*Description of a typical patient seen in the ECHS clinic.
1 Toronto Central LHIN, Integrated Health Services Plan.
**Article as appeared in Hospital News

*Mrs. S. is an 85-year-old woman who lives on her own. Although for most of her life she had been healthy and active, she is now facing an increasing number of health challenges. Her physical health and cognitive abilities are declining and she is finding it more and more difficult to manage her basic activities of daily living. Mrs. S. feels frustrated that her independence is slipping away and calls on her daughter more often for assistance.

Her daughter is becoming increasingly worried for her mother's safety since her mother's condition is worsening and she has already had a fall. She wants to speak to health care professionals who can help her manage her mother's complex care.

The number of seniors is growing steadily in the Toronto Central LHIN. It is expected that by 2016, seniors will make up 14.5% of the population, with the greatest increase in those seniors over the age of 85 years. Current estimates tell us that the fastest growing age group - people 85 years of age and older - will increase by 48.5% from 2005 to 2015. Although many seniors enjoy good health well into the oldest ages, the fact is, seniors are at risk of getting sicker with eventual loss of independence. They may become frail, with greater risk of falling, and are more likely to need community supports. With complex medical needs, frail seniors can benefit greatly from coordinated services that promote abilities and independence.

St. Joseph's Health Centre (SJHC), Toronto is committed to deliver more comprehensive and innovative programs to meet the needs of the increasing number of seniors within the population we serve. The BMO Ambulatory Care Centre includes several specialized care areas to address some of these complex needs. One such service is the Elderly Community Health Services (ECHS) clinic at St. Joseph's. The ECHS has been operating for 12 years and has evolved into an interprofessional team that is focused on assisting seniors whose independence in the community is at risk. Frail elderly individuals with complex medical conditions like Mrs. S, receive expert consultation, assessment and treatment through this outpatient clinic.

The clinic offers an interprofessional approach to caring for patients, through the services of geriatricians, a geriatric psychiatrist, nurse clinician, social worker, physiotherapist, occupational therapist, and speech language pathologist. "At the clinic, patients and their families receive services from a variety of health care providers who may not always be readily available in the community," says Catherine Cotton, Administrative Program Director, for Medicine, Ambulatory and Seniors' Health at SJHC. "It is a great benefit to have all of the care providers in one location for patients and families."

"The goals of the clinic are to provide comprehensive, coordinated service to maximize the patient's independence in the community and avoid unnecessary hospital visits or re-admission to hospital," says Carla Curto-Correia, Patient Care Manager, Ambulatory Care Centre at SJHC. The clinic staff and physicians also work to advance the success of the primary care model, to assist and co-manage patient illness and to provide patients and families with education and the resources they need to be successful in managing their health issues. Through its dedication to keeping seniors independent, the clinic is also continuing to look at ways to improve access to services through ongoing liaison with community resources.

Typically, patients are referred to the clinic from the Emergency Department, community referrals (i.e. the patient's family doctor), or within the Health Centre (i.e. they may have been admitted to another department in the Health Centre and referred to ECHS).

"An individualized care plan is determined based on the patient's needs and goals. The assessment may include a number of interviews with the patient and their caregiver to gain a better understanding of the issues they are facing," says Curto-Correia.

Patients at the clinic could have a number of aging-related concerns including:

• Loss and/or decrease in mobility and physical functioning
• Reduction in ability to perform the basic "everyday" activities (i.e. getting out of bed, self-care, shopping, social components, etc.), leading to a loss of independence
• Decline in cognitive abilities and the psychosocial issues associated with the decline in cognitive abilities
• Multiple and challenging medical conditions (i.e. heart disease, osteoporosis, arthritis and other chronic diseases)
• Managing many medications (polypharmacy)

One of the key areas of focus for the staff and physicians within the ECHS is in helping seniors manage their multiple medications. "As we age, physically there is greater risk of developing chronic conditions such as heart disease, osteoporosis, and arthritis - conditions that will impact a person's ability to remain independent. As these conditions manifest, patients need a number of different medications to manage so the issue of polypharmacy arises. The clinic helps to 're-jig' some of the medications to ensure that medications are taken safely and side effects are minimal," said Cotton.

As with many of the clinics and services offered at St. Joseph's, the ECHS is moving towards a more defined chronic disease management model. "A chronic disease management framework is a priority for us as many of the medical conditions we see are not stagnant. There will be changes to the patient's condition and we can try to anticipate and put plans in place to assist with that and help prevent or decrease loss of independence for our patients," adds Curto-Correia.

The ECHS clinic is just one of many services offered by St. Joseph's to help seniors at risk. To meet needs of seniors in the community, St. Joseph's also has a large and active geriatric service with five full-time geriatricians and a geriatric psychiatrist. In addition to assisting patients with many aging-related issues, our geriatric services also allow us to provide care to seniors with mental health and addictions challenges.

"Our focus on senior care is a priority in our strategy to Put Patients First and Enhance the Health of the Communities we Serve, with seniors being one of the largest populations for whom we provide care," says Cotton. Through the ECHS clinic, St. Joseph's is making it easier for seniors and their caregivers, like Mrs. S. and her daughter, to access coordinated and seamless services, helping seniors to continue living independently in their home for as long as possible.

For more information on the ECHS clinic, please contact 416-530-6770.

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Page last updated: April 30, 2010