Canadian Hospice Palliative Care Association Model to Guide Hospice Palliative Care).  
    • For additional resources to support comprehensive and holistic assessments, please visit the Provincial Palliative Care Programs Palliative Care Toolkit.

• Reach out to the ProvincialPalliativeCareProgram@OntarioHealth.ca if you require information on supports and partners in your local area