Integrated Geriatric Care: Supporting Seniors' Health and Well-being

1. Intensive Geriatric Service Worker (IGSW) Janice Paul – WW IGSW Lead Heather Higgs - WW IGSW Thursday, August 12, 2010 GiiC

2. Outline • Setting the stage – integrated system of care • Intensive Geriatric Service Worker (IGSW) • Case Review

3. What is an integrated system? • A cohesive, coordinated model of delivering geriatric care • Strong partnerships with stakeholders • Evidence of improvement in patient outcome measures • Capacity building

4. What does Integration Mean? • Integrated team approach to complex issues • Linkages across the continuum of care • Targeted to high risk seniors • Presently initiated: ED, ALC, SGS— “ripple effect”—flows across the continuum

5. How did We Get to Where We are Today? • Health Accord Funding • RGP Central – Support • Networks • Partnerships • Environmental Scan • Linkage with academic Settings • Evaluations • Aging at Home Funding

6. WWGSN Guiding Principles – High Level • Senior Centered: services will respond to the need of seniors • Community Based and Integrated: within broader health system • Equitable: recognize demographic and geographic challenges

7. Guiding Principles Continued…. • Cost Effective; best care at optimal cost recognizing benefits of volunteerism, local community responses • Results Oriented: results defined and measured

8. Senior’s Services Flow Dr. John Yang

9. Design Principles • Process capable of meeting need and demand • Process will deliver client value and demonstrate outcomes • Robust and Reliable • Uses and Improves Existing Infrastructure • Clearly defined operations that can be enabled with information technology. • Improves flow by minimizing all types of waste and by creating “pull” • Has positive impact on system goals

10. Intensive Geriatric Service Workers (IGSW)

11. IGSW Key Roles • “Walk with” the frail, complex senior and/or the family who needs extra help accessing services in the community after discharge home from hospital. • Provide timely intensive support, transition and follow-up. Work closely with primary care, specialty care, community support services, and CCAC as partners in the senior’s care. • For the senior who is reluctant to accept any supports, the IGSW can help pave the way for other services in the community

12. IGSWs Can: • Accompany the senior to the primary care doctor or specialist appointment • Arrange and accompany for a Pharmacy consult • Accompany senior to a day program, dining, exercise or other social programs • Help link senior with community programs ie. Transportation, social programs • Tour Retirement Homes with the senior • Coach senior and/or their family to support self management

13. Client-centred Focus • Length of involvement and level of intensity differs for each individual client • Remain involved until client is “cemented” into services in the community

14. IGSW GoalsHEALTHY, HAPPY, SAFE

15. Referral Guidelines • Frequent user of the emergency department • Recent hospital admission (90 days) and/or ED visit (30 days) • Complexity of needs (number and/or type of support required) • Socially isolated

16. Referral Guidelines – cont’d • Resistant to assistance or support • Ability to access services is limited due to financial reasons • Language or cultural barrier • MD or RN concern about ability to follow through with recommendations • Caregiver burden, lack of caregiver support or long-distance caregiver

17. Who can refer a patient to an IGSW? • GEM Nurses • Geriatric Clinical Nurse Specialists in Acute Care • Specialized Geriatric Services

18. Referral Process Seniors in need CCAC central Database Community ED SGS: Geriatric Medicine Psychogeriatric Assessment GEM and CCAC Admit Home IGSW Required ServiceOrder request to Trellis CARE PLAN IMPLEMENTED Hospital Community

19. IGSW Statistics

20. IGSW Statistics Min age: 48 Max age: 98 Average age: 80

21. IGSW Statistics

22. IGSW Statistics

23. IGSW Statistics

24. IGSW Qualifications • Recruitment- IGSWs cross-section of academic preparation: • Gerontology • Rec therapy • Social Work • Pastoral Care • Psychology • Social Services • Geriatric experience within the team: • Community support • Long-term care • Mental Health • Community Ministry • Retirement Home • Day Program • Private Home care • Acute Care • Rehab • Language, ethnicity, culture • German, Italian, Dutch, French, Mennonite

25. Keys to Success • Focus on SMART (Specific, Measurable, Attainable, Realistic, Time-Measured) Goals • Unique role in the home – IGSWs do not “assess” they “do” • Roles belong to the system not one agency (Trellis is Lead agency, accountable to WWLHIN) • Integrated into Community Support Service Agencies – IGSW offices are within community partner agencies

26. Keys to Success • Strong partnership with CCAC • Collaborative approach with GEM Nurses, SGS and Acute Care • IGSWs are part of the Circle of Care • Process designed to “pull” patients out of hospital and into the community • Communication Communication Communication

27. An IGSW Success Story…

28. Case Review The Role of an IGSW

29. Case Review • 90 year old gentleman presented to the ED with Shortness of Breath • GEM Nurse Assessment completed • Treated and sent home same day with prescription • IGSW appointment arranged for following day at 11:00am.

30. SMART Goals • Obtain Family Doctor • Have Hearing Tested • Arrange Transportation • Lifeline • Encourage use of walker instead of shopping cart

31. Initial Visit Upon initial visit the following was observed: • Using his oven to heat his apartment • Using a shopping cart and dowel stick as a gait aid • Using a lawn chair as a bath chair • Fridge completely empty • No CCAC or formal supports

32. Initial Visit cont. • Blood sugar monitor and sharp’s disposal in kitchen covered with a thick layer of dust. Client unable to state what they were used for • Medication prescribed in the ED was taken improperly. Too many missing. • Alcohol on kitchen counter • Client expressed paranoid thoughts

33. Cognitive Concerns Identified by IGSW • Client forgot appointment • Not orientated to time/day. • Unable to state how long he had lived in his apartment • Married 4x – unable to name wives or if any are still living • Unable to recall family doctor • Unable to understand Power of Attorney therefore impossible to ascertain if he had one.

34. Family • Client stated his niece had recently visited and brought food (later found out that was 1st visit in over a year) • Daughter who lived next door who helps with cleaning/laundry • Sister lives down the street but has a strained relationship.

35. Daughter • Through phone call with the niece found out that client does not have a daughter. • Called client’s sister to confirm. Sister states that “daughter” is a drinking buddy and it is a relationship they’ve tried to discourage for years. • Sister freely admits poor relationship with her brother and very limited involvement. • Social Work investigated relationship with client and daughter and determined that he has contact with her by choice.

36. What’s Been done… • 1st call after initial visit back to GEM to discuss findings and new SMART Goals • GEM nurse able to arrange appointment with Geriatrician within a few days • Thorough medical workup with Geriatrician • Diagnosed with dementia, “severely diabetic”, high blood pressure • Medication prescribed and put into a blister pak

37. What’s Been Done… • PSW in place in AM for med cueing • Nursing in 2x weekly for blood sugar monitoring • Meals on Wheels 2x a week • Family doctor found – hadn’t seen since 2002. New family doctor obtained • Now has walker and bath chair • IGSW visits weekly in addition to accompanying to any medical appointments

38. What’s Been Done… • Case Conference held with family • Discovered that sister and niece (not the one visiting) are in fact Power of Attorney • Family agreed to reconnect • Family visited and brought a basket of food for the 1st time in 5 years. • Visited optometrist, cataracts diagnosed, should have had them removed 5 years ago – only sees movement • Ophthalmologist appointment arranged

39. Bumps along the road… • Missed initial Geriatrician’s appointment (mixed up appointment time so wasn’t at home when I arrived to take him). • Sweater went missing at the same time as the social worker’s 1st visit. He is convinced she stole it and wouldn’t let her back in. New social worker assigned • Cancelled meals, PSW, his medications at different times. I was able to convince him to take them back with changes.

40. Successes • He is now medically stable • Cognition is improving – Called my voice mail for the 1st time ever and left an appropriate message • Was able to use buzzer for controlled entry at his apartment for the 1st time since I’ve met him • Geriatrician assessment: Scored the same on his MMSE but had significant improvements in Recall 2 out of 3 vs. 0 out of 3 in January and marked improvement in his clock drawing.

41. It Takes a Village… Many people working together to provide his care… • GEM nurse, Geriatrician, Nurse Practitioner, Family Doctor, Pharmacist • CCAC Case Manager, OT, PT, PSW, Social Work, Nursing • Community supports • IGSW • Family

42. Ongoing Support • Family doctor appointments ongoing • First visit with Ophthalmologist, now waiting for cataract surgery –he has been medically cleared to have surgery • Work to complete initial SMART Goals – after cataract surgery we will see an audiologist. • Ongoing support as needed through weekly visits

43. Questions

44. Contact Information • Janice Paul –Intensive Geriatric Service Worker Lead: 519-576-2333 x 277, cell 519-400-8176, jpaul@trellis.on.ca • Heather Higgs – Intensive Geriatric Service Worker hhiggs@trellis.on.ca • Jane McKinnon Wilson –Waterloo Wellington Geriatric Systems Coordinator: jmckinnon@trellis.on.ca • Maria Boyes- GEM Clinical Resource Consultant: mboyes@cmh.org • Carrie McAiney – Lead Evaluator: mcaineyc@mcmaster.ca