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Waterloo Wellington SGS-BSO Redesign. Waterloo Wellington Geriatric Services Network May 8, 2013. Redesign- Integration. “The best way to predict the future is to invent it” Allan Kay. Change Management. System of Changes. View from the Sector Health care.

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Waterloo wellington sgs bso redesign

Waterloo Wellington SGS-BSO Redesign

Waterloo Wellington Geriatric Services Network May 8, 2013

Redesign integration
Redesign- Integration

“The best way to predict the future is to invent it”

Allan Kay

Change management
Change Management

System of Changes

View from the sector health care
View from the Sector Health care

Primary Care Community Care Acute Care LTC

View from the Person and Family Health Care

Four quadrant person and family directed care challenge frail elderly
Four Quadrant Person and Family Directed care Challenge – ‘Frail Elderly’

  • Cognitive/ Behavior

  • Function

  • Psychiatric/ mental health and


  • Multiple medical

    Providers and services driven

Thinking About Person Centered and Family Care and Transitions From a Stratified Population Perspective

Primary / Community Care

Self Management / Community

The Many Faces of Person / Family Centered Care

Tipping Point /


Tipping Point /


Community Care, Multiple Services

High Risk Need

What is an authentic partnership
What is an Authentic Partnership? Transitions

An Authentic Partnership…

  • actively incorporates and values diverse perspectives and includes all stakeholders directly in decision making

  • means working with not for others

Authentic care integration
Authentic Care---- Integration Transitions

  • Every Door is the right door

  • “integration=successful partnerships, transitions, access to service, quality and outcome based”

    • Clinical Intake and Triage to Access and Transition

Transitional components
Transitional Components Transitions

  • Information Continuity

  • Management Continuity

  • Relationship Continuity

    Haggerty et al 2003

“One person, One Plan, One Person Team”

Management operational

Management – Operational Transitions

7 Sites SGS, – 10 Service Areas, 14+ providers

Redesign integration system information management and relationship
Redesign - Integration System – Information, Management and Relationship

  • Simplified computer ‘fax’ referral method and Timebook infrastructure for SGS and CRBT clinical intake with access to partner agencies

  • SGS and CRBT service categories defined

  • Orientation complete to partner agencies

Waterloo wellington integrated clinical intake
Waterloo Wellington – Integrated Clinical Intake and Relationship

  • video http://www.easyreferral.net

  • www.caredove.com/wwsgs

Deliverables achieved
Deliverables Achieved … and Relationship

  • Service descriptions of SGS and CRBT service categories that can be used for training purposes with referral sources.

  • Develop ongoing case based learning approaches for clinical intake team and partner agencies.

  • Brochure, referral form, and online documents completed and rolled out

Deliverables achieved continued
Deliverables Achieved Continued… and Relationship

  • Single referral form and brochure.

  • Online directory of services is created building on caredove service directory platform in use in WW.

Pillars alignment with wwlhin strategic direction pillars
Pillars Alignment with WWLHIN Strategic Direction - Pillars and Relationship

  • Enhancing Access to Primary Care

  • Experience a More Coordinated and Seamless Health Care System

  • Leading a Quality Health Care System Using Evidence Based Practice

  • Accelerating System Change

Next steps
Next Steps and Relationship

System Management

Operational Management Structure √

Define, Organize, Outcome Measures

  • Sponsorship

  • Council

  • Lead

Next steps continued
Next Steps Continued… and Relationship

Inter-sectoral Interdisciplinary Service Delivery

  • Clinical Intake - in process √

  • PDSA Cycles –

    • Measures to include:

      • Integrated service: information sharing, service providers, timely, accessible,

      • Impact on Senior and their Family

      • Transitions- successes and challenges

      • Impact on continuum of care Primary Care, Community, ED, Acute, Rehab/CC, Long Term Care

      • Role and function of Health Links

Next steps continued1
Next Steps continued… and Relationship

Knowledge Care Team and Capacity Building

Existing Resources – ‘Inventory’

  • BSO Capacity Building Decision Tree

    • Capacity Building Roadmap

    • The Road Ahead

    • Behavioural Education and Training Supports Inventory (BETSI)

    • Person and Practice-Based Learning Tool (PerPLe)

  • http://akeresourcecentre.org/files/Person-Centred-Team-Based-Service-Learning/Person/Practice-Based/Learning/141112.pdf

Enablers in helping to design ww geriatric care system
‘Enablers’ in helping to design WW Geriatric Care System

  • RGPc – Access to Best Practice Information and Resource Support (2006 – present)

  • Integrated System of Care for Frail Elderly in Waterloo Wellington – Dr. George Heckman, (2011)

  • Behavioural Support Ontario (2011-2013)

  • Living Longer, Living Well, Senior Strategy – Dr. Samir Sinha (2013)


  • Dr. Ken LeClair – (slides 4-7,9)

    “Opening the Doors to Quality Care

    Perspectives and Bridges

    Person and Family Care Transitions”

    Feb. 2013