Community Care Services
Promoting Independence
2013 Mount Sinai Geriatrics Institute
Thursday June 27 2013
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Presentation Outline
Part 1
Care Plan Review
Carmelina Marziliano MSW, RSW
Social Worker
Mt Sinai Hospital
Part 2
Linking to the community
Stacey Pustowka BSW, RSW
Social Worker
Housecalls
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Admission criteria for ACE admission Patients 65 years and older with an acute medical illness plus any 3 or more of the following:
Recent decline in functional abilities
Recent change in cognition or abilities
Problems common to older adults (eg: falls, dehydration, urinary /fecal incontinence, acute and / or chronic pain, adverse drug reactions, delirium)
Complex social issues
Identification of Seniors at Risk (ISAR) score >2 on ED assessment
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Assessment process in hospital
Upon admission, automatic referral orders go in for Occupational Therapy, Physiotherapy and Social Work to see patient.
Initial screens are done in order to uncover early concerns regarding discharge back to community or rehabilitation center.
By early identification, concerns can be explored and incorporated into care plans as goals for durable discharge plans.
Communication between medical and allied team members is crucial so that all working with patient and their family on the same goals as the patient and family.
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Assessment process in hospital Areas that are explored:
Living arrangement:
How was everything going at home before coming to hospital?
Did you feel there were any gaps in your care
Are there stairs that you have to manage (inside or outside the home)
Did you already receive help from CCAC or other community agencies prior to coming to hospital
Family Structure:
Do you have immediate family?
I s there anyone else you would consider to be important in your life?
Do you have a Power of Attorney document for personal care and /or finances
At Home:
Were you walking independently?
Did you use a cane or walker?
Do you have any equipment in the bathroom?
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Alice - Care Planning
Education and support to Alice and her common law spouse
Family meeting to discuss medical status, future planning
Facilitator of application to: rehabilitation units (if deconditioned) behavioural units (if needs more intervention to stabilize the behaviours) BSOT Community Support Outreach Team, Convalescent Care (while delirium clears)
Link to Reitman Center
Referral to CCAC to reinstate previous PSW support and assess for increased support (COPD/CHF Self Management Support)
Link to Community Social Worker for continuity and link to community
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Alice in the Community
Community Care Services Promoting
Independence
SPRINT Senior Care Services
Adult Day Services
Community Dining
Dementia Care Residence
Health and Wellness
House Calls
In-Home Services
Meals on Wheels
Social Work
Supportive Housing
Transportation
Volunteer Services
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Interdisciplinary Mobile Team
• Home-Based Geriatric Primary Care Team
Team Members
• Physicians Physiotherapist
• Occupations Therapist Rehab Assistant
• Nurse Practitioner Administrative Data Analyst
• Social Worker
• Team and Intake Coordinator
House Calls
Interdisciplinary Teams
• Client- centered approach and better outcomes for clients
• Team members have complimentary skills
• Comprehensive care plans
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House Calls Goals
Support and Maintain Independence at Home for
Clients and Caregivers
Prevent Emergency Department Visits and
Hospitalizations
Prevent Premature Move to Nursing Homes
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Client
Maintain same
behaviors Maintain
same personalities
Maintain same
relationships
Community services support
independence
Stay active
Strengths-Assessment
Continuity Theory
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Alice over Time
2013
New Diagnosis of Alzheimer’s
Behavioral Problems
Caregiver stress and caregiver isolation
Where to move next?
2012
Linked with CCAC, and Community
Supports
Alice assigned POA documents to Alice
Future Care Wishes and Advance
Directives Discussed
Judy linked with caregivers groups
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Social Work Reassessment for New Care Plan
InterRAI CHA Assessment
Cognitive Testing (Referral to Occupational Therapist)
Alice’s Perception of her Situation
Caregiver’s Needs
Strengths Assessment
Service Review and Linkage
Future Care Planning
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Judies Caregiving Duties
Increased demand for ongoing daily help
with ADL’s (activities of daily living)
Judy now making all financial decisions
that directly affect them both
Judy providing more emotional support to
Alice
Judy researching future care options
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Social Embarrassment and Social Isolation
• Preoccupation with inconsequential matters
• Arguing loudly in public
• Loss in inhibitions
• Personality changes
Some Strategies
• Judy has learned arguing and trying to reason doesn’t help
• Judy has learned being “distracting and agreeable” helps
• Despite the behaviors, Judy still loves Alice
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:
Referrals: Occupational Therapist and Baycrest Community Behavior
Support Outreach Team
• In-service at Adult Day Services
• Caregiver education and support
• Comprehensive care plan
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Profile of Judy
Primary caregiver
Increased knowledge of disease process
No history of mental health problems.
Insight of caregiver stress
Adequate support network
Wants to stay as close to Alice as possible
Member of LGBT community
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Judy’s “Worry List”
Moving
My role as a caregiver?
Changes in role and separation
• Will a move mean moving back into the closet?
• Rethinking downsizing to a condo?
• Does Alice need a nursing home?
• How much will it cost?
• Will new health care professional recognize my relationship with Alice
• What will happen to me if I get sick?
• What happens if I die?
• How long can I cope?
• Alice’s increasing dependence
• Physical and emotional intimacy
• How can I imagine the future as a single person, as a single lesbian?
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Demonstrating Cultural Competency
Learning the language Alice uses to
describe her relationship with Judy
Assessing past experiences of
oppression/homophobia
Reviewing institution’s or agency’s
multicultural policy and practices
Staff Training
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Ewart Angus SPRINT Homes
• Consists of 6 floors
• Well seniors live in market rental apartments on the first three floors
• Seniors with dementia live on the 4 and 5 floor (secure units)
* Ewart Angus is owned by Ewart Angus Homes Inc, a private
not for profit organization
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Programming/Philosophy of Care
• Respect for lifelong routines
• Meaningful, practical activities help the resident remain involved and active
• Individualized care programs
• Health and Wellness, Activation, and Outings
• Culturally Competent
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Caregivers: Family, Friends and Volunteers
• The needs of family members are recognized and supported
• Family members, friends and volunteers significantly enrich the programming
• Families and friends are welcome to visit anytime and participate in as much or as little
26 Ewart Angus SPRINT Homes’ 6th floor
Gardening at Ewart Angus SPRINT Homes
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Benefits
• Prevent premature institutionalization
• Fosters independence, self-esteem and self confidence
• High quality of life for residents
• Significantly decrease caregiver stress
• Supports family relationships
• LGBT-friendly
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Working Together: Referrals, Consults, Discharge Planning
Mount Sinai Hospital
Community Care Access Centre
SPRINT Senior Care and House Calls
Reitman Centre Mount Sinai
Baycrest Community Behavior Support Outreach Team
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Alice’s Careplan
House Calls
Alice attends Adult Day Services
Ongoing behavioral assessment
Linkages to services
Imminent move to Ewart Angus Home SPRINT Home
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Judy’s Careplan
Attendance at monthly caregivers group
Judy uses SPRINT Senior Care programs
Ongoing Systems Navigation
Imminent move to first floor of Ewart Angus Home
Contact Information
CNAP : Community Navigation and Access Program 1-877-540-6565 www.cnap.ca
Ewart Angus SPRINT Homes: 416 544-0689
House Calls: 416-481-5099 www.seniorhousecalls.ca
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SPRINT Senior Care
140 Merton Street, Second Floor
Toronto, ON M4S 1A1
416-481-6411
Presented by:
Stacey Pustowka
Social Worker, BSW, RSW
House Calls Team
www.sprintseniorcare.org