LINKING PEOPLE WITH ALZHEIMER

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LINKING PEOPLE WITH ALZHEIMERS DISEASE AND OTHER
DEMENTIAS TO SUPPORT, INFORMATION AND OTHERS WHO
CAN HELP
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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.

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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.

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Benefits from Participating in First Link

• Caregivers will
• have increased knowledge, skills and confidence.
• be encouraged to develop self care strategies.

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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.

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FIRST LINK REFERRAL RESOURCES

• To Other Services
• The 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.

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FIRST LINK SUPPORT SERVICES

• The Alzheimer Society provides
• phone conversations
• personal appointments
• support groups for
• people with dementia
• caregivers in person and distance telephone
  groups

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FIRST LINK INFORMATION SERVICES

• Alzheimer Society services include
• Print material
• Website
• Information sessions
• Caregiving Building Your Team
• Caregiving with Confidence

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• is your link to
• Help for Today and
• Hope for Tomorrow

Serving People with Dementia
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Click to edit Master

• Winnipeg Regional Health Authority (WRHA)
  GERIATRIC MENTAL HEALTH TEAMS

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Why Change?

• Improve Access
• Reduce Duplication
• Develop linkages
• Improve system efficiency

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Bed Capacity
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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

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Geriatric Mental Health Service Delivery Model

• 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

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Geriatric Mental Health (GMH)

• CENTRAL INTAKE GMH GPAT
• DLC - 800 a.m.-400 p.m.
• Phone [phone] or Fax [phone]
• Open Referral Process- phone/ fax/ mail
• GMH Referral Form

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GMH Intake

• Database entry-
• Flag if known to GMH or GPAT eventually DH
• Based on client address- faxed to appropriate
  team the same day

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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.

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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

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Response Times

• GOAL
• Not a Crisis Response Team
• Non-Urgent contact- 3 days, visit in 10 days
• Urgent contact-1 day, visit in 3 days
• Clinician contact made to determine level of
  risk/ appropriate service schedule appointment

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Weekly Team Reviews

• Team Reviews scheduled with Geriatric
  Psychiatrist -discussion of cases
• Care Planning/ problem-solving/ resources

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Case Closure

• when linked with services required
• when issues stabilized/ improve
• when admitted to hospital-not expected to return

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Winnipeg Regional Health Authority (WRHA)
Geriatric Program Assessment Teams (GPAT)
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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

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GPAT (contd)

• Each clinician receives 12 weeks of specialized
  geriatric training
• This enables each clinician to complete a
  medically based multidimensional assessment in
  the clients home assessing the following
• physical, functional, cognitive, emotional,
  psychosocial, mobility, GI/GU, safety,
  polypharmacy.

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GPAT Emergency Room (ER) Involvement

• In Aug. 04 ER Task force made recommendations
  about GPAT as follows
• GPAT clinicians will have a standard approach in
  assessment process in all ERs 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

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GPAT response to ER Task Force

• Restructured 5 teams to 6 to service 6 ERs 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 resourcessome 2 3 person
  teams with Geriatrician

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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

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GPAT contd

• 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.

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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)

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GOALS (Contd)

• 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

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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

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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.

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Contacts

• Marlene Graceffo, Rehab Geriatrics Regional
  Manager
• 831-2537
• Lois Stewart-Archer, Geriatric Mental Health
  Regional CNS
• 831-2179
• Jill Moats, Rehab Geriatrics Regional Educator
• 831-2150

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Questions
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PRIME

• A Health Centre for Seniors

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Who does PRIME serve?

• Targets community-dwelling seniors who are
• Not functioning well in the community
• At risk of institutionalization
• Wish to remain in the community

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PRIME Goals

• Maintain seniors in the community
• Enhance care coordination and service delivery
  for the frail elderly
• ? Personal care home placement
• ? Hospital/Emergency use

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PRIMEUmbrella of Care

• Case Manager
• Day Centre
• Primary Health Clinic
• After hours support
• Inpatient beds

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Day Centre

• Transportation
• Personal care/ grooming/ personal laundry
• Recreational and social activities
• Rehabilitation /exercises
• Health promotion activities
• Lunch meal

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Primary Health Clinic

• Transfer of care to PRIME physician
• Coordination of on-site off-site appointments
• Medications provided weekly

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After hours support

• Evening and weekend nurse
• Home visits and telephone response
• Provincial Health Contact Centre

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Facilitate Access toInpatient Beds

• Treatment
• Intensive rehabilitation
• Emergency respite
• Assessment

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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

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Edmonton Outcomes (contd)

• High participant family satisfaction
• Maintained health status of participants
• Slowing of health decline
• Improved quality of life
• Support community living

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PRIMEA Health Centre for Seniors

• Judy Ahrens-Townsend
• Regional Manager
• Phone [phone]
• Email jahrens_at_deerlodge.mb.ca