The CONNECT Collaborator Series is an interview series where we host conversations with healthcare professionals and partners with the goal of encouraging deeper collaboration in the healthcare industry.
Watch the full CONNECT Collaborator Series video featuring our Co-Founder, Lorie Spence and Founder of the Kawartha Centre, Dr. Jenny Ingram.
Lorie Spence: The CONNECT Collaborator series is an interview series where we host conversations with healthcare professionals and partners with the goal of encouraging deeper collaboration in the healthcare industry. Today, we have the unique pleasure to have Dr. Jennifer Ingram with us. Dr. Ingram is a specialist in internal medicine and geriatric medicine, founder of the Kawartha Centre for Redefining Healthy Aging, Consultant to Seniors Care Network and GAIN Geriatric Assessment and Intervention Network. Adjunct professor at Trent University, a member of the Trent Center for Aging and Society and Chair of the ODCA Ontario Dementia Care Alliance.
Welcome Jenny and thank you for joining us.
Dr. Jenny Ingram: Thank you.
Lorie Spence: So, maybe to get started, I know you’ve had a really unique career of firsts, and looking back at your career, maybe you can tell us one of those first waves of geriatricians followed by your work with GAIN, how the GAIN model is so relevant to where we are today in practice in medicine in Ontario and in Canada?
Dr. Jenny Ingram: Well, it’s a pleasure to extoll the virtues of GAIN. GAIN is an acronym that stands for Geriatric Assessment and Intervention Network, and it symbolizes a development that occurred in Central East Ontario in 2010, 2011 through to 2013 when a collaborative group developed a model for what was needed for frail senior care in our area, and we have one of the highest populations in each of the little municipalities and centers of seniors from across Canada. So, it was a labour that took many of us over a year to develop the model, though, it’s unique because it is a geriatrician supported, but NP or nurse-practitioner led program, of an interprofessional team trained to do complex geriatric assessment and care on the most frail within the senior population.
What is unusual about this development, was that it was so fully-funded. In the first year of funding, four of these teams were created, two in the Scarborough area, one in the Durham area and one in our area of Peterborough, followed subsequently by eight additional fully funded teams. So the fact that it was longitudinal funding was unique. The fact that it had NPS at the helm was unique. The fact that it didn’t always have its funding going through a hospital. It used community care agencies and others to be the organizer of the local enterprise, and it was grounded in the smaller community. So, there’s a GAIN team up in Halliburton, there’s a GAIN team in Campbellford, there’s a game team in Port Hope, smaller communities populated by nurse practitioners and professionals who live in those communities, so they’re a part of the community. We don’t just catapult in and stay briefly and remove ourselves. We’re there for the long haul. So, it’s an excellent model that basically magnifies the impact of the specialist clinicians into the smaller communities, and over its career, it’s done so many unique things. Including allowing people to self-refer for their care, which is really unique, and that is made possible by this nurse practitioner at the helm of the GAIN team. So, I’m very pleased to see its evolution in the 11 sites over the last decade or 15 years.
Lorie Spence: That’s fantastic. And we know collaborative care is really becoming the evolutionary model. Another integral area of healthcare delivery is in rural areas, and I know this is an area you’re both passionate about and have done a lot of research in. So, maybe you can tell us how these research initiatives have impacted healthcare in smaller communities.
Dr. Jenny Ingram: What we’ve learned from our study of the GAIN system is that, the process of delving into the complex senior health history, drug history, social history, functional history, cognitive history, is a skill that is very necessary to help the very challenged families manage well at home. And 95% of all people, when asked, will say that as they age and accumulate all the problems of aging, they want to remain home and none feel this more strongly than in the smaller communities which we serve by having local clinicians who are pulled together to support that group of very frail seniors, has meant that people, and there are 1000s and 1000s of people per year supported by GAIN across Central East Ontario. They are supported through very comprehensive ongoing care, trying to avoid unnecessary use of hospitals, unnecessary transfer to distant locations, unnecessary admission to long term care, and nowhere else other than in small communities, is this felt so sort of vibrantly.
I would also like to comment that because the home care program is also affiliated with our our program and in the smaller centers, the primary care physicians are often heavily integrated, as are the EMS staff, they pull from other areas that might not be so usual in a large center, and there’s a, I’m going to say, a real feel, if you will, in the smaller communities where gain is active of the community sort of building a safety net that has depth and breadth and the potential to help families who would otherwise be traveling for hours to get this kind of evaluation, or be seen by itinerant specialists who just pop in and out.
So it really has made a difference on the basic offering of health care in smaller communities. It’s not perfect, but there are many attributes to GAIN that, if extended across Ontario’s smaller communities and rural environments, and having a hub in a larger center, would make health care for seniors and complex seniors, in particular persons with dementia, so much more palatable for all concerned on the user end, the people in the community and for the health care system. So, I think it’s a model worthy of governmental overview and reproducing across Ontario.
Lorie Spence: Excellent, and that kind of leads into the next area of focus, that’s really evolved, is the Alzheimer space. And I know this is an area you’re very passionate about as well. Can you tell us more about the primary care initiatives that you’re leading in this space?
Dr. Jenny Ingram: I often say that, we in Canada, are very fortunate to have geriatric medicine so boldly and enthusiastically embrace the part of the healthcare system that is challenged on a routine basis by individuals who have cognitive difficulties, and it’s because our healthcare system was really founded on the conceptual model of people being physically unwell, having intercurrent illness, and then getting back to good health and carrying on. And that’s not the case when you have complex illness in seniors, and especially when you have dementia. First of all, dementia is often not identified at the front end when people go into hospital or when people are seen about a fracture, or seen about a fall. The dementia kind of gets lost in the shuffle. I often say that dementia chose us, as opposed to any other mechanism, because when the medications for Alzheimer’s disease and related dementias came into being in the 1990s, geriatric medicine clinicians were often the sort of centerpiece of getting access to these medications in the early days, and helping primary care understand how to use these medications. And so we developed, in my community, a kind of a role that was, on the one hand, wanting to see as many patients as we could with dementia, but on the other hand, recognizing that I was, at that time in 2000 through to 2010, quite alone in this community of, you know, I serve an area that’s 11% of the province. I needed all the primary care physicians to engage in this new initiative and in understanding dementia diagnosis that has led me through a series of events. Initially, we trained nurses within the family health teams that were funded in about 2004 to do good cognitive evaluations, and subsequently we realized that that just wasn’t sufficient. And that’s not sufficient because the diagnosis of dementia is not made by looking at the numbers from a cognitive evaluation, and many people have the very incorrect assumption that that makes the diagnosis and it does not.
What you really need is the functional analysis of how that individual has changed from a fully functional adult to the present day person, and that skill of doing a functional evaluation is one that we have introduced into our most recent iteration, which we call the Primary Care Embedded Memory Service. So, it takes the individual nurse from the Family Health Team and adds a second person who then does an evaluation, which is accrued from the care partner. That may be a family member who lives with the person with cognitive difficulty. It may be a person in the family who lives at some distance. It may be a neighbour, it may be the border, who lives downstairs, but whoever it is that knows that functional history is then also interviewed at intake. And our most recent iteration of how this has really transformed the information available to primary care is most heartening. We presented it at the Alzheimer International Conference in a poster format. It describes that the nurse from the Family Health Team joined by an additional individual, and it can be from an external agency. In our case, we were supported by the Alzheimer Society in our area to have two of their client support coordinators join us whenever there was a memory clinic willing to be trained. And they were then trained to do a collaborative integrated report back to the primary care physician that would be embedded in their EMS in their file, which would supply them with all the information needed to make the diagnosis, which includes functional status, evaluation of the cognitive testing, a review of the medications, a look at what their concerns are; if it relates to alcohol, driving, drugs, drug abuse, social issues, etc, and the caregiver experience, and we have found that this is not only well received by physicians, but we are now looking at what they do with this information. Because they’re given a care pathway designed for primary care to follow to make the diagnosis. And in our next presentation, I think we’re going to find that the family physicians who were able to access this service were very comfortable making the diagnosis of dementia or the diagnosis of mild cognitive impairment, free dementia, or the diagnosis of normal or other diagnoses of intercurrent things such as depression or alcohol that was making them appear to have a dementia. And the family physicians are both willing and able, but not supported to do this, and that’s what I want to show, that the primary care physicians can and will and do want to participate actively in their own patients journey through dementia.
Lorie Spence: I know empowering primary care is really a big focus, and it is almost full circle back to your GAIN model. As you’re moving into these other areas, can you tell us how empowering them is really helping with that identity and refer, and I know you spoke about the embedding, but maybe the other loop of that care path.
Dr. Jenny Ingram: I think what you’re really driving at is that no one part of the healthcare system can soldier forward alone as the persons with dementia, and we’re talking specifically about dementia here, are expected to triple over the next 25 years. So, I think there are very few conditions within the healthcare system that we can predictably say if you have a person with dementia in 10 of your 20 beds in the hospital ward in two decades, you’re going to triple that number unless we change how we do things. So the issue of primary care being empowered to be heavily involved in making a diagnosis of dementia, involves this system that we describe as the care pathway. And in the care pathway, there are relevant points where all clinicians may see the information and wonder, am I on the right track? And want to move the questions forward to the next level. Now, this is where the memory clinics provide a wonderful service, because the memory clinics that were developed by Dr. Linda Lee are able to see many individuals with the care of the elderly primary care physician, someone who has specifically developed their skills to be able to look more carefully at some of those unique types of dementia and provide guidance and reassurance to the primary care physician. But, in in addition to that, and this is where the GAIN clinics are so important, the specialists operate within this interprofessional team that is prepared to assist at both levels, whether the memory clinic or the embedded memory service at primary care has questions, or individuals that are, shall I say, exhausting their services that they have available. And many individuals with dementia do have multiple other conditions, Parkinson’s disease, diabetes, congestive heart failure, respiratory illness, and all of those medications can affect how you present cognitively. It is understandable why we need all the levels of intervention. Canada is very unique, I might add. We have done five iterations of the consensus guidelines for dementia management nationally, and all of them have endorsed that primary care needs to be the starting point for individuals to get their diagnosis, and that’s not to downplay the importance of the specialist interprofessional teams designed for the most complex or the mint memory clinics as a consultant to primary care, but I’m again, just offering my opinion that by starting at primary care and empowering primary care, you will develop a relationship with the patient and the primary care physician. They understand the issues that are hidden in the family often, and they will be a full and ready participant when things evolve, whether you are going to a specialist, whether you need home care, whether you need hospital or long term care. So again, it’s a system of multiple ways to manage the future of dementia.
Lorie Spence: And I know you’ve been working on a passion project, smitten with dementia. Can you leave us with a bit more on this film? And you know why it’s so important?
Dr. Jenny Ingram: I think in medicine and in healthcare in general, we have done a bit of a disservice to the seniors within our sphere of influence in that the health care programs and offerings seem to have followed suit with hospitals in designing their services around a hip that needs replacement, a cataract that needs removal, a pneumonia that needs antibiotics, a cough or a cold that needs tending. And in the same way that the acute care services are overwrought and overwhelmed with individuals that came in for something simple, but the problem was a whole lot more complex once you get the person in the bed and you realize they were hanging on by a thread at home. And now that that pneumonia is done, look at all these other things that need to be tended to, and so we’ve developed a culture in this country of kind of accepting that individuals are not going to get that help in the community that they need. And that’s wrong. It’s wrong headed. It’s expensive because you’re moving people into a high cost service to sort out things that should have been sorted out in the community. Home care is the bedrock of our service delivery system that goes into the home and when someone has a very complex case, complex medical illnesses. Home care is very helpful, or can be very helpful, but their systems often overestimate the necessity for brief interventions and underestimate the impact long term of their dementia and the need for interventions that continue to be active with the family, with the patient, with the care provider, and that has been a part of health care that has sadly gone unwitnessed. I thought for certain in the pandemic, when so many people were voicing such concerns with how desperately people were managing both at home and in long term care, that there would have been a light bulb go off. But we are many years since the pandemic, and really things have not dramatically changed, other than to build more long term care facilities with smaller room sizes, and what really the healthcare system needs is a reevaluation of how to manage people in the community. Home care for individuals with dementia is something that currently starts only when you need help with getting dressed or bathing, and that tends to be very close to the final cortice quartile, the final quarter of the illness. And yet all the patients I see are at the beginning, and so for the first two thirds, three quarters, of their disease evolving when all the problems are sort of being dealt with. The Home Care system remains as a non participant. I felt that I couldn’t say this adequately, and decided about a year ago that I would approach a nonprofit called Geriatric Health and approach the Alzheimer Society to see if they would be interested in helping the public understand how to use home care appropriately and how we might view a home care system that is dementia friendly, starting from the time of diagnosis, offering services, not having to have our patients beg for service. And it is close to completion now, and hopefully by January 2026, we’ll we’ll see a home care for persons with dementia overview film that is hopeful and future, futuristic, and that it’s encouraging that living at home and living your life fully after the diagnosis of dementia is possible, but it requires help, and where we get that help, in many cases, is from our governmental agencies. And I’m hoping in the future, there may be some improved options that we can become more Denmark, like in our offering to seniors of home care options that are better suited to them.
Lorie Spence: Fantastic. We look forward to it coming out and viewing it in the new year. As we close, Jenny, where can people find you?
Dr. Jenny Ingram: I’m available at my office at Kawartha Centre, and we can flash up at the end the email. My email for clinical things is jenny@kawarthacentre.com, and for advocacy and other issues, my email is drjingram@leaders4seniorchange.ca. Both emails get to me, and I’d be delighted to hear more from individuals interested in these areas.
Lorie Spence: That’s fantastic. Well, thank you for taking the time to join us today.
Dr. Jenny Ingram: And thank you.
