Facilitating Integration from the Community: …...Facilitating Integration from the Community:...

Facilitating Integration from Facilitating Integration from the Community: Intensive the Community: Intensive Geriatric Service WorkerGeriatric Service WorkerGeriatric Service Worker Geriatric Service Worker

ProgramProgram

Janice Paul & Heather HiggsJanice Paul & Heather HiggsO b 21 2010O b 21 2010October 21, 2010October 21, 2010

OverviewOverviewOverviewOverview

To describe the integrated service for frail,To describe the integrated service for frail, To describe the integrated service for frail, To describe the integrated service for frail, atat--risk seniors in Waterloo Wellingtonrisk seniors in Waterloo Wellington

To describe the Intensive Geriatric Service To describe the Intensive Geriatric Service Worker program and highlight a successWorker program and highlight a successWorker program and highlight a success Worker program and highlight a success storystory

To review interim evaluation findings and To review interim evaluation findings and highlight lessons learnedhighlight lessons learnedhighlight lessons learned highlight lessons learned

What is an integrated system?What is an integrated system?What is an integrated system? What is an integrated system?

A cohesive, coordinated model ofA cohesive, coordinated model of A cohesive, coordinated model of A cohesive, coordinated model of delivering geriatric care delivering geriatric care

Strong partnerships with stakeholders Strong partnerships with stakeholders

Evidence of improvement in patient Evidence of improvement in patient p pp poutcome measures outcome measures

Capacity buildingCapacity building

What does What does IntegrationIntegration Mean?Mean?

Integrated team approach to complex Integrated team approach to complex issuesissuesissuesissues

Linkages across the continuum of care Linkages across the continuum of care

Targeted to high risk seniors Targeted to high risk seniors

Presently initiated: ED, ALC, SGSPresently initiated: ED, ALC, SGS——“ i l ff t”“ i l ff t” fl th tifl th ti“ripple effect”“ripple effect”——flows across the continuum flows across the continuum

How did We Get to Where We are How did We Get to Where We are T d ?T d ?Today?Today?

Health Accord FundingHealth Accord Funding

RGP Central RGP Central –– Support Support

N t kN t k NetworksNetworks

PartnershipsPartnerships

Environmental ScanEnvironmental Scan

Li k ith A d i S ttiLi k ith A d i S tti Linkage with Academic Settings Linkage with Academic Settings

Evaluations Evaluations

Aging at Home Funding Aging at Home Funding

Guiding PrinciplesGuiding Principles –– High LevelHigh LevelGuiding Principles Guiding Principles High Level High Level

Senior Centered: services willSenior Centered: services willSenior Centered: services will Senior Centered: services will respond to the need of seniorsrespond to the need of seniors

Community Based and Integrated: Community Based and Integrated: y gy gwithin broader health system within broader health system

Equitable: recognize demographic Equitable: recognize demographic and geographic challengesand geographic challenges

Guiding Principles ContinuedGuiding Principles ContinuedGuiding Principles Continued….Guiding Principles Continued….Cost Effective: best care at optimalCost Effective: best care at optimalCost Effective: best care at optimal Cost Effective: best care at optimal

cost recognizing benefits of cost recognizing benefits of volunteerism and local communityvolunteerism and local communityvolunteerism and local community volunteerism and local community responses. responses.

Results Oriented: results defined and Results Oriented: results defined and measuredmeasured

System AccountabilitySystem AccountabilitySystem AccountabilitySystem Accountability

WWGSN WWGSN -- System of Care for Seniors System of Care for Seniors ––

Accountability Agreements signed by all Accountability Agreements signed by all partnerspartners

Data collectionData collection

Ongoing integrated evaluationsOngoing integrated evaluationsOngoing integrated evaluationsOngoing integrated evaluations

Integrated Services for SeniorsIntegrated Services for SeniorsIntegrated Services for SeniorsIntegrated Services for SeniorsDr. John Yang

Design PrinciplesDesign PrinciplesDesign PrinciplesDesign Principles1.1. Process capable of meeting need and demandProcess capable of meeting need and demand

2.2. Process will deliver client value and demonstrate outcomesProcess will deliver client value and demonstrate outcomes

3.3. Robust and Reliable Robust and Reliable

4.4. Uses and Improves Existing Infrastructure Uses and Improves Existing Infrastructure

5.5. Clearly defined operations that can be enabled with information Clearly defined operations that can be enabled with information technology.technology.

6.6. Improves flow by minimizing all types of waste and by creating Improves flow by minimizing all types of waste and by creating “pull”“pull”

7.7. Has positive impact on system goalsHas positive impact on system goals

Intensive Geriatric Service WorkerIntensive Geriatric Service WorkerIntensive Geriatric Service Worker Intensive Geriatric Service Worker (IGSW)(IGSW)

Key Roles: IGSWsKey Roles: IGSWsKey Roles: IGSWsKey Roles: IGSWs To implement care plans from GEM Nurses, acute care To implement care plans from GEM Nurses, acute care

health team (including hospital CCAC Case Manager) orhealth team (including hospital CCAC Case Manager) orhealth team (including hospital CCAC Case Manager), or health team (including hospital CCAC Case Manager), or Specialized Geriatric ServicesSpecialized Geriatric Services

To provide timely intensive support, transition and followTo provide timely intensive support, transition and follow--up with primary care, specialty care & community up with primary care, specialty care & community support servicessupport servicessupport servicessupport services

To support personTo support person--centered selfcentered self--directed care (i.e.,directed care (i.e., To support personTo support person centered selfcentered self directed care (i.e., directed care (i.e., coach seniors and caregivers)coach seniors and caregivers)

IGSW Goals IGSW Goals –– Healthy, Happy, Healthy, Happy, S fS fSafeSafe

Referral GuidelinesReferral GuidelinesReferral GuidelinesReferral Guidelines Frequent user of the emergency departmentFrequent user of the emergency department Frequent user of the emergency departmentFrequent user of the emergency department

Recent hospital admission Recent hospital admission pp(90 days) and/or ED visit (30 days)(90 days) and/or ED visit (30 days)

Complexity of needs Complexity of needs (number and/or type of support required)(number and/or type of support required)( yp pp q )( yp pp q )

Socially isolatedSocially isolatedyy

Referral Guidelines (cont’d)Referral Guidelines (cont’d)Referral Guidelines (cont d)Referral Guidelines (cont d) Resistant to assistance or supportResistant to assistance or support

Ability to access services is limited due to financial Ability to access services is limited due to financial reasonsreasonsreasonsreasons

Language or cultural barrierLanguage or cultural barrier

MD or RN concern about ability to follow through with MD or RN concern about ability to follow through with recommendationsrecommendations

Caregiver burden, lack of caregiver support or longCaregiver burden, lack of caregiver support or long--distance caregiverdistance caregivergg

Referral Referral PP

Senior in need

C itHosp

databaseProcessProcess EDCommunity database

CCACdatabase

AssessmentGEM and CCAC

AssessmentSGS

Geriatric MedicineGeriatric Psychiatry

Hospdatabase

Admit Home

CCAC database

TrellisCaseworksDatabase

IGSW

Processbook Website

required

TrellisCaseworksDatabase

Assessment & Notes

Faxed to IGSWTeam

Care plan implemented

Secure Web Portal for GEM Secure Web Portal for GEM f lf lreferralsreferrals

IGSW appointment slipIGSW appointment slipIGSW appointment slipIGSW appointment slip

IGSW QualificationsIGSW Qualifications RecruitmentRecruitment-- IGSWs crossIGSWs cross--section of academic preparation: section of academic preparation:

GerontologyGerontology

IGSW QualificationsIGSW Qualifications

GerontologyGerontology Rec therapyRec therapy SociologySociology Pastoral CarePastoral Care PsychologyPsychology PsychologyPsychology Social ServicesSocial Services

Geriatric experience within the team:Geriatric experience within the team: Community supportCommunity support

LongLong term careterm care LongLong--term careterm care Mental HealthMental Health Community MinistryCommunity Ministry Retirement HomeRetirement Home

Day ProgramDay Program Day ProgramDay Program Private Home carePrivate Home care Acute CareAcute Care RehabRehab

Language ethnicity cultureLanguage ethnicity culture Language, ethnicity, cultureLanguage, ethnicity, culture German, Italian, Dutch, French, Portuguese, MennoniteGerman, Italian, Dutch, French, Portuguese, Mennonite

CelebratingCelebratingCelebrating Celebrating SuccessSuccessSuccessSuccess

Case ReviewCase ReviewCase ReviewCase Review

ED PresentationED Presentation::ED PresentationED Presentation: : 87 year old female that a neighbour found 87 year old female that a neighbour found

wandering in hallway of apartment building. wandering in hallway of apartment building. g y p gg y p g The neighbour noticed an increase in confusion The neighbour noticed an increase in confusion

and arranged for EMS to take her to the hospital. and arranged for EMS to take her to the hospital. g pg p In the ED she admits she was wandering around In the ED she admits she was wandering around

as she was seeing people in her apartment, as she was seeing people in her apartment, including her dead husband. This has been including her dead husband. This has been happening for quite some time. happening for quite some time.

Comprehensive GEM AssessmentComprehensive GEM AssessmentComprehensive GEM Assessment Comprehensive GEM Assessment Social / Functional:Social / Functional: Widow of 4 years, no children. Lives alone in an apartment.Widow of 4 years, no children. Lives alone in an apartment. Widow of 4 years, no children. Lives alone in an apartment. Widow of 4 years, no children. Lives alone in an apartment. Manages bathing / dressing on her own. No trouble toileting. Manages bathing / dressing on her own. No trouble toileting. Walks with no aid, but has had several falls “more than I can count”. Walks with no aid, but has had several falls “more than I can count”. Reports difficulty managing medications often forgets if she has takenReports difficulty managing medications often forgets if she has taken Reports difficulty managing medications often forgets if she has taken Reports difficulty managing medications often forgets if she has taken

them or not (this also was evident from her blood work). them or not (this also was evident from her blood work). Meals are a gap, her neighbour assists with groceries but she admits she Meals are a gap, her neighbour assists with groceries but she admits she

is not eating well. She relies on taxis or her neighbour to get around. is not eating well. She relies on taxis or her neighbour to get around. Is interested in retirement living but does not know how to go about it. Is interested in retirement living but does not know how to go about it.

Cognition:Cognition:gg Admits her memory is poor “My head is all messed up”. MMSE 23/30. Admits her memory is poor “My head is all messed up”. MMSE 23/30. She was also having ongoing hallucinationsShe was also having ongoing hallucinations. .

PLANPLANPLANPLANAfter the GEM assessment, it was clear that this women After the GEM assessment, it was clear that this women G ,G ,

would benefit from and do well with IGSW support. A would benefit from and do well with IGSW support. A plan for discharge was created and included:plan for discharge was created and included:

1.1. Referral to geriatrics (further cognitive assessment Referral to geriatrics (further cognitive assessment and falls assessment)and falls assessment)and falls assessment)and falls assessment)

2.2. CCAC to assess CCAC to assess 33 IGSW to assist arranging meals on wheels,IGSW to assist arranging meals on wheels,3.3. IGSW to assist arranging meals on wheels, IGSW to assist arranging meals on wheels,

attending appointments, looking at retirement attending appointments, looking at retirement options and medications compliance. options and medications compliance.

Bridging gapsBridging gapsBridging gaps … Bridging gaps … IGSW bridge a huge gap. GEM was able to bookIGSW bridge a huge gap. GEM was able to bookIGSW bridge a huge gap. GEM was able to book IGSW bridge a huge gap. GEM was able to book

an IGSW appointment prior to ED discharge. an IGSW appointment prior to ED discharge.

Historically, discharge suggestions are made to Historically, discharge suggestions are made to patients, followedpatients, followed--up by CCAC and few suggestions up by CCAC and few suggestions are followed through by patients (forget don’t seeare followed through by patients (forget don’t seeare followed through by patients. (forget, don t see are followed through by patients. (forget, don t see importance, confused)importance, confused)

Discharge suggestions forwarded to IGSW, ‘Smart Discharge suggestions forwarded to IGSW, ‘Smart Goals’ and for this patient, every recommendation has Goals’ and for this patient, every recommendation has been met and morebeen met and more

Home in the CommunityHome in the CommunityHome in the CommunityHome in the Community Client seen by IGSW in her home less than 24 hours Client seen by IGSW in her home less than 24 hours

f di h j i i i i h CCAC C i Cf di h j i i i i h CCAC C i Cafter discharge, joint visit with CCAC Community Case after discharge, joint visit with CCAC Community Case Manager.Manager.

During visit, extra medications cleaned out and During visit, extra medications cleaned out and returned to pharmacy. (Entire shopping bag filled returned to pharmacy. (Entire shopping bag filled including medications over 10 years old that she including medications over 10 years old that she g yg ybrought when she moved from Toronto). brought when she moved from Toronto).

Client was concerned she missed a pacemakerClient was concerned she missed a pacemaker Client was concerned she missed a pacemaker Client was concerned she missed a pacemaker appointment, called to confirm date of appointmentappointment, called to confirm date of appointment

Plans made to accompany client to pacemaker clinicPlans made to accompany client to pacemaker clinic Plans made to accompany client to pacemaker clinic Plans made to accompany client to pacemaker clinic next weeknext week

Smart Goals (as written for Smart Goals (as written for client)client)

The hospital has recommend the following for you....The hospital has recommend the following for you....

Book a follow up visit with family doctorBook a follow up visit with family doctor Appointment with GeriatricianAppointment with Geriatrician Appointment with GeriatricianAppointment with Geriatrician Visit and choose retirement homeVisit and choose retirement home Ensure correct medications are taken at the correct Ensure correct medications are taken at the correct

tititimetime Meals on WheelsMeals on Wheels

I ill k ith t th bI ill k ith t th b I lI lI will work with you to arrange the above.I will work with you to arrange the above. I am also I am also happy to go with you to these appointments.happy to go with you to these appointments.

Heather Higgs IGSWHeather Higgs IGSWHeather Higgs, IGSW Heather Higgs, IGSW 519519--772772--87878787 x 219x 219

To dateTo dateTo dateTo date

Arranged for Meals on WheelsArranged for Meals on Wheels Arranged for Meals on WheelsArranged for Meals on Wheels Arranged for medication to be put in a Arranged for medication to be put in a

blister packblister packblister packblister pack Accompanied to Pacemaker appointment, Accompanied to Pacemaker appointment,

d t d b kd t d b kdrugstore and bankdrugstore and bank Accompanied to GeriatricianAccompanied to Geriatrician Accompanied to Family DoctorAccompanied to Family Doctor

To date (cont’d)To date (cont’d)To date (cont d)To date (cont d)

Toured 3 different retirement homesToured 3 different retirement homes Toured 3 different retirement homesToured 3 different retirement homes Accompanied to the lab for weekly blood Accompanied to the lab for weekly blood

workworkworkwork Arranged for move to retirement homeArranged for move to retirement home Follow up visit with GeriatricianFollow up visit with Geriatrician Seen in May Seen in May –– moved to retirement home moved to retirement home yy

by end of June. by end of June.

CurrentlyCurrentlyCurrentlyCurrently Using walker Using walker Now settled at retirement home and is happy with the Now settled at retirement home and is happy with the

move. She is aware she was not coping at home.move. She is aware she was not coping at home. Now eating better (hadn’t cooked since husbandNow eating better (hadn’t cooked since husband Now eating better (hadn t cooked since husband Now eating better (hadn t cooked since husband

passed away several years ago). passed away several years ago). INR levels regulatedINR levels regulated Memory is improvingMemory is improving Memory is improvingMemory is improving Hallucinations have stoppedHallucinations have stopped Now socializing regularly Now socializing regularly –– was very isolated beforewas very isolated before Now safeNow safe Family now visiting weekly. At home family was Family now visiting weekly. At home family was

calling but not visiting. calling but not visiting. g gg g

It Takes a VillageIt Takes a VillageIt Takes a VillageIt Takes a Village

Meals on WheelsMeals on WheelsMeals on WheelsMeals on WheelsCCAC services including Occupational CCAC services including Occupational

Th PSW d iTh PSW d iTherapy, PSW and nursingTherapy, PSW and nursingPharmacy AssistantPharmacy AssistantyyPrimary Care doctorPrimary Care doctor

G i t i iG i t i iGeriatricianGeriatricianFriend/FamilyFriend/Familyyy IGSWIGSW

Ongoing involvement:Ongoing involvement:Ongoing involvement:Ongoing involvement: Accompanied to follow up Geriatrician appointmentAccompanied to follow up Geriatrician appointmentp p ppp p pp

Geriatrician very pleased with her progress and wrote in Geriatrician very pleased with her progress and wrote in li t’ fil “Si l t b i h h fl i h d ”li t’ fil “Si l t b i h h fl i h d ”client’s file: “Since last being seen she has flourished.”client’s file: “Since last being seen she has flourished.”

Plans to accompany to 2 more appointmentsPlans to accompany to 2 more appointments Plans to accompany to 2 more appointmentsPlans to accompany to 2 more appointments

Client now confident she can attend appointments on Client now confident she can attend appointments on h h h f ilh h h f ilher own or arrange through family. her own or arrange through family.

Happy Healthy SafeHappy Healthy SafeHappy, Healthy, SafeHappy, Healthy, Safe

“I couldn’t believe it and everybody was so nice. I “I couldn’t believe it and everybody was so nice. I wish everybody could have the service I had ”wish everybody could have the service I had ”wish everybody could have the service I had. wish everybody could have the service I had.

Waterloo WellingtonWaterloo WellingtonIntegrated Services for Integrated Services for

SeniorsSeniors Interim EvaluationInterim EvaluationSeniors Seniors -- Interim EvaluationInterim Evaluation

EvaluatorsEvaluatorsCarrie McAiney, PhDCarrie McAiney, PhDCarrie McAiney, PhDCarrie McAiney, PhDLoretta Hillier, M.A.Loretta Hillier, M.A.

ReferralsReferralsReferralsReferralsPercentage (#)Percentage (#)

Total # of clients referred to IGSWsTotal # of clients referred to IGSWs Guelph siteGuelph site

Waterloo siteWaterloo site

35135142%42%38%38% Waterloo siteWaterloo site

Cambridge siteCambridge site38%38%20%20%

Clients served by IGSWsClients served by IGSWs 95% (334)95% (334)

Reasons clients were not servedReasons clients were not served service was not neededservice was not needed 1.4% (5)1.4% (5) client refused serviceclient refused service client died before first IGSW visitclient died before first IGSW visit clients waiting to be servedclients waiting to be served

0.3% (1)0.3% (1)0.6% (2)0.6% (2)2.6% (9)2.6% (9)gg ( )( )

Carrie McAiney &Loretta Hillier 2010

IGSW ActivitiesIGSW ActivitiesIGSW ActivitiesIGSW Activities

ActivitiesActivities Percent (#)Percent (#)ActivitiesActivities Percent (#) Percent (#) of Hoursof Hours

Client ContactClient Contact 37%37%Client ContactClient Contact faceface--toto--faceface telephonetelephone

37%37%32%32%5%5%

C ll t lC ll t l 19%19%Collateral Collateral services/consultation/collaborationservices/consultation/collaboration

19%19%

DocumentationDocumentation 19%19%DocumentationDocumentation 19%19%AdministrationAdministration 13%13%

TravelTravel 12%12%TravelTravel 12%12%


DischargesDischargesDischargesDischarges

N bN bNumberNumber

Total # of clients dischargedTotal # of clients discharged 132 (38%)132 (38%)Total # of clients dischargedTotal # of clients discharged 132 (38%)132 (38%)

Among existing clients:Among existing clients:g gg g avg. length of time on avg. length of time on serviceservice

89 days89 days1 1 –– 248 days248 days

rangerange


Referral SourcesReferral SourcesReferral SourcesReferral Sources

250208

200

250

rals

100

150

er of Referr

52 4119 19 12

50

100

Numbe

12

0GEM Inpt

UnitsSGS Ger'ns CGS AAH

NursesUnits Nurses


Reasons for ReferralReasons for ReferralReasons for ReferralReasons for ReferralActivitiesActivities Percent (#) of Percent (#) of

HoursHoursHoursHoursMD / RN concern; Recommendation f/upMD / RN concern; Recommendation f/up 58%58%

Social isolationSocial isolation 52%52%

Recent hospital or ED visitRecent hospital or ED visit 50%50%Caregiver burden / lack of supportCaregiver burden / lack of support 42%42%C l dC l d 40%40%Complex needsComplex needs 40%40%

Resistance to service / supportResistance to service / support 24%24%

Service access issues due to financesService access issues due to finances 10%10%Service access issues due to financesService access issues due to finances 10%10%

Frequent use of EDFrequent use of ED 6%6%

Cultural / Language barrierCultural / Language barrier 4%4%

MiscellaneousMiscellaneous 1%1%


Client CharacteristicsClient CharacteristicsClient CharacteristicsClient CharacteristicsAgeAge

MeanMean 80 years80 years MeanMean RangeRange

80 years80 years48 48 –– 95 years95 years

GenderGender MaleMale FemaleFemale

36%36%64%64%

Marital StatusMarital Status WidowedWidowed MarriedMarried Divorced / SeparatedDivorced / Separated

45%45%30%30%12%12%

SingleSingle 9%9%

No family physicianNo family physician 5%5%

N t i l d ith CCACN t i l d ith CCAC 16%16%Not involved with CCACNot involved with CCAC 16%16%


IGSW ExperienceIGSW ExperienceIGSW ExperienceIGSW ExperienceGEMGEM IGSWIGSW

Did t h t it l tDid t h t it l tDid not have to wait long to see…Did not have to wait long to see… AgreeAgree DisagreeDisagree NeutralNeutral

74%74%6%6%6%6%

83%83%00

17%17% NeutralNeutral 6%6% 17%17%

Satisfaction with amount of time spent with…Satisfaction with amount of time spent with… AgreeAgree DisagreeDisagree

99%99%00

97%97%00 DisagreeDisagree

NeutralNeutral00

1%1%00

3%3%

Greater understanding of my condition as a Greater understanding of my condition as a result of interaction with…result of interaction with…

AgreeAgree DisagreeDisagree NeutralNeutral

86%86%00

11%11%

90%90%00

10%10%


IGSW: Other ImpactsIGSW: Other ImpactsIGSW: Other ImpactsIGSW: Other ImpactsImpacts as a results of assistance from the IGSWImpacts as a results of assistance from the IGSW IGSWIGSW

Y bilit t t k f lfY bilit t t k f lfYour ability to take care of yourself…Your ability to take care of yourself… Worse nowWorse now About the sameAbout the same Better nowBetter now

0013%13%83%83% Better nowBetter now 83%83%

Your knowledge of who or what organization to call for Your knowledge of who or what organization to call for services you needservices you need

Worse nowWorse now 00o se oo se o About the sameAbout the same Better nowBetter now

0027%27%67%67%

Your ability to meet your goals for better healthYour ability to meet your goals for better healthYour ability to meet your goals for better healthYour ability to meet your goals for better health Worse nowWorse now About the sameAbout the same Better nowBetter now

0000

100%100%


IGSW: Other ImpactsIGSW: Other ImpactsIGSW: Other ImpactsIGSW: Other ImpactsImpacts as a results of assistance from the IGSWImpacts as a results of assistance from the IGSW IGSWIGSW

Y h lthY h lthYour healthYour health Worse nowWorse now About the sameAbout the same Better nowBetter now

0037%37%57%57% Better nowBetter now 57%57%

Your knowledge about when you need to go to the EDYour knowledge about when you need to go to the ED Worse nowWorse now About the sameAbout the same

0060%60%About the sameAbout the same

Better nowBetter now60%60%37%37%

Your ability to talk to doctors and other health Your ability to talk to doctors and other health professionals about your healthprofessionals about your healthyy

Worse nowWorse now About the sameAbout the same Better nowBetter now

0073%73%27%27%


Summary of the Ways in Which the IGSWs H l f l t P ti t /C iwere Helpful to Patients/Caregivers

Increased access to community support services (16)(e g system navigation Meals on Wheels home help personal care grocery(e.g., system navigation, Meals on Wheels, home help, personal care, groceryshopping service, Lifeline, friendly visiting, adult day programs, Alzheimer Society)

Accompanied client to appointments (14)(e.g., medical appointments, visit housing options, day programs, pharmacy, errands)

Emotional support (14)Emotional support (14)(e.g., someone to talk to at length about concerns, morale support, support tocaregivers – understanding and managing dementia related behaviours)

Increased access to information (13)(e g information on illness symptoms management strategies housing options(e.g., information on illness, symptoms, management strategies, housing options,internet access – improved computer skills)

Increased access to transportation (10)(e.g., arranged transportation, assisted with application for paratransit/ senior’sservice or bus pass)service, or bus pass)

Assistance with a variety of tasks (10)(e.g., correspondence client could not understand, preparation of questions fordoctor’s appointment, interpretation of doctor’s recommendations, arranging forincome tax form preparation management of hoarding behaviours home safety/ fallincome tax form preparation, management of hoarding behaviours, home safety/ fallprevention, smoking cessation)


Summary of the Ways in Which the IGSWs H l f l t P ti t /C i ( t’d)

Arranged appointments (5)(e g with doctors dentists medication review)

were Helpful to Patients/Caregivers (cont’d)

(e.g., with doctors, dentists, medication review)

Follow-up calls and visits (3)(e.g., ensures clients are well, questions if they assistance)

Communication with family members (3)(e.g., provides clients’ children with updates/ information on health status)

Arranged for interventions/ equipment (2)Arranged for interventions/ equipment (2)(e.g., physiotherapy, home equipment such as raised toilet seat, grab bars, walkers)

Ensured compliance with treatment recommendations (2)(e g adherence to medication regime diet)(e.g., adherence to medication regime, diet)

Identification of issues within the home (1)(e.g., issues that can only be identified by home visit such as safety issues)


IGSW: Other ImpactsIGSW: Other ImpactsIGSW: Other ImpactsIGSW: Other Impacts

Do you think the help you received fromDo you think the help you received fromDo you think the help you received from Do you think the help you received from the IGSW has helped to keep you out of the IGSW has helped to keep you out of hospital or from visiting the ED?hospital or from visiting the ED?hospital or from visiting the ED?hospital or from visiting the ED?

YY 53%53%Yes:Yes: 53%53%No:No: 20%20%Not sure:Not sure: 27%27%


Satisfaction with IGSW ServiceSatisfaction with IGSW ServiceSatisfaction with IGSW ServiceSatisfaction with IGSW Service

80

60

70

80

ses

40

50

of Respons

IGSW

20

30

Percent o IGSW

0

10

Neutral Somewhat Very Extremelyy y


Selected QuotesSelected QuotesSelected QuotesSelected Quotes““IGSW has gotten me a lot of help. I've had more visitors in the IGSW has gotten me a lot of help. I've had more visitors in the g pg ppast 2 months then in the past 2 years. I told the nurse that came past 2 months then in the past 2 years. I told the nurse that came by the other day that my mood is better and she asked if I'm ever by the other day that my mood is better and she asked if I'm ever depressed and I said it's been at zero for quite some time now.depressed and I said it's been at zero for quite some time now. ““p qp q

“She has helped us with a lot of things and this has really made “She has helped us with a lot of things and this has really made us feel more confident about being here at home and stayingus feel more confident about being here at home and stayingus feel more confident about being here at home and staying us feel more confident about being here at home and staying here a bit longer before we need to move to somewhere when here a bit longer before we need to move to somewhere when we need more assistance. When she says she going to do we need more assistance. When she says she going to do something she does it and it’s always good to work withsomething she does it and it’s always good to work withsomething, she does it, and it s always good to work with something, she does it, and it s always good to work with someone who's dependable.someone who's dependable. ““


Evaluation: Next StepsEvaluation: Next StepsEvaluation: Next StepsEvaluation: Next StepsActivityActivity Time LineTime Line

Continue to collect information on referrals & Continue to collect information on referrals & activitiesactivities

OngoingOngoing

W k ith LHIN d h it l t bt iW k ith LHIN d h it l t bt i O iO iWork with LHIN and hospitals to obtain more Work with LHIN and hospitals to obtain more data on ED and hospital utilizationdata on ED and hospital utilization

OngoingOngoing

Surveys/Interviews with patients and Surveys/Interviews with patients and Sept/Oct 2010Sept/Oct 2010caregiverscaregivers Jan/Feb 2011Jan/Feb 2011

Survey of health professionalsSurvey of health professionals January 2011January 2011

Stakeholder interviewsStakeholder interviews January 2011January 2011


Lessons Learned: IGSWsLessons Learned: IGSWsLessons Learned: IGSWsLessons Learned: IGSWsFacilitating Factors:Facilitating Factors:

CrossCross--sector representation in planning rolesector representation in planning role Formation of: Implementation & Operational Formation of: Implementation & Operational

Working GroupsWorking GroupsWorking GroupsWorking Groups Hiring all 9 IGSWs at the same timeHiring all 9 IGSWs at the same time IGSWs hosted by a variety of community IGSWs hosted by a variety of community y y yy y y

organizationsorganizations IGSW Lead roleIGSW Lead role

S hi CCACS hi CCAC Strong partnership CCACStrong partnership CCAC Good IT supportGood IT support

Development of SMART goalsDevelopment of SMART goals Development of SMART goalsDevelopment of SMART goals

Lessons Learned: IGSWsLessons Learned: IGSWsLessons Learned: IGSWsLessons Learned: IGSWs

Roles belong to the system not one agencyRoles belong to the system not one agency

Collaborative approach with GEM Nurses, SGS Collaborative approach with GEM Nurses, SGS and Acute Care and Acute Care –– GEM support does not end GEM support does not end

h i l th h it lh i l th h it lwhen senior leaves the hospitalwhen senior leaves the hospital

IGSW t f th Ci l f CIGSW t f th Ci l f C IGSWs are part of the Circle of CareIGSWs are part of the Circle of Care

Communication Communication

Lessons Learned: IGSWsLessons Learned: IGSWsLessons Learned: IGSWsLessons Learned: IGSWsChallenges:Challenges:

Differing cultures of the various IGSW host agenciesDiffering cultures of the various IGSW host agencies Role clarityRole clarity Lack of uniform information system (available to all sectors) Lack of uniform information system (available to all sectors) ac o u o o a o sys e (a a ab e o a sec o s)ac o u o o a o sys e (a a ab e o a sec o s)

for tracking clients in both community & hospitalfor tracking clients in both community & hospital

S i D li I th t Th t IGSWS i D li I th t Th t IGSWService Delivery Issues that Threaten IGSW Service Delivery Issues that Threaten IGSW Effectiveness:Effectiveness: Keeping up with increasing demands for serviceKeeping up with increasing demands for servicep g p gp g p g Maintaining client flowMaintaining client flow Managing unrealistic goals from referral sourcesManaging unrealistic goals from referral sources

QuestionsQuestionsQuestionsQuestions

Contact InformationContact InformationContact InformationContact Information Janice Paul Janice Paul ––Intensive Geriatric Service Worker Lead: Intensive Geriatric Service Worker Lead:

519519--576576--2333 x 277, cell 5192333 x 277, cell 519--400400--8176, 8176, [email protected]@trellis.on.ca

Heather Higgs Heather Higgs –– Intensive Geriatric Service WorkerIntensive Geriatric Service [email protected]@trellis.on.ca

Jane McKinnon Wilson Jane McKinnon Wilson ––Waterloo Wellington Geriatric Systems Waterloo Wellington Geriatric Systems Coordinator:Coordinator: jmckinnon@trellis on cajmckinnon@trellis on caCoordinator: Coordinator: [email protected]@trellis.on.ca

Maria BoyesMaria Boyes-- GEM Clinical Resource Consultant: GEM Clinical Resource Consultant: [email protected]@cmh.orgy @ gy @ g

Carrie McAiney Carrie McAiney –– Lead Evaluator: Lead Evaluator: [email protected]@mcmaster.ca

Facilitating Integration from the Community: …...Facilitating Integration from the Community:...

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