Community Care Services

Promoting Independence

2013 Mount Sinai Geriatrics Institute

Thursday June 27 2013

2

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

2

3

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

3

4

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.

5

5

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?

6

6

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

9

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

10

10

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

12

12

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

13

13

Client

Maintain same

behaviors Maintain

same personalities

Maintain same

relationships

Community services support

independence

Stay active

Strengths-Assessment

Continuity Theory

14

14

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

15

15

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

16

16

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

17

17

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

19

19

:

Referrals: Occupational Therapist and Baycrest Community Behavior

Support Outreach Team

• In-service at Adult Day Services

• Caregiver education and support

• Comprehensive care plan

20

20

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

21

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?

21

22

22

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

23

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

24

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

25

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

28

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

29

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

29

30

30

Alice’s Careplan

House Calls

Alice attends Adult Day Services

Ongoing behavioral assessment

Linkages to services

Imminent move to Ewart Angus Home SPRINT Home

31

31

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

33

33

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