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

is your link to Help for Today and Hope for Tomorrow

Serving People with Dementia

Winnipeg Regional Health Authority (WRHA):

GERIATRIC MENTAL HEALTH TEAMS

Click to edit Master

Why Change?

Improve Access Reduce Duplication Develop linkages Improve system efficiency

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

Winnipeg Regional Health Authority (WRHA):

Geriatric Program Assessment Teams (GPAT):

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

Questions

PRIME

A Health Centre for Seniors

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

PRIMEUmbrella of Care

Case ManagerDay CentrePrimary Health ClinicAfter hours support Inpatient beds

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

Facilitate Access toInpatient Beds

TreatmentIntensive rehabilitationEmergency respiteAssessment

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: jahrens@deerlodge.mb.ca