Diagnostic Evaluation: specialized geriatric assessment of high risk seniors by qualified • geriatric teams using a combination of standardized screening, diagnostic assessment, and clinical expertise to inform appropriate plan of care Investigations: laboratory testing, diagnostic imaging, etc. • Treatment: delivery of evidence-informed treatments that are aligned with • goals, priorities and prognosis; treatment plans take into account the interacting effects of multiple co-existing chronic diseases (crossing traditional specialty boundaries to provide integrated chronic disease management) Enhanced System Navigation: efficient navigation and care coordination of assessed • seniors to/with the most-appropriate provider(s), setting(s), and type(s) of intervention(s) Education, Counselling, & Caregiver Support: improving capacity of patients and • caregivers to self-manage disease, and to prevent crises that lead to avoidable unnecessary use of acute care services Prevention of Adverse Outcomes: optimizing the environment and supports (e.g. • environmental modification, devices, human resources, etc.) to prevent traumatic and adverse events (e.g. motor vehicle crashes, medication errors, falls, or burns that lead to prolonged hospitalizations), and to reduce the burden of other chronic diseases (e.g. CHF, Diabetes) that also lead to avoidable hospitalization when poorly managed Advance Care Planning: patient-centered goals of care to prevent unnecessary • investigations and treatment that carry unacceptable cost and risk to patients while offering little to no benefit to the patients Integrated Chronic Disease Management of Multimorbidity: supports Mind, Mobility, • and Medications in the Multimorbidity (M4) experience of older people (crossing the traditional disease-specific specialty boundaries e.g. managing DM, CHF, COPD in the – face of dementia, mental health issues, or social determinants of health) Collaborative/Shared Care: integration and linkages with primary and community care • providers and caregivers to support care plans; to ensure gains made are retained and
• Diagnostic Evaluation: specialized geriatric assessment of high risk seniors by qualified geriatric teams using a combination of standardized screening, diagnostic assessment, and clinical expertise to inform appropriate plan of care • Investigations: laboratory testing, diagnostic imaging, etc. • Treatment: delivery of evidence-informed treatments that are aligned with goals, priorities and prognosis; treatment plans take into account the interacting effects of multiple co-existing chronic diseases (crossing traditional specialty boundaries to provide integrated chronic disease management) • Enhanced System Navigation: efficient navigation and care coordination of assessed seniors to/with the most-appropriate provider(s), setting(s), and type(s) of intervention(s) • Education, Counselling, & Caregiver Support: improving capacity of patients and caregivers to self-manage disease, and to prevent crises that lead to avoidable unnecessary use of acute care services • Prevention of Adverse Outcomes: optimizing the environment and supports (e.g. environmental modification, devices, human resources, etc.) to prevent traumatic and adverse events (e.g. motor vehicle crashes, medication errors, falls, or burns that lead to prolonged hospitalizations), and to reduce the burden of other chronic diseases (e.g. CHF, Diabetes) that also lead to avoidable hospitalization when poorly managed • Advance Care Planning: patient-centered goals of care to prevent unnecessary investigations and treatment that carry unacceptable cost and risk to patients while offering little to no benefit to the patients • Integrated Chronic Disease Management of Multimorbidity: supports Mind, Mobility, and Medications in the Multimorbidity (M4) experience of older people (crossing the traditional disease-specific specialty boundaries – e.g. managing DM, CHF, COPD in the face of dementia, mental health issues, or social determinants of health) • Collaborative/Shared Care: integration and linkages with primary and community care providers and caregivers to support care plans; to ensure gains made are retained and
Specialized-Geriatric-Services-May-25-2015.docx