Eldercare Access Strategy in Emergency Rooms (easier+)

Eldercare Access Strategy in Emergency Rooms (easier+) is an innovative, multi-component strategy to improve health care outcomes of the high-risk frail elderly in the emergency room (ER). It represents a collaborative partnership between acute care hospitals, specialist services for the elderly and community based programs.

Building on an evidence-based strategy, easier+ aims to target high risk elderly and create improved integrated care responses through linkages and liaisons between the ER, Primary Care, the Community Care Access Centre (CCAC), Community Support Services (CSS) and Specialist Services for the Elderly.

• easier+ Objectives
• easier+ Process

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easier+ Objectives

The objectives of this collaborative effort between the SE LHIN, Providence Care, CCAC, CSS and the Hospitals are:

1. To improve care and outcomes of elderly individuals in the ER.
2. To reduce unplanned repeat ER visits by elderly individuals.
3. To improve linkages between the ER and community / outpatient services.
4. To improve capacity within the ER for geriatric assessment and management.
5. To improve patient, family, and staff satisfaction in providing care to the frail elderly in the ER.

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easier+ Process

1. The Triage Risk Screening Tool (TRST) is a six-item validated tool for use in ER's. TRST is used by the ER Nurse to screen for the risk of frailty in those individuals 75 years and more. When the TRST score is two plus a referral is sent to the CCAC Geriatric Assessor (GA).
2. The CCAC GA completes a comprehensive geriatric assessment with preliminary recommendations to the ER Physician and team. When disposition of the individual is to discharge home (which is decided by the ER physician), the GA develops and coordinates a service plan which is intimately linked to community case management processes within CCAC and CSS. The GA coordinates the delivery of an individualized care plan for those who can be discharged which may include high-intensity community-based services and referrals to Specialized Services for the Elderly (Geriatric Medicine or Psychiatry).
3. Continuity of care and communication to the Family Physician is made by the GA within 24 hours or next business day. The practice ensures primary care linkages and, if needed, timely follow-up.

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