October 23, 2017

Edmonton Pride Seniors Group Notes at SAGE – Oct 23, 2017

Attendees: Tammy Horne, Larry Jewell, Blair MacKinnon, Thais McKee, Michael Phair, Jan Schmitz, Robert Smith, Eric Story.

Regrets: Dave Gilbert, Sydney Goss (on leave), Stephen Quinn, Alvin Schrader

  1. Welcome. Eric will bring Laurie Winder (ED of Ashburn) to the November meeting. Jan to send Laurie a copy of the October notes.
  1. Intergenerational Conversations – Ann Goldblatt’s report should be ready soon. Todd was out of country and should have his project finalized by the end of November. Ingrid is no longer head of Age Friendly Edmonton. Diana O’Donoghue is.

Thaya advised on next steps – both seniors and youth want to be involved to engage freely in a safe space.  Lauren can continue to work with us.  Need for a new location. Edmonton General, Pride Centre, Ashburn are possible options.

Michael advised there is a possibility of a small grant to hire a coordinator and have some food for the next conversation. Possible topics –  how to have seniors advocate for themselves.

  1. Learning module – Andre Grace has reviewed and Eric has incorporated the suggestions. Meeting with Owen next Wednesday to discuss 3 to 4 minute videos. Don’t need new money for this.
  1. Housing Feasibility Study – Robert advised we have received the money and a draft template for the contractor from SAGE. The final report is due in June. Contractor wishes to have a discussion with our committee.  Eric, Blair, Robert, Jan, Karen McDonald, and Diana O’Donoghue will form the committee.  A meeting will be scheduled next week.
  1. Provincial Conference Report – Blair attended the conference in Red Deer. Key topics geared to providers. Different models of primary health.  Eg Provost – AHS works with a TEAM assessing seniors for frailty, cognitive ability, medications, etc. There has been a noticeable reduction in ambulance trips and ER visits. Eg. Oliver PCM and Covenant Health have a HUB which identifies frail based on mobility, strength and energy.  There is a medication review and it emphasizes self management.  Successful comments like “my father is still at home and not in a nursing home. Pegasis from Age Friendly Edmonton identifies isolated seniors. Attached are Blair’s summary of Seniors Conference in more detail and the Resources and Supports for Caregivers in Alberta.
  1. Seniors Advocate Meeting – Jan, Robert and Alvin had a successful meeting on Sep 28 with Sheree Kwongsee. Knowledgeable, supportive, asked the right questions, sense of taking this seriously, concerns will be addressed if you go to her. She requested examples of government practice or policy that affects the GLBTQ2s community.


– Partner in long term care is not recognized if not officially married. Staff are not willing to do much with the partner.

– Use of terms on forms is getting better, now there is a same sex choice but this doesn’t happen on the ground level

– Policy is different than practice. Regular staff and admin have made changes.  How do they insure the other people in the center can provide improved attitudes? Nurses and doctors practices are different that recreation coordinators, music programmers, physios who often provide information on how a patient is doing.  Casuals and LPN’s don’t necessarily know the patients as well

-Nurses are so busy only spend the minimum amount of time.

-There are difficulties putting confidential stuff in records – eg Bill is Robert’s partner but Roberts family doesn’t know

  1. Alberta Health, Continuing Care – have asked for a volunteer. Michael will volunteer for a couple of months and then Larry will take over. They have a website.  Marnie Panis is a staff member there. Have guidelines working with trans. No GLBT voice there which is a bit of a concern.  Michael will meet with Michele Taylor to discuss tomorrow.
  1. Website – Michael has met with Karen at SAGE. It can be hosted here. Simple straight format with links to other more elaborate website. There is some money, Michael and Eric will handle. Some one else will need to maintain it.
  1. Updates

– GEF – Nothing further to report.  Michael and Eric will follow up

– Session in Camrose – Robert and Michal had a good presentation.  Difficult getting dinner guests. Lots of closetness going on.

  1. Other

Alvins list – please review the public speaking engagements to date and send your additions to Alvin.

Prepare for a 2 hour meeting on Nov 27.  Anne Goldblat will present.

Official Invitation of the Opening of Michael Phair Junior High School – Monday January 22, 2018. See attached.

Next Meeting – NEXT MEETINGS

Monday November 27 at 4:30 at SAGE- Robert sends his regrets.

Monday January 8, 2018

Notes prepared by Jan Schmitz


Official Opening Michael Phair Junior High School

17 10 23 Oct 23 2017 Resources-Caregivers-Inventories-of-Resources-and-Supports-for-Caregivers-in-AB-Doc-20160721-1

Summary of Seniors Conference- Red Deer, Oct. 10, 2017

  1. Drivers of Health Care Costs:
  • If we spend more on primary and community care will we have lower costs, better outcomes and higher quality
  • Top diseases by costs: Hypertension 2. Diabetes 3. Depression 4. Asthma 5. Dyslipidemia 6. Coronary artery disease
  • Health care costs are driven by the common chronic diseases that are managed by primary care every day
  • health systems that invest in primary care have lower costs and better outcomes
  • Keeping people out of hospital, is the single most important way of reducing health care costs
  • Frail elderly and those with chonic diseases account for largest proportion of costs
  • Main reasons for hospitalization are:
    • \Hypertension 72.5%  Acute Musculoskeletal Diagnosis 39.3%  Acute Respiratory Diseases/COPD 33.7% / 22.6%  Osteoarthritis 31.8%  Diabetes 28.5%  Congestive Heart Failure 20.8%  Neuromuscular/Neurological Diagnoses 20.7%  Depressive and/or Other Psychoses

Who are the top 5%?

  • 78% of Albertans in the “top 5%” were not there the year before – the top 5 % does not represent “frequent flyers”• Only 11% of “top 5%” have been there 3 or more year
  • 15% of the “top 5%” costs are related to end-of-life
  • In a 7 year period, 20% of Albertans will be in the “top 5%”
  • >50% of Albertans will be in the “top 5%” sometime in their lives
  • Commonest reason for hospital admission for heart failure
    • urinary incontinence
    • falls
    • care-giver not able to cope

Therefore, the “5/65” is somewhat of a myth:  ( ie that 65% of costs by 5% of population

  • By the time the “5/65” are identified, it’s too late, they have moved on to be mostly become low cost patients
  • We need to be able to predict who the “5/65” will be
  • Resources need to spent on complex high needs patients
  • What can be done to keep them out of hospital?
    • “Medically, this person didn’t need to be in hospital but…
    • – I couldn’t send them home…
    • – I knew they couldn’t manage at home…
    • – I knew that if I sent them home they would be right back
  • Issues identified to facilitate aging in place (source: Aging in Place Study- Edmonton 2007)
    • Mobility and Access to Transportation
    • Daily Living
    • Health and Well-being
    • Home Maintenance and Housing
    • Other (finances, cultural sensitivity, abuse)
    • Social isolation
  • Factors affecting mobility and access to transportation
    • Insufficient length of pedestrian crossing lights
    • Bus drivers sometimes insensitive to seniors’ needs, will fail to wait for a senior trying to catch a bus or will move away from a stop before the senior is seated
    • Not being able to walk to a bus stop (for reasons of stamina or other limitations)
    • Not being able to get on or off buses unassisted
    • Lack of familiarity with or understanding of the transit system or bus routes
    • Inability to endure long bus rides
    • Not being able to afford taxis, but not being eligible for specialized services such as DATS or assisted drivers


  •  One of the most effective ways of reducing health care costs and utilization is to have, and access, a family doctor/primary care provider
  •  Most health system costs are generated by hospitalization; more than 14 hospital days per year puts a person into the top 5% of costs
  •  Keeping people out of hospital is the single most important intervention to reduce health care costs
  •  It is mostly the frail or sick elderly who drive hospitalizations
  •  We need to ask ourselves “what could have been done to have avoided this hospitalization?” and act on it
  •  Often it is not an individual disease that leads to hospitalization but its contribution to frailty; investing in social supports can be an effective strategy
  1. Frailty in Primary Care
  • To discuss the emerging concept of frailty and its impact; ❖
  • To optimize identification of frailty and motivate the assessment and management of fraility and its components;
  • To demonstrate an innovative model in primary care

No one agreed upon definition but includes:

  • Unintentional weight loss (≥5% in the last year)
  • ✓Self-reported exhaustion
  • ✓Weakness (based on grip strength)
  • ✓Slowness (based on walking 3m)
  • ✓Low physical activity (based on kcal expended per week

Why it matters

  • Prevalence of frailty increases with age and is higher in women;
    • 10% of people 65+ and 25% – 50% of people 85+ are living with frailty;
    • Not an inevitable part of ageing;
    • Dynamic, progresses over 5 to 10 years;
    • Episodic deterioration with minor stress;
    • Can be reversed or attenuated by interventions;
  • 45 percent of annual Canadian healthcare cost ($220 billion a year) is spent in people over 65, while they only represent 15% of population; • Frail seniors are the major consumers in all settings; • 25 percent of those over age 65, and 50 percent of those over 85, over one million Canadians, are medically frail; • In 10 years, over two million Canadians may be living with frailty.

Many tools to measure it-no one agreed upon yet

New Model of Care

The frail elderly“An older person living with frailty”



Presentation late and in crisisEarly identification, preventative and proactive care; supported by self management and personalized coordinated care plan



Hospital basedCommunity based
  1. New Model of Care Collabaoration between Oliver PCN and Covenant Network of Excellence In Seniors Health and Wellenss

Seniors’ Community Hub: Toolkit for Primary Care to Support Seniors Living with Frailty

  • Frailty identification
  • Frailty measurement and assessment tools
  • Frailty Management:
  • Medication review
  • Self-management
  • SCH care and support planning
  • Helpful resources for care and support planning
  • SCH team roles and responsibilities

Very positive comments from families and patients participating in HUB

  1. Supporting Family Caregivers of Seniors Living with Chronic Conditions and Frailty

Covenant Health

  • Champion a future where seniors live to the fullness of their capacity as active and connected members of their communities
  • Network of Excellence in Seniors’ Health and Wellness: established in Covenant Health November 2013.
  • Mandate to engage with seniors and those who support them to promote innovation to foster wellness and transform care.
  • Promote: seniors’ independence; quality of life; change through collaboration; consideration of long-term sustainability; new models of care.

Objective of presentation was

  • The role and contributions of family caregivers of older adults.
  • The challenges and consequences of caregiving.
  • The strategies, resources and supports to foster caregiver resilience.

Numbers of Caregivers

  • According to Stats Canada, 28% of population are caregivers:
  • estimated (36,146,780 * 0.28 =) 10.1 million caregivers in Canada (2016) – estimated (4,252,879 * 0.28 =) 1.2 million caregivers in Alberta (2016)

Discussed role and impacts on caregivers-isolation, burn out, loneliness, exhaustion etc.

Provide Supports and resources to caregivers-sent inventory to Jan

Inventory of Caregiver Supports

  • In 2014 AHS’ Continuing Care Resolution Team (CCRT) talked to over 1000 Albertans and identified 17 key opportunities for improvement in Alberta’s continuing care system • In response to one of the opportunities, the Network led the development of a document containing inventories of resources and supports for Alberta’s caregivers. – partnered with Alberta Health, Caregivers Alberta and the Alzheimer’s Societies of Calgary and Alberta
  1. Innovative Model of Primary Care for Geriatric Patients- Provost PCN

Our team consists of:  Physicians, Homecare(PT/OT/Nursing/Speech/Social work), Pharmacy, Rehab, Mental Health, Acute Care, Continuing Care, Dietary, Geriatric Specialist and Respiratory on a continuing as needed basis

  • Assess patients by team
  • Includes home visit with patient and family member
  • Coordinated access to health records
  • After assessment, develop a plan to address patient needs

Results: By implementing our PCN team approach Provost has been successful in reducing extended Long Term Care admissions by assisting our geriatric population to age in place. With a comprehensive and cohesive frame work our team works to ensure the best possible care is in place for our elderly population

Patient Population: 1174 patients discussed

Results: \

  • Since 2006 ambulance trips to the lodge have been reduced
  •  ER visits have been greatly reduced with the physicians being available to do home visits
  1. Another Model of Care: Integrated Geriatric Services Initiative
  • 5 Central Zone Primary Care Networks
  • Seniors Health Strategic Clinical Network & Primary Health Care Integration Network
  • Alzheimer Society of Alberta and Northwest Territories
  • Focused on dementia

Focus was education of providers: Integrated community-based health and social services, organized around the needs of People Living with Dementia

Dementia Care Partners  5 Priority Messages for Primary Health Care Teams

  1. Certification and Better Education in Dementia Care for all Health Care Professionals
  2. Earlier Diagnosis with Care Partner Input
  3. Referral and Access to Dementia Resources ➢ to current available resources ➢ development of more comprehensive resources and a better delivery system through a multidisciplinary team

Comments from providers:

  • It’s been a good learning experience. We all felt out of our depth and still struggling a bit, but getting more comfortable with the whole process. I enjoy working with the team, the group works well together-we can do more (for the patient) than we can do in our own offices”.
  • “I always thought I had a good grasp of geriatrics and geriatric syndromes, especially dementia. I had a steep learning curve. Frankly it opened my eyes on the needs of our elderly population and how we can serve them”.