Team profiles :

Newfoundland and Labrador Health Services

At a Glance   

Region: Newfoundland and Labrador 

Setting: Urban, Northern, Rural and Remote

EAIP program principle(s): 

• Access to specialized healthcare services 
• Access to social and community supports. 
• Access to system navigation and support 

Implementation (new, spread, and/or expand):   

• New 

Team Profile  

Newfoundland and Labrador Health Services leads this initiative, with team members including interdisciplinary representatives from each geographic zone (Eastern Urban, Eastern Rural, Western, Central, Labrador-Grenfell). The team comprises directors, administrative leaders, and members experienced in quality improvement and evaluation. Patient and Family Experience Advisors also support this work. 

Community

• All geographic zones (Eastern Urban, Eastern Rural, Western, Central, Labrador-Grenfell) will collaborate to support the senior population in aging in place with appropriate support and resources tailored to their specific needs. 
•  All geographic zones (Eastern Urban, Eastern Rural, Western, Central, Labrador-Grenfell) will collaborate to support the senior population in aging in place with appropriate support and resources tailored to their specific needs. 

Program Focus 

Program Description  

• The Acute Care of the Elderly (ACE) Strategy in Newfoundland and Labrador addresses the specific healthcare needs of older adults with acute medical conditions, frailty, and age-related issues. By employing an interdisciplinary team approach, ACE units aim to reduce patient length of stay, prevent deconditioning and social isolation, and minimize readmissions. Research supports the benefits of ACE units, including fewer falls, reduced pressure ulcers, lower delirium risk, and decreased functional decline post-discharge. The strategy aims to enhance senior-friendly care, create supportive care pathways, and enable aging in place.   

Implementation Approach: 

• Education and Training: Provide comprehensive training for healthcare staff on ACE-related care, including screening tools, geriatric assessments, person-centered care, cultural competency, and dementia support strategies. 
• Interdisciplinary Team Development: Facilitate regular multidisciplinary reviews to assess complex cases, promote team collaboration, and develop individualized care plans recognizing social determinants of health. 
• Patient Education: Create tailored educational materials and sessions for older adults in the ACE unit, focusing on medication management, mobility, nutrition, fall prevention, and self-care, empowering patient participation. 
• Community Connections: Strengthen ties with community supports, ensure awareness of the Home First Philosophy, and establish partnerships to provide necessary resources and follow-up care for patients transitioning from the ACE unit. 
• Establish ACE Units: Develop new ACE units at Western Memorial Hospital (15 beds) and St. Clare’s Mercy Hospital (26 beds) to support older adults with acute medical conditions and frailty, providing comprehensive services and individualized care plans.  
• Provincial Approach: For zones not ready for a dedicated ACE unit, leverage working groups and learnings from existing units to incorporate senior-friendly services across the care continuum, enhance staff capacity, and create care pathways and linkages to support seniors in aging in place, varying implementation according to zone readiness.