Serving People with Dementia
LINKING PEOPLE WITH ALZHEIMER’S DISEASE AND OTHER DEMENTIAS TO SUPPORT, INFORMATION AND OTHERS WHO CAN HELP
FIRST LINK ™
A referral program that will: link people diagnosed with
dementia to support, information and services that can help.
assist caregivers of people with dementia by linking them to services as early as possible in the disease process.
BENEFITS FROM PARTICIPATING IN FIRST LINK ™
People with dementia will have increased health information enabling
them to make informed decisions about their health care needs.
People with dementia and their caregivers will have more information about dementia,
health services and non-medical community services.
BENEFITS FROM PARTICIPATING IN FIRST LINK ™
Caregivers will have increased knowledge, skills and
confidence.be encouraged to develop self care
strategies.
FIRST LINK ™ REFERRAL RESOURCES
To First Link ™Referral by physicians and other
health care professionals, diagnostic and treatment services and community service providers.
Self referral by the person with dementia or their family.
To Other ServicesThe Alzheimer Society will provide
information about primary health and community-based non-medical services.
Alzheimer Society services such as Safely Home™ - the Alzheimer Wandering Registry.
FIRST LINK ™ REFERRAL RESOURCES
FIRST LINK ™ SUPPORT SERVICES
The Alzheimer Society providesphone conversations personal appointments support groups for
people with dementiacaregivers – in person and distance telephone groups
FIRST LINK ™ INFORMATION SERVICES
Alzheimer Society services includePrint materialWebsiteInformation sessions
Caregiving: Building Your TeamCaregiving with Confidence
Bed Capacity
SITE PAST FUTURE
Bethania Mennonite Personal Care Home
9 behavioural treatment 10 “PCH Cottage”
Deer Lodge Centre 12 assessment & rehab
36 dementia care personal
care
0 assessment & rehab
47 specialized dementia
& behavioural care
Riverview Health Centre
10 behavioural treatment
60 dementia care personal care
10 Acquired Brain Injury
Rehab
60 dementia/behavioural
care
Seven Oaks General Hospital
19 Geriatric Psychiatry 19 Geriatric Psychiatry
Geriatric Mental Health Service Delivery Model:
June 1st, 2006 6 teams- 6 catchments Service to PCH & Community Geriatric Psychiatrist on each team 1 Central Intake Consistent response to referrals Data Entry done daily- retrieval/ stats
Information Sheet for public 65 or older with 1st onset Mental Illness 65 or older with history of Mental Illness-disease
and aging process- GMH service 65 or younger with behaviour/MH symptoms or
cognitive issues related to aging
Geriatric Mental Health Service Delivery Model:
Geriatric Mental Health (GMH):
CENTRAL INTAKE – GMH & GPAT DLC - 8:00 a.m.-4:00 p.m. Phone: 982-0140 or Fax: 982-0144 Open Referral Process- phone/ fax/ mail
GMH Referral Form
Database entry- Flag if known to GMH or GPAT & eventually
DH Based on client address- faxed to
appropriate team the same day
GMH Intake:
GMH Teams:
River East & Transcona (ARE) St. James-Assiniboia/Assiniboine South (DLC) River Heights/Fort Garry (RHC) St. Boniface/St. Vital (Tache) Inkster/Seven Oaks (1050 Leila) Point Douglas/Downtown (DLC)
Each team consists of 2 clinicians + Geriatric Psychiatrist.
GMH Service:
Provide timely geriatric mental health assessment
Recommendations (Geriatric Psych.) Short-term intervention Connect with service to clients in the
Community or recommend care in Personal Care Homes
Response Times:
GOAL:Not a Crisis Response TeamNon-Urgent – contact- 3 days, visit in 10 daysUrgent – contact-1 day, visit in 3 daysClinician contact made to determine level
of risk/ appropriate service & schedule appointment
Weekly Team Reviews:
Team Reviews scheduled with Geriatric Psychiatrist -discussion of cases
Care Planning/ problem-solving/ resources
Case Closure:
when linked with services requiredwhen issues stabilized/ improvewhen admitted to hospital-not expected
to return
Geriatric Program Assessment Teams (GPAT):
• Outreach program within the WRHA Rehab & Geriatrics Program
• Developed in 1999 & modeled from Ottawa/Carlton Geriatric Outreach Teams
• Started with 2 teams of 3 clinicians in each team then grew to 5 teams of 3 clinicians by Sept. ‘99
GPAT (cont’d)
Each clinician receives 12 weeks of specialized geriatric training
This enables each clinician to complete a medically based multidimensional assessment in the client’s home assessing the following: physical, functional, cognitive, emotional, psychosocial,
mobility, GI/GU, safety, polypharmacy.
In Aug. ’04 ER Task force made recommendations about GPAT as follows: GPAT clinicians will have a standard approach in
assessment process in all ER’s in Wpg. to improve care to geriatric clients
GPAT clinicians will prioritize the ER in their caseload GPAT will refer directly to Home Care to decrease wait
times for clients’ services in the community
GPAT Emergency Room (ER) Involvement
GPAT response to ER Task Force
Restructured 5 teams to 6 to service 6 ER’s in Wpg. in mid Nov. ‘04
Researched database information on clients over age 65 in the community and in Personal Care Homes in 12 community areas
Developed new catchment boundaries for 6 teams with no additional resources…some 2 & 3 person teams with Geriatrician
Geriatric Program Assessment Teams (GPAT):
There are 6 teams across the city of Winnipeg Concordia Deer Lodge Center Health Science Center Riverview St. Boniface Seven Oaks Hospital
Each Team consists of 2-3 disciplines and a Geriatrician + .6 float BN, BPT, BOT, BSW
GPAT: cont’d
After the clinician has completed the assessment they review with the Geriatrician and team.
Clinicians will make referral to community resources & recommendations to family MD with geriatrician input.
GOALS
To ensure the “right care, in the right place at the right time”.
Maintain functional ability in their home Partner with community caregivers for
management to prevent hospital admission (Home Care, Day Hospital, Age and Opportunity friendly visitor, CNIB)
GOALS (Cont’d)
Facilitate the transfer of appropriate clients to geriatric medicine and rehab units.
Assist in-patient teams with the discharge planning of complex, frail, elderly (ER).
Provide care management/ follow-up, short term intervention
POPULATION SERVED
The frailest, at-risk elderly, 65+ years.
Complex health concerns affecting their ability to function.
Geriatric Issues: mobility, ADL problems, Toileting, Confusion, Depression, Social Support, Medication problems
REFERRALS
Open Referral Process: Anyone can refer to our service:
Family member, friend, bank manager, Home Care, caregiver, & physicians, etc.
To refer to GPAT, either call the Central Intake Line at 982-0140 or fax Central Intake Form to 982-0144.
Contacts:
Marlene Graceffo, Rehab & Geriatrics Regional Manager
831-2537Lois Stewart-Archer, Geriatric Mental Health
Regional CNS831-2179
Jill Moats, Rehab & Geriatrics Regional Educator831-2150
Who does PRIME serve?
Targets community-dwelling seniors who are:Not functioning well in the communityAt risk of institutionalizationWish to remain in the community
PRIME Goals
1. Maintain seniors in the community
2. Enhance care coordination and service delivery for the frail elderly
33 Personal care home placement
33 Hospital/Emergency use
Day Centre
TransportationPersonal care/ grooming/ personal laundryRecreational and social activitiesRehabilitation /exercisesHealth promotion activities Lunch meal
Transfer of care to PRIME physicianCoordination of on-site & off-site
appointmentsMedications provided weekly
Primary Health Clinic
After hours support
Evening and weekend nurseHome visits and telephone responseProvincial Health Contact Centre
Program Model & Outcomes
Modelled on Edmonton CHOICE and U.S.A. PACE
Edmonton CHOICE results:emergency visits reduced by 62.9% inpatient days reduced by 70% ambulance claims reduced by 51.5%
Edmonton Outcomes (cont’d)
High participant & family satisfaction Maintained health status of participants Slowing of health decline Improved quality of life Support community living
PRIMEA Health Centre for Seniors
Judy Ahrens-TownsendRegional ManagerPhone: 831-2192Email: [email protected]