St. Mary’s General Hospital Celebrates Successful Geriatric Medically Complex Clinic Pilot

St. Mary’s Geriatric Medically Complex Clinic staffAbout a year ago, The Ministry of Health and Long-Term Care and the Ontario Medical Association made a commitment to fund special projects that provide extra support for patients with complex medical needs. One such project that received funding, through the Medically Complex Project, is the Geriatric Medically Complex Clinic (GMCC) at St. Mary’s General Hospital in Kitchener. 

This one year demonstration project is transforming lives and the way geriatric patients with multiple, complex medical conditions access and receive care.

Lee-Ann Murray, Project Lead for the GMCC, explains why a project like this is so important. “In our Local Health Integration Network (LHIN) we have a significant proportion of the medically complex population who are geriatric patients who have conditions such as dementia, delirium, fractures and chronic pain as just a few examples. These conditions by themselves are challenging enough. However, in many cases these conditions can be aggravated by other factors such as cognitive decline, frailty and taking multiple prescription medications. When these individuals are unable to see a family doctor or other primary care provider, they resort to what we call safety net resources such as crisis teams and hospital emergency departments. This places a significant cost to the health system. We knew there was a more efficient, cost-effective way to help these patients.

“The GMCC combines resources into one team made up of health care professionals including: geriatricians, nurse practitioners, a clinical nurse specialist in geriatrics, elder focused pharmacist and social workers. This approach allowed us as part of this pilot to build and enhance upon three components of our local health system: Out-reach model of the frail elderly project (St. Mary’s), the Primary Care outreach for housebound frail elderly, and Outpatient Geriatric Services (St. Mary’s).”

The benefit of the clinic is the development of a targeted plan of care that allows patients to seamlessly transition from the emergency department (ED) or inpatient hospital care to community care. Clinic staff can also continue to provide care to patients within the community. The patient’s plan of care is created after a comprehensive assessment done by the clinical team and in collaboration with our community partners such as Community Care Access Centre (CCAC), Day Programs and Primary Care.

There are many success stories from the clinic’s first year and here is one example of how seamless, coordinated care helps people get back to their lives.

Betty is 78-years old.  She lives alone in a small apartment. Her only family is a brother she hasn’t seen in many years.  One day she began to experience foot pain.  She visited the emergency department at St. Mary’s where she was assessed by a Geriatric Emergency Management (GEM) nurse who knew about the GMCC and helped Betty connect with appropriate staff. Patients need a referral to receive care at the clinic.

The pain in her foot was caused by infection and was treated in the emergency department. It wasn’t until Betty met with the social worker in the GMCC  that a larger health story began to unfold. 

Betty’s medical challenges are many. She’s been diagnosed with pre-diabetes and a thyroid condition. She suffers from obsessive compulsive disorder and as a result has become a hoarder.  She also takes various medications that affect her moods, make her anxious and sometimes confused. In addition to her health concerns, she also struggles with some changes in her lifestyle that affect her overall health. Betty used to play piano. Now she can’t. She used to see her brother regularly. She lost that connection.   But Betty is not always comfortable talking about her problems. The team at the GMCC worked to build a strong rapport with Betty and encouraged her to talk about her challenges. 

The team at the GMCC prepared a comprehensive care plan for Betty that included treating her medical conditions, ensuring she had appropriate medications, coordinating a referral to a geriatric psychiatrist. They connected her with resources in her community to help her manage her daily life such as getting rid of the clutter in her apartment.  Her social worker is also helping Betty to connect back with her social life including re-connecting with her brother. She is even looking forward to playing the piano again. 

“I visited her the other day because it is important to see the patient in the home setting. You get a better sense of them and their life.” says Dr. Nicole Didyk, geriatrician and physician lead for the clinic. “You get the real picture of how they are coping. Her life had become so small and so it’s very gratifying to see her life change for the better.”

If you know an elderly person in the community who may be dealing with medical challenges, encourage them to see their family doctor or, in an emergency situation, visit a walk-in clinic or emergency department for a referral to the GMCC. 

*Photo of Dr. Didyk and Lee-Ann Murray at the Geriatric Medically Complex Clinic