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The Ottawa Hospital (TOH) is the largest teaching hospital in the Champlain LHIN and is made up of the Civic, General and Riverside campuses. There are two Emergency Department (ED)s (General and Civic) which have an average of 170,000 patient visits per year.

The complexity of providing care for high-risk seniors in the unique environment of the ED is increasingly more challenging. The demands and constant pressures to manage wait times in the ED can lead to incomplete and inaccurate assessments of high-risk seniors resulting in deterioration and return to hospital.

The Ottawa Hospital Geriatric Emergency Management Plus program (GEM Plus) has been in place since 2008 and has serviced over 10,000 patients. TOH has the largest GEM Plus program in the Champlain LHIN. GEM nurses at TOH support the two EDs seven days a week. Unique to TOH, the role of the Advanced Practice Nurse (APN) for the GEM Plus program develops, implements & evaluates the program to improve clinical outcomes and provides a consultation to the other GEM nurses in the Champlain LHIN.

GEM Plus is an evidence-informed program that targets high risk seniors who visit the ED and will be discharged home. Criteria for GEM referral include an administrative screen or direct referral from staff. The administrative screen is initiated for patients who present to the ED, are ≥ 75 years of age, resident in Champlain LHIN, not currently in Long Term Care, have had previous ED visit within the last 6 months and are categorized as Canadian Triage and Acuity Scale (CTAS) 3, 4 or 5. Additionally, staff can refer patients who are ≥ 65 years of age, residents in Champlain LHIN, not currently in Long Term Care, and are categorized as Canadian Triage and Acuity Scale (CTAS) 2, 3, 4 or 5. Regardless of the referral method, patient referral reason must address a geriatric concern (cognition, mobility and falls, pain, nutrition, functional assessment, continence, mood, behavior and safety in the home).

GEM nurses are specially trained nurses’ who work in collaboration with ED staff; they perform a structured, abbreviated geriatric assessment focused on geriatric giants (cognition, mobility and falls, pain, nutrition, functional assessment (ADL’s & IADL’s), continence, mood and behavior). The GEM nurse will provide patient education and recommendations to the patient’s primary healthcare provider and coordinates referrals to Specialized Geriatric Services (SGS) and Community Support Services (CSS). Access to SGS and CSS are critical to patients successfully being safely discharged home. Therefore, prompt and timely access to these service providers is essential to optimizing the patient health outcomes and quality of life.

The PLUS component of the GEM program is a critical factor that brings multiple organizations and service sectors together in a coordinated effort to support GEM clients. Urgent capacity response and accountability agreements with CSS and SGS provide an advantage for the GEM nurses to access services on a priority basis, thus preventing unnecessary hospital admissions and unnecessary return ED visits. The Champlain LHIN GEM PLUS program ensures that high risk seniors are provided access to the right service, at the right time, in the right place and delivered by the right person.

PROGRAM GOALS

  • To develop an action plan for each high-risk senior identified to be at risk for functional and /or medical decline and at risk of hospitalization, as a result of the identification and assessment in the ED
  • To provide individualized and a coordinated approach in order to optimize and support the capacity of seniors to remain in their own homes • To use an evidenced-informed approach for screening of high-risk seniors (ISAR) • To reduce rate of hospital admissions, as well as repeat ED visits
  • To improve the quality of the ED discharge process and experience for high risk seniors
  • To initiate earlier referral to Community Support Services and Specialized Geriatric Services
  • To build geriatric capacity within the ED team Funded as part of the Ontario Aging at Home Strategy, the GEM PLUS program was rolled out in 2008 with TOH as the lead. This leading best practice has spread over the last decade. Administered by the Regional Geriatric Program of Eastern Ontario (RGPEO), the GEM PLUS program is an integrated regional program that coordinates and incorporates evidenced-informed GEM initiatives in 9 separate hospital ED’s with over 20 partner organizations.

The impact of GEM PLUS program includes successful safe and sustainable hospital ED discharges, prevention of hospitalization, access to SGS and CSS resulting in significant cost savings to the health care system. Early identification of high risk seniors, coupled with a patient-centered coordinated approach leads to improved patient outcomes and quality of life.

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