Wellness, Independence & Quality of Life in Aging

What We Do

North Simcoe Muskoka Specialized Geriatric Services Vision and Mission



The NSM SGS Program has five key roles related to the care frail seniors and their caregivers in the North Simcoe Muskoka region:

Leadership:

We provide system leadership and help with planning and priority setting.  We are involved with the design and redesign of services and programs for frail seniors in the region and play a role in monitoring the impact and effectiveness of services and system changes.  We promote system coordination, encourage communication among partners and build relationships locally and provincially.  The NSM SGS Program is a key resource to the NSM LHIN on issues related to frail seniors and their caregivers.  We are a member of the Regional Geriatric Programs of Ontario, which ensures our local work is connected to organizations and providers doing similar work across the province.
 

Clinical Service:

Clinical service is the heart of the NSM SGS Program.  We are involved in direct care, we help build standards of practice across the region and we provide leadership in clinical programming.  The scope and structure of our clinical services continue to evolve over time.  Two key planning resources provide information related to our clinical service scope and direction: In 2016, a working group of 33 individuals came together to develop a plan for the clinical services within the SGS Program.  With frail seniors and their caregivers in mind, the final design will lead to:
  • Improved patient outcomes
  • Enhanced system capacity
  • A more affordable, sustainable and accountable system
The clinical design outlines key services and resources for frail seniors and their caregivers.  It includes plans for a central intake service with the goal to create one number to call for those needing care from the SGS team. 
Within the clinical design, recommendations include: building five SGS teams across the region; building a toolkit of standardized regional resources; increasing partnerships between geriatric medicine and geriatric psychiatry teams; and improving communication among health care providers so everyone is aware of the senior’s needs and plan of care.
 
The clinical design plan will guide the implementation of our clinical services in the coming years.  With this roadmap in hand we have a clear course ahead that will continue to improve the health and well-being of NSM seniors and their caregivers.
 

Education & Mentorship:

The NSM SGS Program plays an important role in providing education and mentorship to frail seniors and their caregivers, health care professionals, community providers and students.  With the 2017-2019 Education Strategy now in place our role with education and mentorship will continue to grow as we set plans in motion and build relationships.  Early work has included building resources like the Antipsychotic Toolkit and providing leadership and oversight to Behaviour Supports Ontario education funding opportunities in early 2017.  We are developing Communities of Practice and leading the development of key clinical resources and tools like those established through the Behaviour Success Agent project. 
 
As an example, in 2016-2017 within the SGS Program, 45 education events took place.  These events focused on SGS Program updates as well as clinical topics like delirium, dementia, polypharmacy, anxiety and pain.  More than 1012 health care professionals participated in these sessions.  Between December 2016 - March 2017 additional education was rolled out specific to responsive behaviours with events focused on:  Recovery Mental Health; PIECES; Intimacy and Sexuality in Dementia; and Compassion Fatigue.  This represented 26 education days and 13,910 hours of education.  As a highlight, 19 providers in the region became trainers in compassion fatigue and all Behaviour Support System staff received certification in Mental Health Recovery!
 

Research & Ethics:

With a key leadership role and role in clinical service, it is essential that we be aware of current best practices and research.  This knowledge will help us build capacity, inform decision-making, design better programs and services and improve outcomes.  Conducting research is part of practice on a small scale at this time as we think about evaluating our programs and initiatives.
 

Advocacy:

On a daily basis we advocate for change.  This can be with frail seniors and their caregivers, with health care providers, with our partner organizations in the region and with system planners and policy makers.  Our advocacy can could be as straightforward as advocating for a change in medication or as complex as developing proposals and business cases for Program funding.  We are working hard to build our partnerships and relationships, recognizing the value these play in helping our frail seniors and their caregivers.