Designing for integrated older persons’ care across systems, networks, and people

IntroductionIn the province of Ontario, Canada, integrated care is particularly relevant, and to a significant degree lacking, in older persons’ care. This oral presentation describes the creation of Provincial Geriatrics Leadership Ontario, a new province-wide clinical leadership structure focused on connecting the perspectives and insights of clinical experts and older adults across the health and social services system to advance integrated, person-centred care for older adults living with complex health needs in Ontario and their caregivers.Policy Context and Objective Ontario is embarking on an ambitious transformational agenda for its health sector. Among emerging Ontario Health Teams - new entities that unite health and social service delivery across sectors and by geography - older adults living with complex health conditions have frequently been identified as a population of focus. Until now, there has been no coordinated province-wide infrastructure focused solely on this population. Siloed approaches have weakened the multidisciplinary contributions of clinical experts and impeded their ability to co-design best approaches to integrated care with older persons, caregivers and other partners.  As a result, evidence-based geriatric models can be overlooked by leaders engaged in this transformational work.The objective of PGLO is to overcome these silos and drive clinical excellence, build system capacity for effective and integrated older persons’ care, and influence seniors’ health policy in Ontario and beyond. The objectives of this session are to share the journey, successes and learnings to-date as PGLO works from the standpoint of older persons to integrate clinical perspectives and define integrated care for older adults living with complex and chronic health conditions in a changing provincial landscape.Targeted Population This session will appeal to older adults, caregivers, health leaders and clinicians who are grappling with the optimal design of integrated health and social services to enable excellent health and social care driven by what matters most to older persons.   Highlights Highlights of this session include an overview of a nimble ‘backbone’ entity that drives a collaborative engagement structure, enabling participation in planning and health service design. We illustrate impact through grass-root pandemic responses and other initiatives. Also featured is our seminal report “Design Elements of Integrated Care for Older Adults Living with Complex and Chronic Health Needs” and current work identifying indicators and a framework to enable measurement and evaluation of the efforts underway to create a system of integrated care for older adults in Ontario.Comments on Transfer-abilityThe content of this session is transferable to any jurisdiction celebrating a population that is living to advanced age and looking to provide integrated, health and social service care to support older persons to live well.Conclusions Key lessons learned include: enablers for effective and inclusive network leadership; strategies to support ongoing connection; mechanisms for identifying and engaging leaders of all stripes; and adaptations needed to support integration required in older persons’ care. We conclude that these learnings must shape the design of health care systems of the future.