Psychogeriatric Community

1

• Psychogeriatric Community
• Support Program

Presented by Sheryl Bernard, Whitby Mental
Health Centre and Ron Whyte, Cope Mental Health
Program, CCD
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Background

• 2006 Health Accord funding proposal for special
  populations
• Focused on psychogeriatric services for older
  adults living in the community
• Limited funding Memorandum of Understanding
  between CCD and WMHC
• Implementation Committee formed
• PCSP launched January 2007

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Purpose/Goals and Objectives

• Purpose
• Provision of outreach mental health and addiction
  plus support services to older adults (usually
  age 65 and older) living in the community.
• Goals/Objectives
• To improve the quality of life for seniors with
  mental health needs.
• To provide an accessible, community based
  outreach service for assessment, referral and
  supports for seniors with mental health needs.
• To improve the systems capacity to respond to
  the needs of seniors with health problems.
• To maintain older adults with mental health needs
  in their home at optimal level of functioning.
• To improve integration of the primary care,
  mental health and addictions plus the support
  service sectors within a shared care model

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Team Members

• Sheryl Bernard, Administrative Director, Special
  Services, WMHC
• Ron Whyte, Director, COPE Mental Health Program,
  Community Care Durham

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Changes/Improvements

• Program Components
• Outreach assessment/consultations by nurse
  clinician in consultation with psychiatrist.
• Supportive services by COPE staff to include
  individual short-term supportive counselling
  psycho-educational and social recreational
  support groups and one-to-one support provided
  by trained volunteers.

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Outcome Measures/Results

• Measurable Outcomes
• Targets for clients served met
• Referrals to various sources
• Improved patient outcomes, including selected
  measures of mental status, self care, and others
  as determined
• Client satisfaction surveys
• Feedback from referral sources
• Feedback from agencies receiving referrals

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Analysis of caseload and client service contacts

• The number of telephone visits per face-to-face
  visits shows a 76 overall increase from quarter
  1 to quarter 4
• More importantly, the proportion of telephone
  visits out of the total of telephone and
  face-to-face visits has been increasing, from 69
  in quarter 1 to nearly 80 in quarter 4
• Increasing the proportion of telephone visits per
  face-to-face visits is a cost and resource
  efficient approach
• We will monitor whether the proportion of
  telephone visits continue to increase and
  determine how this correlates with the increase
  in client numbers
• We will review the cost effectiveness
  implications of this trend by assessing its
  impact in terms of improvement or deterioration
  of the health outcome and quality of life of the
  seniors on the Program.

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Key Success Factors/Enablers

• Innovative approaches
• Unique partnership of mental health, primary care
  and community support sector
• Focuses on the management of transitions across
  continuum of care
• Enablers for change
• COPE Mental Health Program
• WMHC experts willing to do outreach in the
  community

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Barriers to Improvement

• Overall limited resources for a target population
  where there were no current services.
• Organizational requirements and process for the
  provision of assessment/consultation reports.
• Provision of key psychiatrist assessment/consultat
  ions.
• Internal referrals low

What did one paradigm say to the other
paradigm? Shift happens !!
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Lessons Learned

• Importance of role and mandate clarification
• Family physician support for program
• Acuity of patients referred and living in the
  community
• Problem of few internal referrals from other CCD
  community support sector programs

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Next Steps

• Demonstration of the model
• Enhancement of the model to include
• Outreach assessment/consultations
• Case management
• Family caregiver support education
• Functional assessments interventions
• Case based educational consultation
• Supportive services

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Contact Information

• Psychogeriatric Community Support Program,
  Community Care Durham
• www.communitycaredurham.on.ca
• 905-434-1693